Journal of Social Work Practice

Psychotherapeutic Approaches in Health, Welfare and the Community

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Reflections on supportive psychotherapy in the

st
21 century

Brian Rasmussen & David Kealy

To cite this article: Brian Rasmussen & David Kealy (2019): Reflections on
st
supportive psychotherapy in the 21 century, Journal of Social Work Practice, DOI:
10.1080/02650533.2019.1648245

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JOURNAL OF SOCIAL WORK PRACTICE
https://doi.org/10.1080/02650533.2019.1648245

Reflections on supportive psychotherapy in the 21st century

Brian Rasmussena and David Kealy b

a
School of Social Work, University of British Columbia, Kelowna, Canada; bDepartment of Psychiatry,
University of British Columbia, Vancouver, Canada

ABSTRACT KEYWORDS
Supportive psychotherapy (SP) continues to be an indispensible Supportive psychotherapy;
psychotherapeutic approach for a range of mental health diag- support; psychotherapy;
noses, taught to and practiced by psychiatrists and other mental clinical social work;
relational theory
health professionals. However, confusion abounds when attempt-
ing to delineate the boundaries of its intervention strategies, its
theoretical foundation, processes of change, and distinct efficacy
as compared with other approaches—and even its definition. The
primary aims of this paper are three-fold: (1) to review the theore-
tical foundations of SP, (2) to advance a clearer identity for SP and
(3) most importantly, to incorporate contemporary theoretical
approaches to inform the practice of SP. The paper argues for a re-
visioning of SP, in order that it may endure as a viable and distinct
psychotherapeutic approach, in both modern-day practice and
research contexts. Such re-visioning includes the incorporation of
contemporary relational theory and findings from neuroscience.

Introduction
Supportive psychotherapy (SP) continues to be an indispensible psychotherapeutic
approach for a range of mental health problems, taught to and practiced by social
workers, psychiatrists, and other mental health professionals (Brenner, 2012; Douglas,
2008; Hadjipavlou, Hernandez, & Ogrodniczuk, 2015). Despite recognition of SP as
a distinct approach, it remains a ‘not well-defined unambiguous treatment’ (Budge,
Baardseth, Wampold, & Flűckiger, 2010, p. 26). Indeed, confusion abounds when
attempting to delineate the boundaries of its intervention strategies, its theoretical
foundation, processes of change, and distinct efficacy as compared with other
approaches—and even its definition. Further, supportive therapy has historically suffered
the ill-fated burden of being characterized as a lesser form of treatment, particularly when
contrasted with interpretive and more technically active treatment models (Berlincioni &
Barbieri, 2004), and unfortunately tainted as a relic of the past, inextricably linked to so-
called out-dated psychoanalytic theory and therapy (Sjoqvist, 2007). Moreover, the term
‘supportive therapy’ has been misapplied in research settings to denote non-active
treatments (Budge et al., 2010), adding further confusion to contemporary notions of
what SP is all about. Given this state of affairs, the present paper has three primary
objectives: (1) to review the theoretical foundations of SP, (2) to advance a clearer identity

CONTACT Brian Rasmussen brian.rasmussen@ubc.ca

© 2019 GAPS
2 B. RASMUSSEN AND D. KEALY

for SP and (3) most importantly, to incorporate contemporary theoretical approaches to

inform the practice of SP.
The paper begins with an attempt to define SP, followed by a historical review that offers
a contextual understanding of its theoretical grounding and emergence as a major form of
treatment. We highlight the considerable confusion that envelopes SP and various efforts to
bring clarity and distinction to this approach. What follows next is a review of empirical
research to establish SP as an effective intervention, and the challenges inherent in that
endeavor. Finally, the paper contributes a psychodynamically informed relational sensi-
bility to SP, positioning this approach broadly in a ‘two-person’ relational model, while
retaining significant theoretical elements of its origins in ego-psychology. The implications
of this theorizing for research, education, and practice—and for the future of SP—are
discussed. Methodologically, the reviews of the theoretical and empirical literature make no
claims to be exhaustive but rather were selected as representative of the significant
contributions in this area over many decades of writing.

