Trajectories of support intervention in clinical psychology

,


Introduction
Recently, the Commission on Typical Acts of the National Council of Italian Psychologists (NCIP) asked a group of national experts for an opinion on the definition of typical acts for psychologists (i.e., prevention, habilitation, rehabilitation, and support activities), specifying their objectives, methodology, procedures, and actions, with particular attention to the clinical field in distinction to psychotherapy.The opinion was published by Castelnuovo et al. (2023) in The Italian Journal of Clinical Psychology and triggered a lively and stimulating debate in the scientific community on the boundaries and specificities related to psychology, the clinical field in which psychologists work, and psychotherapy.
There are various ways to participate in a discussion: the approach we chose is to place the general question within the specific framework of one's own field of study and expertise (Freda, 2009) by trying to formulate specific issues and then verify if they can contribute to the broader debate in terms of general utility.In this paper, we will attempt to elucidate the NCIP's question by commenting on the work of Castelnuovo et al. (2023) in light of three specific foci: (1) definition of supportive intervention among the typical acts of the psychologist; (2) adoption of a methodological criterion to distinguish between supportive intervention as a psychological-clinical act and psychotherapeutic intervention; and (3) articulation of the discourse in relation to the adoption of narrative methods in clinical intervention.
In relation to the first focus, we have chosen to look at supportive intervention because of the current innovative articulations of the psychological profession, for example in primary care psychology.These articulations increasingly refer to psychological support interventions, which by definition are not psychotherapeutic interventions and are one of the typical acts of the psychological profession.However, unlike psychotherapeutic interventions, there is currently no clear definition of what constitutes a psychological support intervention in the clinical field.As for the second focus, we believe that the difference between psychological-clinical interventions and psychotherapeutic interventions can be better understood by looking at the methodological criteria they use -namely what they aim to "change" within the clinical relationship and how they do this.Finally, the third focus concerns the anchoring of discourse in the use of narrative devices in clinical practice through which we will examine the differences between the typical act of support performed by a psychologist working in a clinical setting and psychotherapeutic intervention.The interpretive framework we have chosen is that of narrative psychology, which is consistent with our background and expertise.In our paper, we will adopt this perspective to illustrate the various trajectories of the use of narrative device based on the type of intervention and, in particular, on the different psychological health needs and, consequently, on the different objectives of the intervention.
In the following paragraphs, we will first provide a brief overview of the current debate on the typical acts of the psychological profession, focusing specifically on the typical acts of psychological support in the clinical field and distinguishing these from psychotherapy.We will then discuss the narrative perspective in clinical psychology.Finally, we will propose a possible articulation of the typical act of psychological support in the clinical field and the psychotherapeutic act in the light of the narrative perspective in terms of methodological criteria and intervention goals.

Psychologist's typical acts: The "case" of psychological support
As is clear from the document by Castelnuovo et al. (2023), the professional figure of the psychologist in Italy is regulated by Law 56/89, which refers to a unified professional profile with no distinction between different areas of intervention (e.g., social, educational, organizational, legal).This legal situation implies that a licensed psychologist can work in all areas of intervention and, from a purely legal point of view, the concept of "clinical psychologist" does not actually exist.What does exist, however, is a psychologist working in a clinical setting.In other words, clinical psychology (just like school psychology or legal psychology, for example) is an area of intervention for psychologists, and to quote directly from Castelnuovo et al. (2023, p. 17), it is: the exercise of the psychological function of knowledge and intervention within the clinical domain, the latter as the set of typical and atypical intrapsychic and relational, individual, couple, family, group, and institutional processes that govern the lives of individuals and groups in aspects related to subjectivity and its externalization (e.g., sense of personal accomplishment, the use of cognitive and emotional skills for the purpose of active adaptation, and the ability to entertain meaningful and beneficial relationships for well-being).
Following this line of reasoning, which aims to distinguish the clinical field from other areas of psychologists' action, the clinical field is defined by both the object of the intervention and the setting.Regarding the object of the intervention, Castelnuovo et al. (2023) argue that the clinical field «consists of the intrapsychic, interpersonal, and contextual processes, factors, conditions, and phenomena (…) related to and/or substantiating states of psychological distress and discomfort» (p.17).The object, therefore, is represented by psychological distress or discomfort.As for the setting, clinical psychological intervention involves professional operations made possible by the mediation of settings that operate at the interpersonal and/or microsocial level.The regulation of these settings requires «interpretive models, methods and techniques designed because of the subjective and intersubjective processes that characterize such human forms» (Castelnuovo et al., 2023, p. 19).Looking at the clinical field from this perspective implies that the specificities of this field do not concern the general functions performed by psychologists (e.g., support, prevention, etc.) or the methods used to perform these functions (e.g., interviews, tests, etc.), but rather the problems to address (i.e., the object) and the organizational formats co-constructed with the user (i.e., the setting).
