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5 keys to good results
with supportive psychotherapy
Evidence-based technique
gains new respect as
a valuable clinical tool
upportive psychotherapy began as a second-class
® Dowden Health Media
treatment whose only operating principle was
1
S“being friendly” with the patient (Box, page 28).
2
Copyright
Critics called it “simple-minded” and sniffed, “if it is
or personal use only
F
supportive, it is not therapy…if it is therapy, it is not
3
supportive.”
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,
page 31).4
To help you make good use of supportive psycho-
therapy, this article describes its evolution and: WELLS
• evidence that demonstrates its effectiveness LEIGH
• 5 key components for clinical practice ©
2007
• how to use it when treating challenging patients.
John Battaglia, MD
Medical director
A proven treatment Program of Assertive Community Treatment
Clinical associate professor
Eff ective long-term therapy. Much research on sup- Department of psychiatry
portive psychotherapy comes from studies in which University of Wisconsin Medical School
supportive psychotherapy was included as a “treatment Madison, WI
as usual” comparison. In an extensive longitudinal
study, for example, the Meninger Psychotherapy Re-
search Project examined 42 patients receiving psycho-
analysis, psychodynamic psychotherapy, or supportive
5
psychotherapy over 25 years.
Despite the institutional expertise in psychoanalysis
and expressive psychotherapy, patients in supportive
psychotherapy did just as well as those receiving the Current Psychiatry
other treatments. Researchers found that each therapy Vol. 6, No. 6 27
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Box used supportive psychotherapy simply en-
A supportive approach couraged patients to ventilate their feelings
may work when expressive and discuss problems. Supportive thera-
psychotherapy fails pists were instructed to be nondirective
and avoid confrontation unless the patient
arly psychotherapy consisted of proposed it.
Edirective methods by which Charcot, Both therapies combined with imipra-
Supportive Freud, and others “suggested” that patients mine produced similar rates of moderate
psychotherapy rid themselves of symptoms while under to marked improvement in patients with
hypnotic trance. Benefi cial effects were with supportive
agoraphobia (85% to 100%
sometimes immediate and dramatic but therapy, 76% to 100% with behavior thera-
rarely lasted. py). For patients with mixed phobias, 71%
Dissatisfi ed with directive techniques, to 100% improved moderately or markedly
clinicians developed psychoanalytic with supportive therapy compared with
principles and expressive psychotherapy, 88% to 100% with behavior therapy. Among
which emphasizes analyzing transference
Clinical Point and uncovering unconscious thoughts, patients with simple phobia, 72% to 86%
feelings, and motivations. Although experienced moderate to marked improve-
AA ccoonnvversaersationaltional expressive psychotherapy became ment with supportive therapy, compared
ssttyleyle allo allowsws gr greeaatteerr popular, many patients—especially those with 87% to 93% with behavior therapy.
with severe mental illness—were deemed
sspontaneitpontaneityy andand unsuitable candidates or failed to improve. Improving personality disorders. Sever-
ccrreeaattivitivityy inin solvingsolving These patients were relegated to al studies examined a form of supportive
pprrooblemsblems supportive interventions, which initially psychotherapy that used a manualized,
were vaguely defi ned methods to reduce structured protocol for treating higher
anxiety and provide encouragement. functioning patients who traditionally
Therapists required little or no specialized have been treated with expressive psy-
training to provide supportive therapy and chotherapy. The protocol used a conver-
did not expect patients to make character
(or structural) change. Surprisingly, sation-based, dyadic style to improve
many patients improved despite vague self-esteem and adaptive skills through
therapeutic guidelines. data-based praise, advice, education, ap-
Source: Reference 1 propriate reassurance, anticipatory guid-
ance, clarification, and confrontation.
carried more supportive elements than Under these reproducible conditions,
was intended, and supportive elements ac- supportive psychotherapy showed good
counted for many of the observed changes. efficacy compared with dynamic thera-
They concluded that: pies for patients with depressive, anxi-
• thinking of change in terms of “struc- ety, and personality disorders.
tural” vs “behavioral” was not useful A review of studies from 1986 to 1992
• change did not occur in proportion to found that supportive psychotherapy was
resolving unconscious confl ict. effective for a variety of psychiatric and
medical conditions, including schizophre-
Combating phobias. A study of behavior nia, bipolar disorder, depression, posttrau-
therapy for treating phobias had similar matic stress disorder, anxiety disorders,
results.6 Patients with agoraphobia, mixed personality disorders, substance abuse, and
phobia, or simple phobias were treated stress associated with breast cancer and
with behavior therapy alone, behavior 9
back pain.
therapy plus imipramine, or supportive
psychotherapy plus imipramine for 26 CASE STUDY
weekly sessions. AA neganegativtivee experienc experiencee
Therapists in the behavior therapy group Mrs. S, a 32-year-old grant writer, is referred to
used a manualized, highly structured treat- a psychiatrist by an emergency department
Current Psychiatry ment protocol that included in vivo desen- physician after she cut herself following an
28 June 2007 sitization and homework. Therapists who argument with her husband. She has chronic
continued on page 31
continued from page 28
Table 1
Diff erences between expressive and BROKEN
supportive psychotherapy
Expressive Supportive
Component psychotherapy psychotherapy
Treatment goal Insight Reduce symptoms PROMISES
Therapist style Opaque Conversational
(“real”)
Transference Examine Nurture positive
transference
Regression Enhance Minimize
Unconscious Explore Focus on conscious
material
Defenses Interpret Reinforce mature
defenses
Source: Reference 4 Adults with ADHD
dysthymia, thoughts of harming herself, low self-
esteem, and indecision about her marriage. were nearly 2x
Mrs. S was not receiving mental health treatment
because her fi rst experience with a psychiatrist had a more likely to have
poor outcome: “He hardly ever said anything; in fact,
sometimes I wondered if he was sleeping. I needed 1
advice desperately, and I was hoping to get some *
been divorced
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 wasnt being The consequences may be serious.