Defining supportive psychotherapy

Defining SP is no simple task. To begin, many forms of psychotherapy arguably endorse
significant elements of psychological support, albeit lacking meaningful definitional
consensus (Berlincioni & Barbieri, 2004). Additionally, several treatments incorporate
the term ‘support’ or ‘supportive’ in their title, adding to the confusion. These therapies
include, ‘supportive therapy’ (Axelrode, 1940; Greenberg, 1986; Gross, 1968; Hollon,
1966; Pinsker, 1997; Piper, Joyce, Mccallum, & Azim, 1998; Rockland, 1992; Winston,
Rosenthal, & Pinsker, 2012), ‘supportive psychoanalytic therapy’ (Carsky, 2013), ‘sup-
portive psychotherapy’ (Frank, 1986; Kates & Rockland, 1994; Werman, 1984),
‘dynamic supportive therapy’ (Misch, 2006), ‘supportive expressive psychodynamic
therapy’ (Crits-Cristoph et al., 2008; Vinnars & Barber, 2008), ‘ego-supportive inter-
vention’ (Holman, 2011), ‘brief supportive dynamic therapy’ (Smith, 2008), ‘supportive
group therapy’ (Marziali, Damianakis, Smith, & Trocme, 2006), ‘ego-supportive group
treatment’ (Levine, 1965), and “short psychodynamic supportive psychotherapy (SPSP)
(De Jonghe, Rijnierse, & Janssen, 1994). Such ubiquitous use of the term ‘supportive’
renders it simultaneously all-applicable and vague. As the Harvard Mental Health Letter
(2004) opined over a decade ago, ‘Supportive therapy is sometimes said to be a name
for what every good psychotherapist does most of the time, often without acknowl-
edging it and without knowing how it is done’ (p. 1).
For our purposes, we define supportive psychotherapy as ‘a talking therapy that aims
to support the client’s adaptive functioning through non-interpretive interventions’. We
will expand on these ideas throughout the paper.

History of supportive psychotherapy

To understand the current standing of SP in contemporary psychotherapeutic practice is to
appreciate its historical context, in particular, its origins in psychoanalytic theory and
psychoanalysis (Sjoqvist, 2007). Briefly, in the mid 20th century, supportive psychotherapy
emerged out of practice realities that found some (if not many) clients were poorly suited to
insight-oriented psychotherapy as determined by the parameters of psychoanalytic
 JOURNAL OF SOCIAL WORK PRACTICE 3

psychotherapy or psychoanalysis proper. Such therapies relied heavily on transference

interpretations and a therapeutic stance offering limited emotional gratification. Clients
needed a capacity to endure regression while tolerating the uncovering of unconscious
psychic conflict. Accordingly, psychoanalysis required considerable ego strength, a capacity
to regulate intense affect, and make use of insight; qualities not found in many individuals
seeking therapy, then and now. Hence, SP emerged in response to individuals who were
deemed unable to benefit from the so-called ‘gold standard’ of psychoanalysis. The early
work of Robert Knight is largely credited with exposing the distinction between expressive
and supportive approaches to psychotherapy (Sjoqvist, 2007; Wallerstein & DeWitt, 1997).
While SP was clearly becoming an appropriate therapeutic intervention for many clients
exhibiting poor ego strength, it was devalued as a lesser form of treatment (Wallerstein &
DeWitt, 1997) since it lacked the interpretive mechanism of action hailed as mutative by
leading psychoanalytic scholars (e.g., Strachey, 1934). Nonetheless, some authors
(Rockland, 1992; Werman, 1984) argued that in fact SP required considerable theoretical
knowledge and a skilled technical hand.

Major proponents of supportive psychotherapy

With the book ‘The Practice of Supportive Psychotherapy’, David S. Werman (1984)
offered a major contribution to the field, advocating for an approach that he thought to
be invaluable, yet often neglected in mental health teaching. He argued that ‘supportive
therapy is not a vague alternative to insight-oriented treatment; it is a well-defined form
of psychotherapy that represents a logical application of psychoanalytic concepts to
a particular class of clients whose characteristics can usually be clearly identified’ (p. ix).
The practice of SP is distinguished from Insight-Oriented Psychotherapy, although
Werman is clear to point out that the boundary between the two is often blurred and
rarely exist in pure forms. The choice of SP is determined by a careful assessment of the
client’s level of functioning, ego strengths and ego deficits. Fundamental impairments in
reality testing, impulse control, affect tolerance, capacity for introspection, and defen-
sive structures—as well as diminished capacity for trust in interpersonal relationships—
point toward a supportive approach. In determining a supportive treatment approach,
Werman cautions that simply following a clinical diagnosis as a guide can be misleading
and limiting, since there is considerable within-group heterogeneity—as for example
with a diagnosis like borderline personality. Once SP is determined to be the treatment
approach, the goals of therapy focus on adaptive functioning with regard to current
real-life problems. Therapeutically, Werman (1984) sees the fundamental task of the SP
therapist as ‘providing the patient with an auxiliary ego and superego’ (p. 43, italics in
original). In facilitating these tasks, Winnicott’s (1965) concept of a ‘holding environ-
ment’ is evoked, denoting the therapist’s effort to spare the client from experiences of
frustration in the management of the therapeutic frame and relationship. At the same
time, the therapist’s stance is described as ‘friendly’ and contrasted with a more neutral
and reserved stance in an insight oriented psychotherapy. Such a stance appears
consistent with later views of the therapeutic relationship in SP, described at times as
‘conversational’ (Pinsker, 1997).
Writing directly to a social work audience, Goldstein (1984) offered an important
contribution to the supportive therapy literature primarily through the lens of ego
4 B. RASMUSSEN AND D. KEALY