The situation of psychotherapy is different, since it stands out as a specialized activity within clinical psychology, which requires a thirdlevel training.Also in this case, according to Castelnuovo et al. (2023), what distinguishes the psychotherapeutic field from all other psychological fields is the object that motivates specialized professional action: the treatment of psychopathology.However, we believe that the cure or treatment of psychopathology is a goal of intervention rather than an object.In this reasoning, we find support in the definition of "supportive intervention" given by Castelnuovo et al. (2023, p. 24), which is the focus of the present: Supportive interventions are not aimed at modifying the psychopathological condition, but at enhancing opportunities for adaptation within the constraints given by that condition (…).Such interventions therefore fall within the clinical psychology, not psychotherapy, domain.
It seems to us that this definition distinguishes the two types of interventions (supportive intervention vs. psychotherapy) on the basis of different intervention goals (i.e., improving adaptive capacity vs. treating psychopathology, respectively) rather than on the basis of the object (psychological distress vs. psychopathology).We share this view and would like to express it in our contribution in terms of a methodological trajectory.With reference to the second focus of this paper, we therefore argue that the goals of any intervention, whether psychological-clinical or psychotherapeutic, should be pursued on the basis of specific methodological criteria.In an attempt to broaden this definition by setting out more decisively the methodological specificities of supportive intervention in the clinical field, we have therefore turned to the scientific literature, but have been profoundly disappointed.
The work that seemed to focus most on the topic we are dealing with is by Serge Lecours (2007).The author approaches supportive intervention from a psychoanalytic perspective and shows how effective and necessary it is with patients who have difficulties with the symbolic functioning of the mind.However, Lecours (2007) refers to supportive interventions in the context of psychoanalytically oriented psychotherapy and suggests a distinction between support and interpretations, the latter being more appropriate for patients with good symbolic functioning of the mind.According to Lecours (2007), supportive interventions are appropriate for individuals who exhibit psychosomatic symptoms, who are prone to acting out or who experience significant personality disturbances.From this perspective, which seems to prioritize the nature and extent of the problems presented by patients as well as the varied use of techniques, supportive interventions aim to transform non-symbolic contents of the mind into symbolic and meaningful contents.This is to be achieved through pragmatic and interactive communication modalities.Although Lecours' (2007) point of view is valid in the context of psychotherapeutic work, it does not seem sufficient to include supportive interventions that do not take place in a psychotherapeutic setting.
Unlike the work of Lecours (2007), many other scientific studies emphasize that psychological support as an intervention, not necessarily in the context of psychotherapy, is effective in promoting health.However, these studies often do not conceptually define what is meant by a "psychological support intervention."Instead, they primarily present empirical data supporting the use of psychological support for specific conditions, such as chronic illness (e.g., Hossain et al., 2021;Reynolds et al., 2018;Sansom-Daly et al., 2012), life events that cause sudden changes (e.g., pandemics, bereavement; e.g., Bertuzzi et al., 2021;Johannsen et al., 2019), or environmental conditions where a family member has significant health problems that challenge the system (e.g., Selwood et al., 2007;Thompson et al., 2007).
Despite the lack of conceptual definitions, we seem to recognize a common dimension in all studies to consider psychological support intervention as a specific type of intervention that can be proposed to support the phases in which a period of vulnerability and disorganization of mental processes occurs after a critical event (Flannery & Everly, 2000).Furthermore, another common dimension often highlighted in the scientific literature is that the activation of narrative processes and meaning making in response to critical events and conditions, as facilitated by psychological support interventions, may be related to health, adjustment, and developmental outcome (Park, 2010).This point leads us to the third focus of the current paper.

The narrative perspective in clinical psychology
Discussing narrative in psychology draws on the historical contribution by Bruner (1990).Bruner emphasizes that when the human mind grapples with a critical experience, it creates a narrative urgency -a drive to seek a tolerable and intelligible meaning for that specific experience.Through narrative, people construct a coherent life story, integrate multiple meanings attributed to different events over time, position themselves from a subjective perspective to make connections between their mental states and external events, and ultimately shape their identity and life story (Fivush et al., 2017;McAdams & McLean, 2013;Neimeyer, 2004).
