The Nuts and Bolts of Supportive Psychotherapy

According to D.S. Werman, supportive psychotherapy has been described as the most widely used psychotherapy and the treatment provided to “the vast majority of patients seen in psychiatric clinics and mental health centers” and generally used by psychiatrists engaged in combined therapy consisting of psychotherapy and medication. However, only in recent years has it become a required element of a psychiatrist’s education.

Supportive psychotherapy has been defined as a psychotherapy designed to ameliorate or reduce symptoms, to maintain or improve the patient’s selfesteem, and to maximize the patient’s adaptive capacities. Supportive psychotherapy and expressive psychotherapy (alternatively called insight-oriented psychotherapy or exploratory psychotherapy) are on opposite ends of the psychotherapeutic spectrum or continuum. However, most psychotherapies are not at either end of the spectrum but fall somewhere in the middle and are a blend of both approaches and called supportive-expressive psychotherapies. There is a continuum from a highly supportive approach to highly expressive/exploratory psychotherapy based on the patient’s level of psychopathology and adaptive functioning. Psychodynamic or psychoanalytic concepts are the basis for both types of treatment.

The titration of exploratory techniques versus supportive interventions is based on a thorough evaluation to assess the patient’s adaptive functioning as well as structural and psychopathology levels. Structure is evaluated by assessing executive (ego) function. Decreasing levels of ego function impairment and increasing psychopathology are indications for a more supportive stance, while with increasing levels of ego functioning and lower levels of psychopathology a more exploratory psychotherapy approach can be used.

The types of interventions or techniques employed will depend on the assessment of the patient. If a more supportive approach is indicated, the techniques include alliance building, skills building, reducing and preventing anxiety, and awareness expanding. Examples of alliance building are expressions of interest, empathy, and conversational style, while examples of esteem building are reassurance, normalizing, and encouragement. Skills building includes advice, teaching, and anticipatory guidance; anxiety can be reduced by normalizing, reframing, and rationalizing techniques. Expanding awareness relies on interventions such as clarification, confrontation, and interpretation. However, interpretation is used sparingly in supportive psychotherapy, and when employed, it is used in a more general or inexact manner. In supportive psychotherapy, defenses generally are strengthened as opposed to expressive psychotherapy, where defenses are challenged so that more in-depth conflicts, feelings, and wishes become accessible to exploration.

Incorporating some techniques of cognitive-behavioral therapy (CBT) into supportive psychotherapy can make it a more integrated and useful psychotherapy. A number of techniques mentioned above, such as normalizing, anticipatory guidance, reframing, and rationalizing are frequently used CBT interventions. In addition, CBT techniques such as identifying and examining automatic thoughts, relaxation approaches, assertiveness training, and exposure treatment can all be used comfortably in supportive psychotherapy.

A more integrated supportive psychotherapy may be especially useful for patients with comorbidities, where different approaches can be applied to a wide variety of symptoms. For example, in patients with personality and relationship issues who also have depressive symptoms, a focus on relationship issues using supportive techniques and an examination of automatic self-deprecatory thoughts as employed in CBT would constitute a more comprehensive approach than using either approach alone.

An important quality of supportive psychotherapy is its highly supportive, empathic, and nonthreatening approach. This is ideal in promoting the therapeutic alliance, which depends on the establishment of a highly positive therapeutic relationship (positive transference). The therapeutic alliance can be conceptualized along the following dimensions: the affectionate bond between the patient and therapist, the agreement on the tasks and goals of the therapy, the patient’s capacity to perform the therapeutic work, and the therapist’s empathic relatedness and involvement. It is well known that the alliance is a good predictor of psychotherapy outcome; therefore, psychotherapies, such as supportive psychotherapy, that are designed to promote the alliance are generally helpful to patients.

In terms of efficacy, supportive psychotherapy appears to be useful across a broad spectrum of psychiatric and medical disorders. However, more research is needed to clarify the indications for supportive psychotherapy and how this treatment should be integrated with other psychotherapy approaches and treatment with medication. In today’s managed care environment and with more limited time that many patients allocate to psychotherapy, a supportive approach has never been more important for clinical psychiatrists.