psychology. According to Goldstein, bringing an ego-oriented perspective to assessment

and formulation allows the practitioner to consider interventions from either an ego-
supportive or ego-modifying orientation. Goldstein explains, ‘Ego-supportive interven-
tion aims at restoring, maintaining, or enhancing the individual’s adaptive functioning
as well as strengthening or building ego where there are deficits or impairments. In
contrast, ego modifying interventions aims at changing basic personality patterns or
structures’ (p. 153). However, like other attempts to make this distinction, Goldstein
notes that such differences are neither clear-cut nor easy to differentiate in everyday
real-world practice. Further, adding to the ego-supportive distinction is the use of
environmental interventions and resources to augment treatment goals and improve
the fit between the individual and the social world. Ego-supportive therapy is concep-
tualized as focusing on current behavior, the experience of a real relationship, and ego
mastery rather than insight and conflict resolution. This approach was deemed appro-
priate for a large portion of social work’s client population, particularly those eviden-
cing acute crisis, ego deficits, low anxiety tolerance and poor impulse control. Social
work contributors have emphasized the supportive therapist’s elaboration of the client’s
strengths, rendering them more available during times of crisis, and augmenting
psychotherapy with external resources in the community (Greenberg, 1986).
With a focus on treating borderline personality disorder, Rockland (1992) outlined
a supportive therapy that was clearly rooted in psychoanalytic theory. Arguing for
a psychodynamically oriented supportive therapy (POST), Rockland believed the
goals of treatment ought to be focused on adaptation and strengthening ego functions
rather than enhancing insight, particularly with individuals exhibiting weak ego struc-
ture. However, similar to others who have noted the blurred boundaries of various
therapies, Rockland (1992) accepts that ‘Actual psychotherapies are variable mixtures of
supportive and exploratory interventions’ (p. 39). In helping to support the client’s
adaptive efforts, the therapist stance is said to be more open, ‘real’, and less frustrating.
The use of interpretation is limited, particularly regarding material related to uncon-
scious mental conflict. In particular, transference is not usually interpreted unless overly
idealized or overly negative in a way that interferes with treatment. Accordingly,
resistance is generally accepted, and typically only addressed when it is maladaptive,
and regression is highly discouraged. The essential techniques include: giving sugges-
tions, advice, educating, reframing, encouragement, clarification, confrontations, and
being a model for identification (Rockland, 1992, p. 44). Rockland (1992) speculates
that the therapeutic mechanisms of supportive therapy include: non-specific effects of
the helping relationship, unanalyzed positive and negative transferences, corrective
emotional experiences, identifications with the therapist, helpful feedback loops in the
real world, and maximizing the client’s level of functioning (p. 50–52). The question of
how supportive therapy works is one that we return to later in this paper.
Pinsker’s (1997) A Primer of Supportive Psychotherapy offered a conceptual model
that is largely consistent with the views of Werman (1984) and Rockland (1992). The
goals of treatment are ‘to maintain, restore, or improve self-esteem, ego function, and
adaptive skills’ (p. 1). The therapeutic style is conversational, defenses are supported,
insight is not a major goal, and anxiety is contained. Accordingly, Pinsker’s (1997)
focus is on the supportive end of the supportive-expressive continuum, best suited for
less healthier clients.
 JOURNAL OF SOCIAL WORK PRACTICE 5

