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Advances in psychiatric treatment (2010), vol. 16, 184–192 doi: 10.1192/apt.bp.107.003855
ARTICLE Supervised case experience
in supportive psychotherapy:
suggestions for trainers
Navjot Bedi & Helena Vassiliadis
Navjot Bedi is a consultant and that there is little guidance on how to teach
psychiatrist in the Nottinghamshire SummARy it (Douglas 2008). It is likely that similar factors
Eating Disorders Service. She has The Royal College of Psychiatrists’ guidelines for are discouraging trainers in the UK from offering
previously worked as a consultant the psychotherapy training of trainee psychiatrists
in general adult psychiatry and in include a supervised case experience in supportive supervised case experience.
undergraduate medical education. psychotherapy. There is, however, a lack of clarity
She is trained in cognitive– over the concept of supportive psychotherapy What is supportive psychotherapy?
behavioural psychotherapy.
Helena Vassiliadis is a consultant and how this might be taught and supervised, There is no straightforward answer to this ques
psychiatrist in psychodynamic and this may discourage trainers from offering tion. Supportive psychotherapy has been, and
psychotherapy in Nottinghamshire formal clinical supervision in this modality. In this
Healthcare NHS Trust. She has a article we briefly describe the history of supportive remains, an evolving concept that has attracted
role in psychotherapy training within psychotherapy, the various ways in which it has many differences of opinion. The term ‘supportive
the North Trent School of Psychiatry. been conceptualised, and some of the research in psychotherapy’ has been used in the literature in
The authors developed an interest a variety of ways and there is no single universally
in supportive psychotherapy while the area. We discuss the case for training and make
working together on a local project practical suggestions for how this experience might accepted definition. We describe some of the views
to implement the Royal College be offered by consultant psychiatrists in an everyday and debates in an attempt to arrive at a clearer
of Psychiatrists’ guidelines for psychiatric setting. understanding of the current status of supportive
psychotherapy training. psychotherapy.
Correspondence Dr Navjot Bedi, DECLARATIoN of INTEREST
Nottinghamshire Eating Disorders None.
Service, Mandala Centre, Gregory Psychoanalytic origins
Boulevard, Nottingham NG7 6LB,
UK. Email: navjot.bedi@nottshc. The early supportive treatments were felt to be
nhs.uk The Royal College of Psychiatrists’ guidelines largely unscientific, relying somewhat on suggestion
for psychotherapy training (Royal College of and varying degrees of showmanship. The majority
Psychiatrists 2008a) emphasise the need for of psychoanalysts attempted to distance themselves
psychiatric trainees to become better trained in the by emphasising the differences between supportive
psychological therapies. Suggestions for training psychotherapy and psychoanalysis. Hence in the
include supervised case experience in supportive 1920s, supportive psychotherapy lacked a positive
psychotherapy. definition, being described in terms of what it was
In considering the local arrangements for not (relative to psychoanalysis), rather than what it
psycho therapy training, we became interested in was. However, as psychoanalysis began to be used
how training in supportive psychotherapy could with more damaged patients, such as those with
be delivered. Discussions with local consultants borderline personality disorder, the limitations of
suggested that although many considered them the ‘classical’ model became increasingly apparent
selves to be practising something akin to supportive and some analysts began to acknowledge that
psychotherapy in their everyday work, there was a certain patients required supportive techniques
lack of confidence in offering supervision. Further, alongside exploratory ones (Holmes 1995).
a national report on implementation of training Nevertheless, the place of supportive interven
(Clarke 2005) identified that more thought needed to tions in psychodynamic/psychoanalytic therapy
be given to the concept of supportive psychotherapy remains contentious. Luborsky (1984), for
and how it might be supervised. Mitchison (2007) example, views supportive and exploratory
suggested that consultant psychiatrists might techniques as lying on a continuum, both being
feel more confident as supervisors if they had a used in a psychoanalytic ‘supportive expressive’
clear account of what was required of them. It therapy as appropriate to the patient’s need.
has been suggested that obstacles to training in Others hold the dichotomous view that therapy is
the USA are that the literature fails to clearly either supportive or exploratory. Indeed, some see
describe supportive psychotherapy (Pinsker 1994) support as anathema to psychoanalysis, where the
184
https://doi.org/10.1192/apt.bp.107.003855 Published online by Cambridge University Press
Advances in psychiatric treatment (2010), vol. 16, 184–192 doi: 10.1192/apt.bp.107.003855 Supervised case experience in supportive psychotherapy
exploration of unconscious emotion is of necessity than weekly (fortnightly, monthly or even two
initially anxietyprovoking (Crown 1988). monthly), lasting from 10 to 60 minutes and
usually continuing over 2 years (Van Marle 2002).
