What is Supportive Psychotherapy?

Supportive psychotherapy is a kind of therapy most physicians can offer their patients. It aims to
improve symptoms and maintain, restore or improve self-esteem and skills. In formal therapy sessions,
supportive psychotherapy may involve examination of relationships (to the therapist and others) and
examination of patterns of emotional response or behavior. In less formal settings such as a primary care
office, supportive psychotherapy may mean an expression of interest, attention to concrete services,
encouragement and optimism.
There are many types of "flavors" of psychotherapy, many of which are effective. Effective therapies
sometimes seem radically different but have a common element among them that makes them effective:
the therapeutic alliance. The therapeutic alliance is the connection that the patient feels with the
physician, as well as the patient's belief that the physician is aligned with the patient's goals, has respect
for the patient and holds the patient in positive regard. It appears that a very good therapeutic alliance is
one of the strongest predictors of good outcome from many kinds of treatments, including medication
treatment of depression.
An important element of the supportive psychotherapy relationship is that it exists solely to meet the
needs of the patient. The physician's gratification must come from professional satisfaction and a job well
done and not from the patients gratitude or from the patient being an audience. Similarly, treatment
planning considers what the patient wants to accomplish. Boundaries are another important consideration.
Boundaries are best thought of as staying within the professional role. The professional physician does not
advise the patient on how to vote, where to vacation or how to decorate a bedroom as these are private or
personal opinions. The interaction between the patient and the physician may be friendly but the two
individuals do not become friends. Physical canted is of course prohibited.
One model for a successful supportive therapist is that of a "good parent." (Misch 2000). The physician
takes on many parental roles including comforting, soothing, encouraging, containment, limit setting and
confronting self-destructive behaviors. This role also includes encouraging growth, autonomy and self-
sufficiency.
Supportive psychotherapy addresses only problems and conflicts that the patient is aware of. Other types
of psychotherapy rely on less direct measures, such as identifying unconscious conflicts. Supportive
psychotherapy looks at abstract entities such as defense mechanisms only when they seem maladaptive.
Techniques of Supportive Psychotherapy

Praise

Reframing

Reframing involves looking at something in a different light or different angle. Reframing can provide a
welcome new way of looking at things.

Language

Careful use of language might boost efforts to supped a patient's self esteem. Example of language that
might be experienced as critical or confrontational are "I'm trying to get you to understand" and questions
that begin with the words "Why…?" or "Why didn't you…?" These phrases are often experienced as attacks
or rebukes. Alternatives to "Why?" are phrases such as "Can you explain how…?" or "Was there something
about… that made you…?" (Pinsker 1997). Another practice which increases the positive relationship with
the patient is choosing questions that elicit a positive response rather than a negative response. For
example, it is better to ask an obese person "Do you find it difficult to exercise," than to ask "Do you like
exercise?" It is better to ask the general open ended question than a closed question whenever passible.
Targets of Supportive Psychotherapy

Self Esteem

Change

Daily Life

For patients who are functioning at a low level, the physician therapist can ask about their dally routine as
a way of finding out about opportunities for improving adaptive skills. It would be useful to know how the
patient understands his or her condition and what feelings are related to that.
Physician: It would really help me understand your situation if you reviewed with me everything you do
from the time you get up in the morning until you go to bed.

Relationships

Relapse Prevention

For patients with history of alcohol or drug abuse, relapse prevention is an important role for the
supportive physician. Topics for the therapeutic conversation in these patients include:
1. Identification of high risk situations
2. Strategies for dealing with high risk situations
3. Coping with negative emotional states
4. Coping with interpersonal conflict
5. Coping with social pressure
6. Identifying relapse
7. Anticipatory planning for dealing with relapse
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GOALS OF TREATMENT

 The aim in supportive therapy is to reduce or relieve the intensity of manifest and presenting
symptoms, distress or disability, and to reduce the extent of behavioral disruption caused by the
patient's psychic disturbances.
 The goal is to improve the patient's adaptation by whatever means are available and to focus the
therapy at the level of manifest stress or disability.
 In some instances the hope is for significant improvement; but in some cases the goal may be to
prevent further disruption and maintain status quo; or even primarily to help the patient remain
outside of a hospital.

THE INDICATIONS FOR TREATMENT

Across the entire spectrum of psychiatric disorder, the majority of patients who present themselves for
treatment are seeking prompt symptomatic and behavioral relief, and thus want supportive and manifestly
symptom oriented psychotherapy.