Empirical support for supportive psychotherapy

Efforts to investigate supportive psychotherapy as a distinct approach under carefully
controlled conditions have been limited. Perhaps more so than any other psychother-
apy, empirical validation of supportive psychotherapy has been hindered by inconsis-
tent definition and operationalization. Many researchers have used the term ‘supportive
therapy’ to describe an active control condition against which an experimental treat-
ment is compared. The nature of the supportive treatment in these trials is often
strikingly divergent from the approach described in clinical texts on supportive psy-
chotherapy. As an example of this divergence, one manual of supportive psychotherapy
(used in trials comparing it with CBT for post-traumatic stress disorder) contained a list
of ‘shall nots’ (Blanchard & Hickling, 2004, p. 399) that included:

(1) no teaching relaxation or anxiety-management skills

(2) no suggestion to re-engage in avoided or feared thoughts or behaviours
(3) no correction of self-defeating self-talk
(4) no correction of logical fallacies
(5) no advice regarding coping with symptoms and related issues

Prohibitions such as these render such versions of supportive psychotherapy highly

questionable with regard to their embodiment of the principles and processes of
genuine supportive psychotherapy. Indeed, Budge and colleagues (Budge et al., 2010)
illustrate several aspects by which researcher allegiance has distorted the empirical
investigation of supportive therapy. These authors regarded only one trial (Clarkin,
Levy, Lenzenweger, & Kernberg, 2007) as examining a genuine psychodynamically-
informed supportive psychotherapy. The scope of Budge et al. may have been too
restrictive: there are other examples where supportive psychotherapy has been studied
as intended to be delivered by supportive psychotherapists. It is clear, however, that any
empirical review based on the term ‘supportive therapy’ will likely lump a variety of
supportive practices—often attenuated offerings of basic care—with the kinds of clini-
cally sophisticated and disciplined versions of supportive psychotherapy that we are
discussing. We believe that any attempt to discern the empirical support for supportive
psychotherapy must begin with the recognition that the various iterations appearing
under this rubric are far from synonymous. Systematic review or meta-analysis would
thus be seriously hampered at the outset by basic definition problems.
Despite these challenges, empirical evidence for the effectiveness of supportive
psychotherapy has accumulated since Wallerstein’s landmark longitudinal research
concerning the long-term effects of psychoanalysis and psychodynamic therapies—
including supportive psychotherapy (Wallerstein, 1989). In that study, 42 clients were
followed for several years post-termination (some over a 30-year period). Supportive
psychotherapy was found to have contributed to greater improvement than expected,
and supportive mechanisms were considered responsible for a significant portion of
outcome across all treatments (Wallerstein, 1989). Since then, several research groups
have examined short-term, manualized versions of psychodynamically-oriented sup-
portive psychotherapy using rigorous clinical trial methods.
6 B. RASMUSSEN AND D. KEALY

