5 keys to good results with supportive psychotherapy
Evidence-based technique gains new respect as a valuable clinical tool.
Supportive psychotherapy began as a second-class treatment whose only operating principle was “being friendly” with the patient (Box).1 Critics called it “simple-minded”2 and sniffed, “if it is supportive, it is not therapy…if it is therapy, it is not supportive.”3
Since its lowly beginning, however, supportive psychotherapy has been proven highly effective, and clinicians have developed operating principles that distinguish it from expressive psychotherapy (Table 1).4
To help you make good use of supportive psychotherapy, this article describes its evolution and:
- evidence that demonstrates its effectiveness
- 5 key components for clinical practice
- how to use it when treating challenging patients.
Differences between expressive and supportive psychotherapy
Nurture positive transference
Focus on conscious material
Reinforce mature defenses
Source: Reference 4
A proven treatment
Effective long-term therapy. Much research on supportive psychotherapy comes from studies in which supportive psychotherapy was included as a “treatment as usual” comparison. In an extensive longitudinal study, for example, the Meninger Psychotherapy Research Project examined 42 patients receiving psychoanalysis, psychodynamic psychotherapy, or supportive psychotherapy over 25 years.5
Despite the institutional expertise in psychoanalysis and expressive psychotherapy, patients in supportive psychotherapy did just as well as those receiving the other treatments. Researchers found that each therapy carried more supportive elements than was intended, and supportive elements accounted for many of the observed changes. They concluded that:
- thinking of change in terms of “structural” vs “behavioral” was not useful
- change did not occur in proportion to resolving unconscious conflict.
A supportive approach may work when expressive psychotherapy fails
Early psychotherapy consisted of directive methods by which Charcot, Freud, and others “suggested” that patients rid themselves of symptoms while under hypnotic trance. Beneficial effects were sometimes immediate and dramatic but rarely lasted.
Dissatisfied with directive techniques, clinicians developed psychoanalytic principles and expressive psychotherapy, which emphasizes analyzing transference and uncovering unconscious thoughts, feelings, and motivations. Although expressive psychotherapy became popular, many patients—especially those with severe mental illness—were deemed unsuitable candidates or failed to improve.
These patients were relegated to supportive interventions, which initially were vaguely defined methods to reduce anxiety and provide encouragement. Therapists required little or no specialized training to provide supportive therapy and did not expect patients to make character (or structural) change. Surprisingly, many patients improved despite vague therapeutic guidelines.
Source: Reference 1
Combating phobias. A study of behavior therapy for treating phobias had similar results.6 Patients with agoraphobia, mixed phobia, or simple phobias were treated with behavior therapy alone, behavior therapy plus imipramine, or supportive psychotherapy plus imipramine for 26 weekly sessions.
Therapists in the behavior therapy group used a manualized, highly structured treatment protocol that included in vivo desensitization and homework. Therapists who used supportive psychotherapy simply encouraged patients to ventilate their feelings and discuss problems. Supportive therapists were instructed to be nondirective and avoid confrontation unless the patient proposed it.
Both therapies combined with imipramine produced similar rates of moderate to marked improvement in patients with agoraphobia (85% to 100% with supportive therapy, 76% to 100% with behavior therapy). For patients with mixed phobias, 71% to 100% improved moderately or markedly with supportive therapy compared with 88% to 100% with behavior therapy. Among patients with simple phobia, 72% to 86% experienced moderate to marked improvement with supportive therapy, compared with 87% to 93% with behavior therapy.
Improving personality disorders. Several studies examined a form of supportive psychotherapy that used a manualized, structured protocol for treating higher functioning patients who traditionally have been treated with expressive psychotherapy. The protocol used a conversation-based, dyadic style to improve self-esteem and adaptive skills through data-based praise, advice, education, appropriate reassurance, anticipatory guidance, clarification, and confrontation. Under these reproducible conditions, supportive psychotherapy showed good efficacy compared with dynamic therapies for patients with depressive, anxiety, and personality disorders.
A review of studies from 1986 to 1992 found that supportive psychotherapy was effective for a variety of psychiatric and medical conditions, including schizophrenia, bipolar disorder, depression, posttraumatic stress disorder, anxiety disorders, personality disorders, substance abuse, and stress associated with breast cancer and back pain.9
CASE STUDY: A negative experience
Mrs. S, a 32-year-old grant writer, is referred to a psychiatrist by an emergency department physician after she cut herself following an argument with her husband. She has chronic dysthymia, thoughts of harming herself, low self-esteem, and indecision about her marriage.
Mrs. S was not receiving mental health treatment because her first experience with a psychiatrist had a poor outcome: “He hardly ever said anything; in fact, sometimes I wondered if he was sleeping. I needed advice desperately, and I was hoping to get some help and direction for my life. Instead he answered every question with a question, and I ended up getting more confused. I felt guilty, like I wasn’t being a good patient because I couldn’t think for myself. I felt like he thought I was stupid. He gave me some antidepressants, but after a few months of feeling even worse I stopped going and vowed to never see a therapist again.”
5 key components
Although all psychotherapies have some elements of support, effective supportive psychotherapy has 5 key components (Table 2).
Adopt a conversational style. In psychoanalytic therapy, as experienced by Mrs. S, the therapist’s opacity is intended to allow the patient to develop transference. In supportive psychotherapy the therapist instead works to create a therapeutic alliance based on the relationship with the patient. Using a conversational style is essential for developing this positive relationship. This style includes:
- asking directive questions
- allowing inflection in your voice
- making gestures
- discussing opinions.