a good patient because I couldnt think for myself. I
felt like he thought I was stupid. He gave me some Screen for ADHD.
antidepressants, but after a few months of feeling
even worse I stopped going and vowed to never see a Find out more at
therapist again.”
www.consequencesofadhd.com
5 key components and download patient support materials,
Although all psychotherapies have some elements coupons, and adult screening tools.
of support, effective supportive psychotherapy has
5 key components (Table 2, page 32).
Adopt a conversational style. In psychoanalytic *Results from a population survey of 500 ADHD adults and 501
therapy, as experienced by Mrs. S, the therapists gender- and age-matched non-ADHD adults which investigated
characteristics of ADHD and its impact on education,employment,
opacity is intended to allow the patient to develop socialization,and personal outlook.
transference. In supportive psychotherapy the ther- Reference: 1. Biederman J,Faraone SV,Spencer TJ,et al.Functional impairments in
adults with self-reports of diagnosed ADHD: a controlled study of 1001 adults in the
apist instead works to create a therapeutic alliance community. J Clin Psychiatry. 2006;67:524-540.
based on the relationship with the patient. Using a
conversational style is essential for developing this
positive relationship. This style includes:
• asking directive questions Shire US Inc.
™
... your ADHD Support Company
• allowing infl ection in your voice ©2006 Shire US Inc.,Wayne,Pennsylvania 19087 A1410 11/06
• making gestures
• discussing opinions.
continued
Table 2 • gaining an understanding of your
5 components of supportive role in the conflict and apologizing
psychotherapy if sincere
• offering solutions to improve the
• Adopt a conversational style confl ict
• Nurture positive transference • providing reassurance that working
• Reduce anxiety through the confl ict will strengthen
Supportive • Enhance self-esteem the therapeutic relationship.
psychotherapy These techniques generally do not in-
• Strengthen coping mechanisms clude interpreting resistance or uncon-
scious confl icts. However, patients some-
Some therapists are uncomfortable times benefi t from reviewing their role and
with this style because they feel more perceptions in the confl ict once their anger
“transparent.” With practice or super- has subsided. Waiting for the negative
vision, however, therapists often learn transference to resolve on its own usually
Clinical Point that a conversational style allows greater is not a good strategy.
spontaneity and creativity. They can solve
HHelpelp pa patientstients talktalk problems in a more relaxed state (closer to Reduce anxiety. In supportive psycho-
aaboutbout painfulpainful ttoopicspics,, “being themselves”). therapy, the primary goal is to lessen the
bbutut alloalloww themthem ttoo patients suffering. Although the patient
CASE CONTINUED often must talk about stressful or painful
pputut offoff ddiscussingiscussing LLeearningarning ttoo ccoopepe topics, you can help him or her do so in a
mmaatttteersrs ttoooo Mrs. Ss new psychiatrist starts her on an tolerable manner. Focus on making it easi-
uuncncoomfmfoorrttableable ttoo antidepressant and once-weekly supportive er for the patient to talk.
eendurnduree psychotherapy. For the initial sessions, the Reducing anxiety means not only
psychiatrist helps Mrs. S explore options for helping the patient talk about painful
her highly conflicted marriage and strategies matters but also allowing him or her to
for coping with panic symptoms. avoid topics that are too uncomfortable
Mrs. S develops a strong feeling of to endure. You can always “earmark” ar-
attachment to the psychiatrist, sometimes eas of concern for later discussion. This
projecting anger onto him by declaring modulation of anxiety is consistent with
that he does not care enough. Instead of the object relations approach proposed
interpreting this transference, the psychiatrist 10 in which emotional pain is
by Kohut,
uses it as an opportunity to explore coping addressed in “small, psychologically
options Mrs. S can try when she feels unloved manageable portions.”
or rejected.
Enhance self-esteem. Virtually all patients
Nurture positive transference. A posi- in supportive psychotherapy suffer from
tive relationship is essential for the low self-esteem, so it is benefi cial to help
therapeutic alliance. In most instances, them feel better about themselves. Take an
a patient naturally develops good feel- active role by using positive comments and
ings toward the therapist over time as a acknowledgements (“plussing”) as well as
result of repeated empathic interchange. compliments when appropriate.
In supportive psychotherapy, you may Most patients with low self-esteem have
acknowledge these good feelings but do defects in the ability to nurture or forgive
not interpret them for unconscious un- themselves (“self-soothe”). Work with pa-
derpinnings. tients to enhance this ability by:
Address transference only if it is nega- • plussing where appropriate
tive. If the patient develops hostility or an- • correcting negative self-distortions or
ger toward you, use techniques to improve self-reproach
the relationship, such as: • educating patients on how to both pla-
Current Psychiatry • acknowledging the validity of the cate and reward themselves.
32 June 2007 patients angry feelings Some patients are unable to do this
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