Beginning in the early 1990s, a group of investigators based in Amsterdam

conducted several RCTs investigating De Jonghe’s 16-session Short Psychodynamic
Supportive Psychotherapy (SPSP) for the treatment of depression (Dekker et al.,
2014). Consistent with De Jonghe’s (De Jonghe et al., 1994) view of psychoanalytic
supportive psychotherapy as distinct from psychoanalysis, SPSP—viewed by its
developers as an active, change-facilitating treatment—is anchored by an overall
supportive technique. Although interpretative interventions are not proscribed, the
provision of supportive interventions is regarded as the ‘most curative factor’
(Dekker et al., 2014) in SPSP. Such interventions include the active expression of
interest in the client’s daily life, encouragement of emotional ventilation, clarifying
and normalizing the client’s feelings, and judicious advice and direct suggestions
where necessary (De Jonghe et al., 1994). A series of trials involving SPSP with or
without concurrent pharmacotherapy found at least equivalent or superior outcomes
for treatment involving SPSP compared to pharmacotherapy alone (De Jonghe et al.,
2004; De Jonghe, Kool, Van Aalst, Dekker, & Peen, 2001; Dekker et al., 2005, 2013).
A fifth trial compared SPSP to CBT for depression, finding equivalent outcomes,
though less than a quarter of clients achieved remission after these brief treatments
(Driessen et al., 2013).
A series of studies conducted by Piper and colleagues compared psychodynamically-
oriented supportive psychotherapy with interpretive psychotherapy, with particular
attention devoted to the influence of client personality variables such as quality of
object relations (QOR) and psychological mindedness (PM). The supportive therapy
examined in these studies was comprised of therapists’ interventions targeting con-
scious thoughts, feelings, and behaviours that are understood as manifestations of
underlying dynamic conflicts. Consistent with traditional models of SP, the supportive
therapy in studies by Piper and colleagues focused on helping the client develop ego-
strength through conveying understanding of the client’s difficulties, collaborating on
practical problem-solving strategies, and providing positive explicit encouragement—as
a positive transference figure—of the client’s adaptive efforts. This group’s study of
time-limited individual therapy among a heterogeneous outpatient sample—in which
matched pairs of clients (on QOR and PM) were randomized to either treatment—
found essentially equivalent benefits between supportive and interpretive therapies
(Piper et al., 1998). Supportive therapy had fewer dropouts, and clients in both condi-
tions maintained improvements at 6- and 12-months following treatment (Piper,
Mccallum, Joyce, Azim, & Ogrodniczuk, 1999). A similar design was used to compare
supportive group therapy with interpretive group therapy for the treatment of compli-
cated grief. Both treatments were beneficial, though clients with lower QOR benefitted
more from supportive therapy (Piper, McCallum, Joyce, Rosie, & Ogrodniczuk, 2001).
A subsequent trial using assignment based on QOR status also found supportive
therapy to be as effective as interpretive therapy (Piper, Ogrodniczuk, Joyce,
Weideman, & Rosie, 2007). This remained so at six-months’ follow-up (Piper,
Ogrodniczuk, Joyce, & Weideman, 2009), contributing to the researchers’ conclusion
that both supportive and interpretive therapies were valuable treatments for compli-
cated grief (Piper, Ogrodniczuk, Joyce, & Weideman, 2011)
A study by Hellerstein and colleagues compared 24 clients randomly assigned to
brief supportive psychotherapy with 25 clients randomly assigned to short-term
 JOURNAL OF SOCIAL WORK PRACTICE 7

dynamic psychotherapy (STDP; Hellerstein et al., 1998) for the treatment of personality
disorder (mostly DSM-IV cluster ‘C’). The supportive therapy examined here was based
on psychodynamic principles and considered an active therapeutic approach intended
to contribute to substantial client change. As with aforementioned models, this
approach emphasized a conversational approach whereby the therapist uses clarifica-
tion, suggestion, praise, and educational interventions. While this model of SP includes
examination of past influences on the client’s present situation, the therapist actively
works to reduce the client’s anxiety by avoiding long silences, de-emphasizing therapist
neutrality, and by not confronting or interpreting resistance and transference. In this
study, brief supportive psychotherapy achieved comparable improvements in symp-
toms, target complaints, and interpersonal problems with the more confrontative/
interpretive STDP.
Longer-term psychodynamically-oriented supportive psychotherapy has also been
examined, specifically in the treatment of borderline personality disorder. In a study of
90 clients with borderline personality disorder, clients were randomly assigned to dialectical
behaviour therapy, transference-focused psychotherapy, or supportive psychotherapy
(Clarkin et al., 2007). The SP in this trial was based on Rockland’s (1992) model and
consisted of the provision of emotional support and guidance regarding daily life problems.
The therapist encourages rational thinking, problem-solving within a relatively positive
transference, largely avoiding interpretation of transference material. The authors con-
cluded that the three treatments were ‘generally equivalent with respect to broad positive
change’ (Clarkin et al., 2007, p. 927). Although transference-focused psychotherapy was
associated with changes in more outcome domains, supportive psychotherapy was
uniquely predictive of non-planning impulsivity. A two-year group-based supportive
psychotherapy was found to produce comparable improvements as a more intensive
mentalization-based treatment, across a number of symptom and interpersonal domains
(Jørgensen et al., 2013). These gains were maintained at 1.5 years post-treatment, with no
significant differences between treatments (Jorgensen, Freund, Boye, Anderson, & Kjolbye,
2014).
Other structured versions of SP, with less of an explicitly psychodynamic under-
pinning, have also been examined research trials. Markowitz and colleagues developed
a 16-week brief supportive psychotherapy (BSP; Markowitz et al., 1995), which has been
utilized as an active control condition in trials examining interpersonal psychotherapy
(IPT) and cognitive behavioural analysis system of psychotherapy (CBASP). In line with
the review by Budge et al. (2010), the consideration of BSP as a genuine form of
supportive psychotherapy may be controversial, since ‘specific interpersonal, cognitive,
behavioural, and psychodynamic interventions were strictly proscribed’ (Kocsis et al.,
2009, p. 1180). Such constraint would be untenable to many supportive psychothera-
pists, who often recognize specific IPT and CBT interventions as part of their technical
arsenal (De Jonghe et al., 1994). Among a sample of 32 HIV-positive clients with
depression, those receiving BSP nevertheless improved, though not as much as those
receiving IPT (Markowitz et al., 1995). A pilot RCT of IPT and BSP for depressed
women struggling with infertility also found significant improvements in depressive
and anxiety symptoms, though with greater effects for those who received IPT—as well
as in social functioning at both post-treatment and six-months’ follow-up (Koszycki,
Bisserbe, Blier, Bradwejn, & Markowitz, 2012). A trial examining treatment of maternal
8 B. RASMUSSEN AND D. KEALY