 These include individuals whose complaints or difficulties are those of recent origin. The patient
may be in a temporary crisis or have been exposed to relatively significant and unresolved trauma,
grief reaction or other kinds of interpersonal life experience or events.
  Their interest may be predominantly in immediate and short-term symptom relief.
 Others may have more chronic, disabling, and severe forms of psychopathology with limited
capacities for effective interpersonal or social adaptation.
 Some may be individuals for whom a relatively extensive therapeutic relationship is necessary
before they can establish a sense of trust; or
 they may be people whose psychopathology makes their capacity for frustration or delay more
limited; or their ability for reality testing more questionable.
 Individuals who are flooded with unstable affects or people for whom affective experience is
distinctly threatening and unavailable may do better in supportive forms of therapy.
 Supportive therapy is also usually indicated for people who have difficult, unstable, or limited
interpersonal relationships;
 for those who are not introspective or curious about themselves and their psychological
functioning;
 or for those whose interest is predominantly in symptomatic change and whose capacity for self-
initiating behavior is limited.
 Patients who in the past have suffered major psychotic episodes or required long periods of
hospitalization are usually candidates for supportive treatment.
 Patients for whom exploratory or expressive psychotherapy seems to be the treatment of choice
are distinguished by the following characteristics: They are aware that the difficulties arise primarily
within themselves (rather than blaming others). They are curious about themselves and have a
willingness to work to understand themselves and resolve some of their disturbances at a definitive
level. They have a basic capacity for trust in people and are able to tolerate anxiety, depression and
other unpleasant affects and to work towards long-term or difficult goals. They have the potential
capacity for introspection and psychological awareness, are capable of entering into a therapeutic
alliance and are willing to tolerate the delays, distress or uncomfortable awareness that exploratory
psychotherapy produces. They are capable of continuing to function in their chosen role in life
while undergoing the therapeutic experience. They have access to affective experience and are
seeking some form of basic personality change. Their difficulties and symptoms are sufficiently
severe to warrant the investment of time and money; and their disability or symptoms are
relatively stable. The reality of their life experience supports the exploratory psychotherapy at
whatever intensity and duration the therapist and patient agree are necessary. They usually do not
require hospitalization and they have a reasonably stable social support system. None of these
qualities is absolute, and patients who lack some of these capacities or qualities may still be treated
by exploratory methods.

THE STRATEGY OF THE THERAPEUTIC PROCESS

 The strategy in supportive psychotherapy focuses primarily upon conscious problems, symptoms,
thoughts, feelings, and memories.
 Affects already consciously experienced by the patient should be expressed and dealt with, but
unconscious conflict, affect responses, and mental processes should be left unconscious.
 The therapeutic relationship should be maintained at a positive level of rapport with deeper
transference responses remaining unconscious and out of the patient's awareness.
 The unconscious transference relationship, however, can be used to foster the therapeutic goal.
Negative transference is discussed early so that it can be dissipated as promptly as possible, and so
 that the patient experiences the therapist as comfortable with the hostile feelings. The therapist
actively participates in establishing goals and offers a variety of transference reinforcements and
responses to encourage the patient to achieve them.
 Conflicts and interpersonal relationships that are already conscious and recognized by the patient
are dealt with in an active and continuing fashion, the therapist often using him/herself as a model
for coping with such problems.
 Those of the patient's defenses that are useful and acceptable can be strengthened and
acknowledged; if the defenses are maladaptive, new ones are suggested.
 The therapist may frequently intervene in active, directive, and judging ways and may use
him/herself as a model for values and information.

THE TACTICS OF THE THERAPEUTIC PROCESS

Whereas the concept of strategy involves the overall plan in broad conceptual terms, tactics involve the
specific individual interventions or therapeutic activities used by the therapist. As much as possible, the
tactics should be compatible with and reflect overall strategy; it is through the specific tactical
interventions that the strategy is ultimately carried out. If persistently supportive tactics are used in an
expressive psychotherapy or expressive tactics are used in supportive therapy the results may be confusing
or lead to disruptive therapeutic impasses. The following are some of the major tactical issues that
separate these two forms of psychotherapy.

1.The Structure of the Treatment Situation: In expressive psychotherapy it is usually better to establish a
regular and sustained therapeutic situation with prescheduled times, constant duration of sessions,
method of payment, rules of confidentiality, etc. In supportive psychotherapy,

 flexibility can be considerably greater.