The relevance of narration for the construction of the self and one's relationship to life experiences makes it a particularly effective methodological tool in the clinical setting, whether in interventions aimed at helping people cope with critical experiences or in psychotherapeutic approaches aimed at treating psychopathologies.
In terms of supportive interventions, we think, for example, of psychological interventions that use expressive writing as a method (Pennebaker, 1997).The possibility of expressing emotions associated with painful or challenging life experiences in narrative form seems to enable their integration into the personal story (e.g., Lu et al., 2018).We also think of autobiographical writing used in psychological interventions to promote the integration and processing of critical experiences.This type of narrative, when conducted in a clinical setting, allows to explore the autobiographical disruption caused by painful experiences and to identify the individual's point of view in his or her own life, also capturing how the critical experience fits into the temporal perspective of one's existence (Kelley & Clifford, 1997;Piana et al., 2010).Along this line, a fairly recent review of the use of narrative interventions for patients with chronic illnesses emphasizes the role of narrative devices as facilitators of meaning-making processes (Gucciardi et al., 2016).
Regarding psychotherapeutic interventions, narrative has been used as a specific methodological tool starting from the narrative therapy (White & Epston, 1990).Narrative therapy is conceptualized as a "reauthoring" process that aims to construct narratives of the self that are more flexible and complex, incorporating contradictory and ambiguous aspects inherent in human experience.Cognitive models also make extensive use of narrative.Those based on a hermeneuticconstructivist approach, which is a narrative elaboration of Kelly's (1970) theory of personal constructs, view psychotherapy as a process aimed at co-constructing a new narrative reality based on an understanding of the meaning of symptoms (Chiari & Nuzzo, 2010).Other cognitive models use narrative tools to support mindfulness by promoting access to new meanings through both bottom-up processes (bodily sensations are seen as knowledge tools from which narratives are constructed) and top-down processes (narratives as a starting point for exploring emotions and bodily sensations) (Rodríguez Vega et al., 2014).Narrative is also an important aspect in the Di Maggio et al. 's (2015) interpersonal metacognitive therapy, which focuses on recognizing interpersonal patterns through narratives of life episodes.Finally, narrative is also an important aspect in psychoanalysis and psychodynamic psychotherapy.For example, Schafer (1980) argued that individuals construct narratives to make sense of their lives and that analyzing these narratives can provide insights into their psychodynamic processes; Spence (1984) developed the concept of "narrative truth" (i.e., subjective, personal narratives that individuals construct about their experiences) and distinguished it from that of "historical truth," which reflects objective and factual events; Corrao (1991) viewed the psychoanalysis as a practice that aims to transform sensory and emotional experiences into thoughts and meanings; and Ferro (2014) emphasized how the psychotherapeutic encounter aims to change the narratives constructed in the intersubjective analytic field.
Based on what we have discussed, we believe that it is possible to define narration as a function of the mind that, through the transformation of experiences over time, can support the psychological adaptation of individuals, especially in the face of critical and somewhat overwhelming experiences that, being outside the ordinary, require psychological work to reorganize and integrate in order to be processed (Freda et al., 2023).The narrative works we have conducted over time and through theory-driven qualitative research methods (e.g., De Luca Picione et al., 2017, 2018;Martino et al., 2023aMartino et al., , 2023b) ) have allowed us to identify, based on the scientific literature, at least four specific functions that narrative fulfills in relation to critical experiences (Figure 1).
Copyright © FrancoAngeli This work is released under Creative Commons Attribution -Non-Commercial -No Derivatives License.For terms and conditions of usage please see: http://creativecommons.orgThe first function, temporal organization, is an organizational function, or rather a function that aims to order events primarily in temporal but also in spatial terms (Brockmeier, 2000;Crossley, 2003;Williams, 1984).From this perspective, narrative serves to inscribe the experiences we have into the time of our existence and to establish connections between the present, the past and the future.Critical states often lead to a kind of "absolute present" that freezes one's life story in a single temporal dimension.Narration therefore makes it possible to reconnect with the past and envision the future.
The second narrative function is the search of meaning (Frank, 1995;Williams, 2000) which in the case of experienced critical conditions could be summarized in the question "Why did this happen to me?"In this sense, narrative might enable us to search for an answer to this question by revealing the meaning of events that seem meaningless.This means that narrative processes allow us to reclaim a critical experience and transform it into something relevant and meaningful.Cognitive theorists would speak of benefits finding (Tennen & Affleck, 2022), or rather the possibility of recognizing a benefit from a critical or traumatic experience and thus putting it at the service of the self.