depression (Swartz et al., 2016) found that women who received BSP (n = 83) achieved
similar improvements in depressive symptoms and functioning as those who received
IPT (n = 85). These gains were maintained through the one-year follow-up period, and
children whose mothers received both therapies also demonstrated improvement in
depressive symptoms (Swartz et al., 2016).
A model of supportive psychotherapy based on Carl Rogers’ principles of empathic
listening and positive regard produced comparable outcomes as CBT in a trial for
clients with chronic post-traumatic stress disorder (Cottraux et al., 2008). As with BSP,
many real-world practitioners of supportive psychotherapy would object to this study’s
requirement that supportive therapists ‘ignore or refuse requests for advice, directive
behaviors, homework, behavioral experiments or exposure to feared situations’
(Cottraux et al., 2008, p. 103). Clients who completed this constrained version of
supportive psychotherapy (n = 9) nevertheless fared as well as those in the CBT
condition (n = 16). Similarly, a trial of year-long versions of these therapies for
individuals with borderline personality disorder found no differences at post-
treatment and minimal differences at one-year follow-up (Cottraux et al., 2009).
Taken together, these efforts provide an initial base of empirical evidence for the
efficacy of supportive psychotherapy. Interestingly, even supportive therapies developed
to serve as a control for an experimental treatment—with the latter expected to
markedly outperform the supportive therapy—seem to fare well with regard to client
outcomes. Thus, even a ‘handcuffed’ supportive psychotherapy—devoid of the full
range of supportive interventions—may be facilitative of significant improvements
across various disorders, with durable outcomes that are fairly comparable to other
treatments. Indeed, in a meta-analysis of 31 trials of ‘non-directive supportive therapy’
for depression, Cuijpers and colleagues found that various iterations of supportive
treatments—most not based on sophisticated theoretical frameworks—yielded equiva-
lent effects as CBT after accounting for researcher allegiance (Cuijpers et al., 2012).
Such findings may be heralded as evidence of non-specific therapeutic factors—the
foundation upon which supportive psychotherapy is built. Unfortunately, however, they
fall short in contributing to a deeper understanding of how supportive psychotherapy
works. Perhaps as it gains traction among researchers as a legitimate and effective
treatment in its own right—rather than a non-specific control—efforts will be under-
taken to examine the processes and mechanisms of change involved in supportive
psychotherapy.

Supportive psychotherapy in light of the relational turn

While it is generally accepted that most forms of talking therapy utilize supportive
elements to advance their particular goals, the question remains: Can supportive
psychotherapy continue to exist as a distinct therapeutic approach in the 21st century?
If so, what theoretical, empirical, and educational reinforcement is required to sustain
its future? In large measure, we are content to define psychodynamically informed SP in
historically traditional ways by what the clinician actually does and how the clinician
thinks about their work. Clinicians who purposefully focus largely on the here-and-now,
attempt to improve mastery, avoid transference interpretations, are directive and con-
sider environmental modifications, can be thought to be operating from a supportive
 JOURNAL OF SOCIAL WORK PRACTICE 9