 Sessions may be briefer or longer depending on the needs and comfort of the patient;
 at times patients may need more or less frequent sessions;
 the setting may be more variable;
 hospital care may at times be necessary;
 methods of payment can be flexible in keeping with the personality of the patient;
 brief sessions (i.e. twenty minutes) foster conscious reporting and discourage introspection;
 interrupting a session may be helpful if the patient feels "finished" for today; etc.

2. The Activation of the Transference: To activate and maintain conscious awareness of transference
experience and fantasy in the patient, the therapist has the following techniques to use: maintenance
of relative personal anonymity; delaying manifest feedback or correction of transference, at least until
elaboration of the transference experience has occurred; allowing oneself to be used for transference
distortion by the patient without personal need for correction; interpretation of defenses against
awareness of the transference; interpretation of the content of the transference experience as
appropriate; maintaining an interest in transference phenomena; maintaining the frame of the
therapeutic situation, which includes appropriate abstinence toward gratification of transference
wishes; scheduling sufficient frequency and duration of therapeutic sessions. Tactics for maintaining
the transference at dilute and unconscious levels include: offering feedback promptly; correcting
transference distortions as soon as they occur; offering appropriate personal information and opinion;
offering reality information about changes in the frame to reduce transference distortion or fantasy in
the patient; maintaining the patient's defenses against awareness and content of transference feeling
 or wishes. Negative transference is discouraged by early explanation and interpretation, and by
avoidance of frustration as much as possible

3. Levels of Consciousness: In supportive psychotherapy

 the focus is on those issues that are already conscious for the patient, and attempts to reduce
defenses or to bring previously unconscious material to awareness are not encouraged.

4. Identification with the Therapist: I n expressive psychotherapy identification by the patient with the
therapist's attitude of curiosity, willingness to suspend immediate judgment, and capacity to discuss any
topic will enhance the therapeutic alliance. I n supportive psychotherapy

 identification with the therapist is encouraged, inasmuch as the therapist, in all likelihood, will be a
more stable, mature, and capable model for the patient than had been the individuals with whom
he/she has identified in the past.
 To this end the therapist may provide personal information and responses, may advise or suggest
ways of resolving problems, may encourage imitation of the therapist's judgment and values, and
may provide active alternative understanding of situations.
 I n this way the therapist provides an active teaching parental figure from whom the patient learns
to adopt new methods of adaptation.

5. Management of Resistance and Defense : I n expressive psychotherapy the therapist searches for
defenses and resistances against awareness or change that can be manifestly and specifically interpreted. I
n supportive psychotherapy

 defenses are for the most part unchallenged and are maintained or even strengthened to promote
more comfortable or solid adaptation to otherwise unexpressed or unacceptable conflict.
 If the resistances and defenses used by the patient threaten the patient's external adjustment or
the therapeutic relationship, new and substitute defenses are suggested and are encouraged to
take the place of the disruptive ones.
 But in essence defenses are respected and are maintained or reinforced by the therapist.

6. Catharsis and Abreaction: I n both forms of therapy, affective experience, expression of emotional
responses, and the reliving of trauma are encouraged and accepted. The biggest distinction between the
two forms is that in supportive therapy

 those emotional responses and affects associated to already conscious memories or traumata are
encouraged, and are then responded to in whatever way seems appropriate.

I n expressive psychotherapy, memories and affects not yet conscious are sought through interpretation of
defenses; memories and associated affects that are already conscious are interpreted and understood in
terms of less-than-conscious sources, meanings, and effects.

7. Adaptation to the Patient's Character Organization: I n supportive psychotherapy,

 the therapist seeks to intervene in ways familiar and compatible with the patient's overall character
structure, thereby striving to avoid confrontation or stress in terms of how the patient
characteristically interacts in various situations. For example, if the patient has an obsessional type
of character structure, the therapist's interventions might include a cognitive and intellectualized
 style; if the patient is passively dependent, the therapist might offer advice and other forms of
gratification of dependent wishes; if, conversely, the patient maintains reaction formation against
dependency, the therapist might emphasize the patient's independence and avoid active advice.

8. Management of Regression: I n supportive psychotherapy

 it is usually important to minimize regression, or to reverse it where possible, or avoid promoting
further regression through the therapist's behavior, interventions, or interactions.
 To this end the therapist actively promotes secondary-process reason and logic;
 correction of irrational fantasy;
 correction of distorted affective or transference experience;
 emphasis on reality testing; and reinforcement of movement in the direction of maturation or
reversal of regression.

