Support or Settle?

Any experienced supervisor will recognize the red flag in the following exchange:

Trainee: My patient is stuck. She comes in every week with the same problems as always. We’re not getting anywhere.

Supervisor: What’s your treatment approach?

Trainee: Well, I was doing CBT, but it wasn’t working, so now I’m providing support.

This common supervisory issue—the therapy is making little progress, but the therapist continues to “provide support”—signals that the trainee’s therapy is in serious trouble. The decision to utilize “supportive” measures when another approach has been unsuccessful, when providing support becomes a fallback position, or when the therapist simply does not know what else to do usually means that the work is at an impasse and will ultimately fail. The problem, then, is that this kind of “support” is not supportive therapy, but rather no therapy.

True supportive psychotherapy is a legitimate treatment that has become an important element of the training process. It provides a response to the growing demands of third-party payers for cost-containment and of the mental health care community for more efficient, time-limited ways to stretch scarce resources. Supportive therapy borrows from other modalities and may include expressive, directive, and experiential techniques combined with a heavy dependence on the therapeutic alliance. It may now be the most frequently used modality. (See, for example, “The Nuts and Bolts of Supportive Psychotherapy” by Arnold Winston, Psychiatric News, June 15, 2012).

Supportive psychotherapy is a prime example of eclectic psychotherapy. As an amalgam of other therapeutic approaches, with no specific techniques of its own, it sometimes seems designed not so much to make patients better as instead to prevent them from getting worse. It may be most useful with two, widely different sets of patients: essentially healthy individuals temporarily overwhelmed by stressful circumstances and chronically ill patients with poor coping skills. For the former, it can provide the stability that allows the patient’s natural healing to occur and, for the latter, it can strengthen weak defenses and teach better coping skills. It may be employed in combination with medication management to bolster compliance and reduce comorbid illness. In light of its many applications, supportive therapy might be considered a nonspecific, that is to say, a broad-spectrum treatment.

But what about our trainee who is “providing support”? If another approach falls short, is this alternative a positive, helpful choice? No, it isn’t. When a therapist falls back on support not knowing what else to do or settles for support in lieu of continuing to work on the problems for which the patient sought treatment, bad things happen. The patient drops out of treatment or continues to meet without any further improvement. Money and time permitting, this interminable but ineffective arrangement can go on and on, sometimes for years. Sessions begin to revolve around day-to-day problems, with the occasional intercurrent crisis to ostensibly justify its continuing life. The therapist may offer “helpful comments” or allow the patient to “vent” or serve as a “sounding board” or provide a sympathetic ear or give short-term advice, but none of these tactics is likely to result in significant improvement or to resolve the problems for which the patient sought treatment. The therapy becomes an end in itself rather than a means to some ultimate benefit.

Effective therapy usually requires both a positive relationship, the therapeutic alliance, and an operational plan, the methodology selected to best meet the patient’s needs. When the therapist gives up the plan and begins to provide only support, the relationship becomes the sole reason to continue. The therapeutic alliance can, of course, promote a positive therapeutic outcome—indeed, therapy will not succeed without it—but it will not be sufficient in itself nor can it be relied on when other, more targeted efforts fail.

Rather than settle for a “supportive” strategy when treatment is unproductive and stalled, the trainee, with the supervisor’s help (or the experienced clinician who runs into the same problem) should look for the reason the therapy falters. The possible causes are many and varied. To name a few: Does the treatment plan need to be revised? Are there problems not apparent at the initial evaluation that should be addressed? Is there an unrecognized problem within the therapy, such as a transference issue? Whatever the identified reason for the stalemate may be, when it is recognized and addressed, therapeutic progress can usually resume and lead to a better outcome. ■