model. Such clinicians are also mindful of the ways psychodynamic theory informs any
deviations from this approach that frequently occur within sessions and over the course
of longer-term treatments.
Nonetheless, we argue that in order for SP to thrive in the 21st century, the
incorporation of contemporary psychodynamic theories is required. To date, SP has
been theoretically situated in a ‘one-person’ model, in contrast with contemporary ‘two-
person’ models (Eagle, 2011). Consistent with this so-called ‘one-person’ model, the
client in SP is assessed as having ego deficits (e.g., affect regulation, impulse control,
identity diffusion; Goldstein, 1984) that are considered to preclude them from making
effective use of uncovering and interpretive interventions. Through active measures the
therapist ‘lends an ego’, problem-solves, and helps to reset the equilibrium of the client,
whose difficulties tend to be attributed to structural deficits that may be exacerbated by
environmental constraints. Consequently, therapeutic gains in supportive psychother-
apy are largely conceptualized in terms of restoring adaptive functioning. The tradi-
tional view of SP sees therapeutic action as comprised of the therapist’s direction and
encouragement toward the client employing more rational thought processes and
engaging in healthier behaviours. Without question, there is considerable value in
this formulation and consequent therapeutic stance, however it risks viewing the client’s
problems as solely a function of their internal world, making them an object of study
and therapeutic intervention. Hence, the client’s subjective experience of the therapeutic
encounter (and indeed the therapist’s own subjectivity) recedes from attention as the
more obvious behavioural manifestations take center stage, potentially negating impor-
tant relational and intersubjective dynamics. The implications of a ‘one-person model’
stance, while helpful, limit our conceptual understandings of this therapeutic encounter,
mechanisms of change, and approaches to research.
Applying a contemporary relational theoretical approach to SP provides the therapist
with a conceptual frame to consider the ‘holding’ elements (Winnicott, 1965), attach-
ment qualities (Fonagy, 2001), mutual regulation (Cozolino, 2014), enactments (Stark,
2000), mentalization (Bateman & Fonagy, 2012) and neurobiological mechanisms of
change (Schore, 2012). Space does not allow for a full expansion of these complex
theoretical ideas, but the point is that SP, however defined, or limited conceptually by
a ‘one-person’ model, is fundamentally experienced in relational ways. Understanding
SP in these terms provides a contemporary, evidenced-informed, broad theoretical
framework for making sense of the therapeutic process and healing properties of this
approach. Conceptualizing the therapeutic process of SP from a relational stance shifts
the therapist’s attention from a sole focus on the client’s deficits to an appreciation of
the therapist’s contribution to the positive and negative moments in the treatment
process.
Relational theory also shifts our conceptualization of therapeutic action. Traditionally,
interventions in a SP mode were more notable for what they avoided doing: genetic
interpretations, transference interpretations, confrontations, challenging of defenses, and
focus past traumatic experiences. Understandably, this left new and novice therapists to
wonder just what it is they were supposed to be doing in SP. Were they simply to prop up
these fragile and vulnerable individuals? Now, bolstered by extensive psychotherapy
research that points toward the role of relational factors accounting for successful out-
comes, we are more confident in the power of the therapeutic relationship to effect
10 B. RASMUSSEN AND D. KEALY

change. This is not to say that a therapist offering SP need only provide warmth,
acceptance, and validation. Experienced therapists everywhere know all too well the
limits of this stance, particularly when working with clients who suffer from complex
conditions such as personality disorders, dissociative and complex trauma disorders, and
co-occurring addiction and mental health disorders. Hence, from a technical perspective,
SP must be conceptualized as an active treatment that is relationally nuanced, in contrast
to the stereotype of SP being ‘hand-holding’. Indeed, the casting of SP as a kind of one-
size-fits-all delivery of basic psychotherapeutic ‘common factors’ is perhaps the greatest
affront to a contemporary, evolving SP. Relational processes are far from uniform across
individual clients and therapy dyads. While foundational to supportive therapy, the
provision of listening, empathy, acceptance, and support may function as pathways of
therapeutic action in highly idiosyncratic ways across clients and over time within
individual therapeutic dyads (and, for that matter, in supportive therapy groups). For
the relationally-oriented supportive psychotherapist, the question is not whether such
interventions will be therapeutically useful, but how and in what iteration for this
particular client. Ideally, the supportive therapist draws upon an evolving formulation
of the client’s therapeutic capabilities and needs—while being attuned to the client’s
sensitivities—to discern the ways in which this particular individual ought to be listened
to, spoken with, and supported.

