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.She also stopped herdefensive grinning and began to consider her valuable relationships with her chil-dren and grandchildren (cf.interpersonal therapy, Chapter 8, which tends to stressthe positive aspects of the social network). 190 | SUSIE VAN MARLE AND JEREMY HOLMESThroughout the 6 years, the psychotherapist regularly liaised with the GP and theconsultant rheumatologist, particularly during exacerbations of her rheumatoidarthritis and her depressive phases.Soon after the commencement of therapy, shedecided to ask for a second opinion about her operation and after a few years she wasawarded compensation.With the money she received she decided to sell her houseand move to accommodation and a community which were better equipped for herneeds.This was located in another part of the country.At the last session sheexpressed her concerns and sadness about leaving her network of support (note thetherapist is not necessarily centre-stage in LTST) but also her pleasure in making themove while she was still fit to do so.Theorizing supportive psychotherapyThere is no clear consensus about the theoretical basis of LTST.Most would agree thatits construction requires the integration of several conceptual building blocks,includingattachment theory (Holmes 2001) the therapist as a secure base;ego psychology s (Vaillant 1977) approach to defences;a developmental model (Bergman and Mahler 1991) where a slow maturationmay be observed over many years; andsystemic thinking, bringing the care network into the consultation as needed,together with a narrative approach (White and Epston 1990) helping patients totell and own their story.Unlike conceptually integrative therapies, such as cognitive analytic therapy(Chapter 6) and dialectical behaviour therapy (Chapter 9), supportive therapy is trulyeclectic, drawing on a mixture of common sense, Rogerian counselling, cogni-tive behavioural strategies, systemic approaches, and psychoanalysis (Crown 1988;Chapter 1).How practitioners build a theoretical basis for their supportive work will bedetermined by personal preferences, training and clinical experience, and exposure todifferent practical and theoretical models.LTST has been described as lacking a singletheoretical basis, being rather like a a shell program (Pinskner 1994) or umbrellaframework (Chapter 1) that fits over most psychotherapies.Another image could bethat of the delta, a confluence of different theoretical components that lead to the eter-nal sea. SUPPORTIVE PSYCHOTHERAPY AS AN INTEGRATIVE PSYCHOTHERAPY | 191An evidence base for supportive therapy?The evaluation of LTST as practised within the NHS is essential and requires the atten-tion of clinicians and researchers, because there are many difficulties that are not easilyovercome.It is a flexible, non-manualized form of therapy which is practised in different waysand at different levels by a wide variety of professionals.It is applied to a range ofpatients with chronic complex psycho-social difficulties.The lack of clear definition andthe heterogeneous patient group pose enormous problems for those committed toevaluation.The long-term nature of the work requires the financial support and the resources forthe clinical work and the evaluation.There are problems of internal validity, as mostpatients in LTST experience important life events external to the therapeutic alliance.Many of the patients are managed by a network of professionals who provide medica-tion and/or support.A meaningful evaluation of LTST will need to consider thesefactors.Roth and Fonagy (1996) point out that the natural history of many health problems isboth chronic and (in some cases) cyclic, and it is against this background that measuresof improvement should be judged.They suggest that in patients with chronic complexdifficulties, psychological interventions may not be curative although they mayimprove an individual s adaptation, reduce the symptoms, and improve quality of life.These are the important aims in LTST and it may be useful to consider the followingduring long-term audit.Measuring disability The measurement of the absence or presence of symptoms mayhave limited use in patients with chronic complex difficulties.Roth and Fonagy (1996)suggest that with patients who have chronic relapsing conditions, it may be more appro-priate to judge improvement by the speed of improvement or the latency to relapse.What is needed is a much broader concept which captures the multifaceted psy-cho-bio-social difficulties of many of the patients seen in LTST.Measuring the patient sdisability is more useful and relevant to this patient population and involves looking at,for example, a psychological dimension, coping skills, interpersonal relationships, andthe patient s physical health and social circumstances, before, during, and after LTST.Monitoring a patient s quality of life is of particular relevance to patients seen in LTST.Level of defensive maturation LTST aims to facilitate some maturation of defences andit may be useful to monitor the predominant defences utilized by the patient through-out the long-term alliance alongside the life events which they experience.Quality of life/patient satisfaction Self-reports on quality of life and patient satisfactionof LTST can be monitored every few months. 192 | SUSIE VAN MARLE AND JEREMY HOLMESUtilization of services Many patients seen in LTST have been high users of NHSresources prior to coming into treatment.Audit of inpatient days, GP consultations,and numbers of referrals to secondary services, alongside an estimation of the resourceswhich are involved in the LTST, would reveal whether there has been a reduction in thetotal health-care cost of the patient.Stress in the patient s network of support Some patients with complex chronic difficul-ties cause considerable stress to their carers and in their professional network of sup-port
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