The third function is the expression of emotions and reflects how the narrative makes it possible to name and differentiate emotions and feelings and to link them to specific events and contexts (Greenberg & Pascual-Leone, 2001;Tronick, 2010).
Finally, the fourth function is orientation to action, or agency (Brockmeier, 2009;McAdams, 2013).It reflects the opportunity the narrative offers to construct our own decision-making and to guide our actions in response to a critical event.
It can be argued that these four specific narrative functions fulfill an overdetermined function that is particularly evident in situations in which a person is confronted with a critical event, i.e., an event that represents a deviation from the norm (Bruner, 1990) and for this reason creates a narrative urgency.We refer to the function of making sense of what has happened.To unfold this point, we turn to the integration of a semiotic and socio-constructivist view of the mind into the narrative perspective, according to which narrative is one of the processes through which the affective, generalized, embodied, and preverbal sense of experience can be transformed into a shared and symbolizable meaning.The attribution of more or less complex meanings to life experiences could thus be the result of a narrative articulation process that begins with a homogenizing and generalizing affective and embodied investment in the experience that we call "sense" and moves toward a direction of discretization, transforming the "sense" of an experience, which may only felt and not thought, into the "meaning" of the experience, something mentally represented and thought (De Luca Picione & Freda, 2012;Freda et al., 2023).In this process, narrative functions play the role of mediators between sense and meaning.In Figure 2, we have attempted to graphically represent the narrative articulation process that involves the transformation of sense into meaning.

A "narrative proposal" on the trajectories of psychological support in clinical field and psychotherapy
If we attempt to apply the theoretical framework we have used to psychological or psychotherapeutic interventions, we believe that the actions of a psychologist working in a clinical field and those of a psychotherapist differ primarily in how the professional uses the narrative and its underlying narrative context, i.e., the goal of the intervention.
In light of defining psychotherapy as an act of the clinical psychologist aimed at treating psychopathology, the use of narration will be consistent with this objective if it enables the activation of a movement from the superficial -understood as that which emerges from the client's narrative (i.e., the meanings) -to the profound (i.e., the sense).In other words, the narrative that the client and the psychologist construct together in the psychotherapeutic relationship organizes a process of "search for meaning", starting from the meanings that emerge from the client's story, which includes the representation he/she has of him/herself, his/her relationships, and his/her symptoms.It is therefore a process of reorganization and restructuring of the self that progresses through the construction of the psychotherapeutic discourse as a space in which individuals can recognize and gradually transform their subjectivity towards a deeper understanding of themselves and their way of being in the world, reducing the manifest symptoms that were often the cause of the request for help.
It is important to emphasize that the narrative movement towards the search for meaning can be interpreted within different theoretical models of the mind.In particular, in the psychodynamic perspective, it could be the gradual narrative production of what could not be consciously thought because it was too emotionally painful and therefore repressed or denied (e.g., Ferro, 2014).In the cognitive perspective, it can be seen as the awareness and restructuring of schemas related to the self and relationships (e.g., Di Maggio et al., 2015).In the systemic-relational perspective, on the other hand, it could be the patients' understanding of their cognitive and emotional representations of early relationships with caregivers based on their narrative modalities and coherence (Dallos, 2004).In summary, we believe that what ultimately characterizes the narrative context of a psychotherapeutic intervention, regardless of the theoretical model of the mind, is the direction of the therapeutic work, which moves from meaning towards sense.
In our view, the direction of the narrative process that characterizes psychological support in a clinical setting is rather the opposite.It is necessary to re-emphasize here that the aim of psychological support, as highlighted by NCIP (2015), is: improving the quality of life and adaptive balances of individuals [our italics] in all situations (both health and illness), as deemed appropriate, by developing and enhancing their strengths and capacities for self-determination.This requires assessing the balance between the individual's disabilities, resources, needs and expectations.
We believe that the attention given to "adaptive balances" emphasizes the need to promote the adaptation of individuals and communities in the face of situations in which a reordering of oneself, one's resources and related contexts may be required.For this reason, we believe that the specific focus of a psychological support intervention in a clinical field can be defined as a condition of psychological difficulty or distress related to a moment of transition or crisis.In this sense, we think of a diagnosis of illness, a sudden loss or a particularly abrupt professional or family change.These events do not necessarily lead to a state of distress, but they can certainly be defined as potentially critical, as they can challenge the meanings that a person has constructed around themselves and the relationships between them and their environment.Therefore, this type of intervention is suitable for people who are experiencing a crisis, regardless of their mental functioning (e.g., severity of pathology, degree of ego strength, degree of mentalization, etc.).