Specificity and intersubjectivity in supportive psychotherapy

From a contemporary relational perspective, SP offers more than ‘non-specific’
aspects of the helping relationship. Rather, the therapeutic relationship—including
components such as the alliance, holding environment, and corrective emotional
experience—may be adjusted according to the phase of treatment and the client’s
therapeutic needs and abilities. Therapists may, for example, accept and accommo-
date an intimacy-averse client’s reluctance to form an attachment bond in the
therapeutic relationship, while inferring the need to develop this ability as an
important treatment goal. Rather than attempt to interpretively address the client’s
avoidant attachment style, the therapist might gradually titrate expressions that
reflect a deepening commitment within the therapy relationship—potentially con-
tributing to eventual changes in the client’s attachment orientation. By the same
token, clients who evince an anxious, hyperactivating attachment style may benefit
from an initial engagement that reassures of the therapist’s availability, with incre-
mental steps taken by the therapist to promote the client’s tolerance for separation
(Mallinckrodt, 2010). In this manner, the supportive therapist may continually infer
the particular relational needs of the client – those that foster optimal development
for this individual, at this point in time – and tailor the treatment accordingly.
Research demonstrates that the provision of responses that hew closely to the client’s
inferred ‘plan’ tends to result in immediate signs of progress (Silberschatz, 2017).
Moreover, far from being unidirectional, with the therapist determining what is or is
not optimally therapeutic, the client may ‘coach’ the therapist by indicating clues as
to the kinds of relational responses that would advance his or her development
(Bugas & Silberschatz, 2000). Both participants thus collaborate in an endeavour that
sees the prioritization of the client’s responsiveness needs (Bacal & Herzog, 2003)
 JOURNAL OF SOCIAL WORK PRACTICE 11

unfold within a secure therapeutic relationship. From an attachment perspective, this

security – and the continual honing of responses to fit the client’s needs – may be
sufficient to foster the very outcome that supportive psychotherapy was not intended
to produce: psychodynamic insight and, potentially, structural change. Indeed, con-
temporary attachment theory suggests that the ‘safe haven’ and ‘secure base’ func-
tions provided in a supportive therapy relationship may contribute to the client’s
development of reflective functioning and enhanced sense of subjectivity (Allen,
2012; Eagle, 2017), particularly as she increasingly finds herself represented—through
the therapist’s empathic responses—in the mind of the therapist.

Supportive therapy at the crossroads

Supportive therapy might be said to be facing a kind of identity crisis. Does SP
accept the status bestowed upon it as a control-condition-like therapy, to represent
basic therapeutic activities presumed to be common across all treatments – or worse,
will it become further misidentified as an inert and minimally effective approach?
Will it remain a less-potent counterpoint to interpretive psychotherapies? Or can it
expand and continue in its evolution, integrating contemporary ideas about rela-
tional mechanisms of action? There is some risk that an affirmative answer to the
latter question might obviate the need for a distinct entity known as supportive
psychotherapy. After all, it could be argued that there is no such thing as either an
interpretive or supportive therapy – only ever-shifting points on a continuum
between these heuristic signposts. Indeed, some contemporary approaches to the
teaching of psychodynamic psychotherapy explicitly frame the latter as a continual
navigation of interventions that either support or uncover (Cabaniss, 2016), depend-
ing upon what is indicated for the client at any given juncture. We regard these as
important questions for SP, and make no claims as to how they might be answered
at this point in time. One could say that SP is at a crossroads in both its conceptual
development and position among the various psychotherapies. At the same time,
however, SP may not even be on the road at all with regard to dissemination as an
active treatment approach. There is some risk that the ascendency of specific, ‘brand
name’ therapies may reduce people’s interest in learning – and mastering –
a nuanced and robust supportive therapy. This is problematic, not merely for the
sake of tradition, but for the benefit of clients who may be better helped by an
unstructured, open-ended, and (largely) non-interpretive approach. Such clients
clearly exist. Given aggregate evidence suggesting near-equivalent effectiveness with
structured and specialized psychotherapies (Cuijpers et al., 2012), more should be
done to ensure these clients gain access to SP. It is thus imperative that efforts are
undertaken to preserve and promote SP among new generations of clinicians, and
that serious research efforts continue to explore the effectiveness and mechanisms of
action in SP for particular types of individuals and problems. We speculate that such
research may find much in the way of nuanced, intersubjectively-determined respon-
siveness, at the heart of good supportive psychotherapy.
12 B. RASMUSSEN AND D. KEALY

Disclosure statement
No potential conflict of interest was reported by the authors.

Notes on contributors
Brian Rasmussen, PhD, RSW is an associate professor in the School of Social Work at the
University of British Columbia, Okanagan Campus, Kelowna, BC, Canada.
David Kealy, PhD is an assistant professor in the Department of Psychiatry, University of British
Columbia, Vancouver, BC, Canada.

ORCID
David Kealy http://orcid.org/0000-0002-3679-6085

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