9. Reinforcement : I n supportive psychotherapy

 the transference relationship is used (rather than analyzed) to achieve whatever goals have
been set.
 To this end appropriate symbolic gratification of an unconscious transference wish or fantasy is
offered by the therapist in response to the patient's movement toward desired behavior. I n
keeping with learning theory, any response that will tend to promote the behavior being sought
will be appropriate to the treatment situation.
 This may occur at various appropriate levels ranging from a vocal sound, nod or smile, through
signs of increased interest, to direct verbal praise, to expressions of the therapist's affective
enjoyment of the patient's progress.
 I n inpatient settings this can include such things as a token encomium for severely ill patients
for whom a concrete sign of approval is required. For those patients manifesting self-punitive
patterns or driven by feelings of guilt the transference wishes may suggest that appropriate
reinforcement by the therapist involves a somewhat demanding, gruff and critical attitude and
an avoidance of praise or positive feeling. I n that way the patient's needs for punishment can
be focussed into the therapy relationship, aggression can be externalized toward the therapist,
and the patient's need to act out with others can be reduce.
10. The Use of Therapist as Alter Ego : The therapist in supportive therapy may at times serve as an
alter ego when the patient is unable to carry out a particular activity, intervention, effort, or pattern
of behavior to satisfy or fulfill his or her needs.
 I n such a situation, the therapist (or therapist's agent) might act for the patient by
intervening in various situations with people with whom the patient feels unable to
maintain or establish his/her own interests.
 I n this way the therapist may help to solve some of the problems the patient has been
unable to resolve, e.g., intervening with employers, family members, children, agencies,
etc.
 The therapist helps to reduce the intensity of stress that the patient experiences, and may
simultaneously present a model of how one can go about resolving such problems, thereby
promoting a pattern of identification with the therapist's methods
11. The Use of Medication:. I n supportive psychotherapy
 medication is much more commonly and frequently used as an adjunct in the control of
symptoms and the alleviation of distressing behaviors.
 12. Insight: I n expressive psychotherapy, self-awareness and insight into the nature of one's own
emotional experience, personality organization, and characteristic methods and modes of
adaptation are part of the process; and the goal of achievement of insight by the patient at an
emotional, as well as a cognitive, level is an important element in the therapeutic process.. I n
supportive psychotherapy,
 insight is considered less important and mainly reflects understanding that is already
conscious in the patient.
 Such understanding is predominantly organized in keeping with process logic, rational
thought, and reasoning.
 Understanding of deeper, underlying, or early-childhood experiences, fantasies, or
expressions, is not sought, and even the acquisition of insight is usually accomplished within
the defensive organization that the patient has established.
 Insight may provide an intellectualized explanation or may provide a more effective defense
in coping with conflict, but it is not one of the major goals of treatment.
13. Termination of Psychotherapy: I n supportive psychotherapy,
 the aim is more to consider the termination of treatment an interruption in the therapeutic
contact, but to maintain a sense of the continuity of the helpful therapeutic relationship, and of
the therapist's continuing interest in and availability for the patient in the future.
 To this extent the structure of the termination process is arranged to minimize the stress and
loss, as well as minimize the impact which this element of the treatment relationship has upon
the patient's adaptation
 Active encouragement and reassurance are offered, and efforts at continuing the sense of a
relationship after the interruption occurs are encouraged.
 The patient may consciously experience sadness, uncertainty, and anxiety about the future
without the therapy, and these reactions should be addressed openly. But their discussion is
limited (in keeping with the overall strategy) to those responses that are already conscious; and
correction of transference fears, continuing expression of interest, acceptance of small gifts,
etc. are all techniques whereby the relationship can be sustained in the patient's mind as
ongoing and continuing

14. Evaluation of Treatment Results : Whatever evaluation of the success of therapy is undertaken at the
end of the treatment process, it must be done in keeping with the original goals that were set and perhaps
modified during the course of the therapeutic experience. Therefore, the mere relief of symptoms or
modification of behavior without underlying significant personality modification, might not be adequate
for a positive assessment of expressive psychotherapy, but it might be a sign of success of a supportive
psychotherapy. I n other words, the assessment of results needs to be done by keeping in mind what the
original aim of the treatment experience was. A major issue in assessment is the question of how lasting
the therapeutic progress is. Adequate assessment requires a significant interval after termination has
occurred.