In our opinion, a psychological intervention aimed at supporting coping with these events can have the following objectives: to the event.To achieve these goals -which do not involve the treatment of psychopathologies or conditions of distress structurally connected to the client's personality -the psychologist can use narrative as a clinical tool that can activate a movement from sense to meaning.In other words, the narrative discourse that is co-constructed within the clinical relationship should support the construction of increasingly complex and articulated representations of oneself and one's relationship to the critical event.
From this perspective, it seems possible to think that if the guiding question for the psychologist in a psychotherapeutic intervention to construct the trajectory of the intervention is "What gives rise to the condition of distress that affects this person, and how do the experiences he/she has gone through in his/her life influence who he/she is now?" (a question that can be framed differently depending on the theoretical reference model), the question that guides the support intervention is "How can this person cope with this critical experience, regaining a sense of mastery over his/herself and his/her life contexts?".Creating a clinical device that promotes the improvement of narrative functions means ensuring that the person's self-narrative and the narrative of the event become increasingly complex and capable of integrating positive and negative aspects of the experience.The psychologist thus contributes to the construction of the client's narrative, not with the aim of promoting deep discovery and self-restructuring, but with the aim of supporting the articulation of narrative functions towards increasingly complex and differentiated modalities.
The narrative functions we described in the previous paragraph are always present in a narration but can be rigid and depowered.For example, the expression of emotions in a narrative may be vague, or individuals may have difficulty distinguishing between similar emotions or connecting their emotional experiences to specific events or contexts.Similarly, the meaning attributed to a critical event may be rigid, have no connection to other significant aspects of one's life, or be denied, as if the critical nature of the experience cannot be acknowledged.Psychological support intervention can support the development of these functions, for example, by helping individuals to recognize the different emotional nuances associated with the same situation, to recognize their responsibility for the experiences that affect them, to acknowledge the pain and suffering associated with a critical event without experiencing the annihilation that hinders the mobilization of their resources.
Ultimately, we believe that the narrative device in an intervention to support the management of critical situations aims to transform the sense of the experience, understood as the affective and non-symbolizable context underlying that experience, into a representable and shareable meaning, as complex and differentiated as possible, capable of guiding the person's choices and restoring an effective sense of mastery.

Conclusion
This paper was written with the aim of contributing to the current scientific debate on the definition of the typical acts of psychologists and psychotherapists.Starting from a narrative perspective, we have tried to formulate the typical support act of a psychologist working in the clinical field and to distinguish it from a psychotherapeutic act in light of the diverse psychological health needs and the different intervention objectives.
Along this line, we believe that what distinguishes the typical act of psychological support from the typical act of psychotherapy is a methodological criterion that takes shape in the direction of psychological work: on the one hand, the psychological work in supportive intervention moves in the same direction as the psychic functions, articulating contexts and devices useful to express those functions toward their development; on the other hand, the psychological work in psychotherapy moves in the opposite direction, identifying and restructuring the basic structures (cognitive, affective, or relational) that feed the functions, regardless of theoretical models.In other words, we could define support intervention as a process in which the clinical relationship serves as scaffolding for psychic functions in the direction of their development and integration.Indeed, supportive interventions seem appropriate both in conditions where the severity of mental functioning does not allow for psychotherapeutic intervention (in which case we could imagine that a support intervention could precede or accompany psychotherapeutic work) and in critical conditions where a disorganization or dysfunction of the mental system can be hypothesized.
Finally, we believe that the use of narrative as a psychological tool in the clinical relationship and its delineation based on the specificities of the clinical contexts in which psychologists work can provide useful tools for the conceptualization of professional practices that characterize the work of psychologists in different intervention contexts (healthcare, education, correctional, etc.).These contexts offer psychologists the opportunity to structure supportive interventions that may be methodologically based on narrative, depending on the nature of the clientele, the settings used and the social and institutional mandates that characterize them.

Figure 1 .
Figure 1.Narrative functions (a) promoting the understanding of the critical event and the changes involved; (b) imagining what role that the critical event has played or can play in one's own life history; (c) mobilizing the person's individual and social resources; (d) supporting decision-making and autonomy in the face of situations of deadlock or persistent indecision; (e) facilitating the expression and understanding of emotions related