Some therapists are uncomfortable with this style because they feel more “transparent.” With practice or supervision, however, therapists often learn that a conversational style allows greater spontaneity and creativity. They can solve problems in a more relaxed state (closer to “being themselves”).
5 components of supportive psychotherapy
CASE CONTINUED: Learning to cope
Mrs. S’ new psychiatrist starts her on an antidepressant and once-weekly supportive psychotherapy. For the initial sessions, the psychiatrist helps Mrs. S explore options for her highly conflicted marriage and strategies for coping with panic symptoms.
Mrs. S develops a strong feeling of attachment to the psychiatrist, sometimes projecting anger onto him by declaring that he does not care enough. Instead of interpreting this transference, the psychiatrist uses it as an opportunity to explore coping options Mrs. S can try when she feels unloved or rejected.
Nurture positive transference. A positive relationship is essential for the therapeutic alliance. In most instances, a patient naturally develops good feelings toward the therapist over time as a result of repeated empathic interchange. In supportive psychotherapy, you may acknowledge these good feelings but do not interpret them for unconscious underpinnings.
Address transference only if it is negative. If the patient develops hostility or anger toward you, use techniques to improve the relationship, such as:
- acknowledging the validity of the patient’s angry feelings
- gaining an understanding of your role in the conflict and apologizing if sincere
- offering solutions to improve the conflict
- providing reassurance that working through the conflict will strengthen the therapeutic relationship.
These techniques generally do not include interpreting resistance or unconscious conflicts. However, patients sometimes benefit from reviewing their role and perceptions in the conflict once their anger has subsided. Waiting for the negative transference to resolve on its own usually is not a good strategy.
Reduce anxiety. In supportive psychotherapy, the primary goal is to lessen the patient’s suffering. Although the patient often must talk about stressful or painful topics, you can help him or her do so in a tolerable manner. Focus on making it easier for the patient to talk.
Reducing anxiety means not only helping the patient talk about painful matters but also allowing him or her to avoid topics that are too uncomfortable to endure. You can always “earmark” areas of concern for later discussion. This modulation of anxiety is consistent with the object relations approach proposed by Kohut,10 in which emotional pain is addressed in “small, psychologically manageable portions.”
Enhance self-esteem. Virtually all patients in supportive psychotherapy suffer from low self-esteem, so it is beneficial to help them feel better about themselves. Take an active role by using positive comments and acknowledgements (“plussing”) as well as compliments when appropriate.
Most patients with low self-esteem have defects in the ability to nurture or forgive themselves (“self-soothe”). Work with patients to enhance this ability by:
- plussing where appropriate
- correcting negative self-distortions or self-reproach
- educating patients on how to both placate and reward themselves.
Some patients are unable to do this without external support from a significant other, family member, support group, or health care worker. In such cases, help the patient seek out and use supports he or she needs to provide soothing.
Strengthen coping mechanisms. In supportive psychotherapy the therapist acts as a coach, giving the patient suggestions on how to cope with difficult matters. As part of treatment, you might assign the patient homework and instruct him to practice specific coping strategies.
CASE CONTINUED: Feeling stronger
Eventually Mrs. S is able to talk in a limited fashion about childhood sexual abuse. With her psychiatrist’s encouragement, she begins to write about her feelings in a journal and exercising to help her “feel strong.” The psychiatrist often acknowledges her struggle and compliments her attempts at coping in healthy ways. After a year of supportive psychotherapy Mrs. S is better able to modulate her feelings and make decisions without feeling overwhelmed.
An option for challenging patients
Psychotic disorders. Although it may seem intuitive that psychotic conditions are a contraindication for psychotherapy, patients with schizophrenia and other psychotic disorders often benefit immensely from supportive psychotherapy. A supportive therapist’s guiding influence can help psychotic patients cope with fractured social and family life, struggles with independence, loneliness, frequent disturbances of reality, stigmatization from society, and difficulty with decision-making.
In my experience, many patients with schizophrenia benefit from reflecting on their struggles and exploring ways to cope. Also, by repeatedly spending time with patients, a supportive therapist is building credibility (internalized “good” object) that will be needed when patients experience psychosis.
During a patient’s acute psychotic episodes, you can draw on the therapeutic relationship you have established, strongly advising the patient to accept treatment when he or she is paranoid and rejecting help. In such situations, you might say, “Joe, you know me. You know that in the past I have helped you get through some tough times. You are going to have to trust me that you need this medicine now, even if you don’t want to take it.”
Borderline personality disorder. Supportive psychotherapy’s emphasis on reducing anxiety and nurturing a therapeutic relationship makes it a good treatment for patients with borderline personality disorder. The focus on adaptive skills, self-esteem, and higher order defenses—such as repression, sublimation, rationalization, intellectualization, inhibition, displacement, and humor—is particularly suitable for self-injurious and suicidal patients.11
In addition, dialectical behavior therapy is congruent with supportive psychotherapy.12 I have found it useful to let patients know I am experienced and strong enough to undergo therapy with them and can live with the chaos of their lives. This often comforts patients with borderline personality disorder, as their internal state conveys a sense of destruction not only for them but anyone close to them. From a psychoanalytic perspective, conveying a sense of safety is a core healing component of supportive therapy.13