Supportive psychotherapy The patient group at which this longterm work
within a psychodynamic framework is aimed is often described as being chronically
Several authors have conceptualised models in psychologically weakened and unsuitable for more
which supportive interventions lie firmly within exploratory work. In practice, this group of patients
a psychodynamic framework. In Rockland’s usually have severe and chronic psychotic, mood,
(1987) psychodynamically oriented supportive personality or anxiety disorders. Hartland (1991)
psychotherapy, practised in the USA, patients with defines this type of supportive psychotherapy as ‘a
borderline personality disorder are seen once or longterm psychotherapy aimed at maximising the
twice weekly for 50 minutes. de Jonghe et al (1994) patient’s strengths, restoring his equilibrium and
describe psychoanalytic supportive psychotherapy, acknowledging, but attempting to minimise, his
and argue that it is a therapeutic modality in dependence on the therapist.’
its own right. Another example is supportive This view of supportive psychotherapy as long
analytical therapy, described by Holmes (1988) term work for patients with chronic disorders has
as lying somewhere between a formal analytical/ moved on. Shortterm supportive psychotherapy is
psychodynamic psychotherapy and ordinary good now well described for a wide range of psychiatric
psychiatric practice. disorders, including depression, anxiety,
adjustment disorders or other acute crisis or loss
Supportive psychotherapy as an integrative events. It is most suitable for patients who have
model current acute difficulties, perhaps associated
The concept of supportive psychotherapy in more with selfblame or internal conflict, but who
recent literature has broadened. It is now viewed had good premorbid functioning. Other patient
by many as an integrative therapy which has no characteristics which suggest suitability for short
single theoretical background, but draws from term work include psychological mindedness,
many approaches, including psychoanalysis, motivation for treatment, good impulse control,
Rogerian counselling, cognitive, behavioural, good reality testing, and mature coping and
systemic, interpersonal and ego psychology and defence mechanisms (Novalis 1993).
attachment theory. The practitioner will choose Some authors view supportive psychotherapy as
from the available techniques on the basis of the being a component of ordinary good psychiatric
patient’s need and, probably, their own training practice. For example, Pinsker (1997) makes
background. a convincing argument when he writes: ‘Many
Some view supportive psychotherapy as a psychiatrists see patients briefly for management
‘common factors approach’ (Trijsburg 2007). of psychopharmacologic treatment. Remarkably,
Common factors are the elements found in all often patients are efficient about the medication
psychotherapies, regardless of model, and it has issues and quickly attempt to involve the
been suggested that it is these commonalities that “medicating” psychiatrist in conversation about
are the effective ingredients of psychotherapy his or her life, so supportive therapy is part of the
(Frank 1991). Supportive psychotherapy contains package whether intended or not’.
many of these common factors. Pinsker (1994) Taking this flexible framework further, it has
conceptualises supportive psychotherapy as been suggested that supportive psychotherapy
a body of techniques, or a ‘shell’, which can can take place in the context of just one or two
function comfortably with many various meet ings (Rockland 1989) or in regular annual
theoretical orientations. However, it is noted by sessions (Crown 1988). Within this broad view, it
Douglas (2008) that despite these moves towards could be said that supportive psychotherapeutic
an integrative model, psychodynamic language work is carried out by many different healthcare
and theory continue to be present in much of professionals and in a wide variety of settings, both
the literature, making it difficult to practise within and outside psychiatry. As Tyrer states:
supportive psychotherapy without some degree of ‘Literally thousands of therapists are providing
psychodynamic understanding. something akin to supportive psychotherapy every
working day throughout the land’ (Robertson
Models of practice 1995).
Summarising from all of this, the current
The traditional view of supportive psychotherapy position of supportive psychotherapy is perhaps
in National Health Service work in the UK is most accurately described by Van Marle & Holmes
that of a longterm therapy, held less frequently (2002) as ‘a flexible, nonmanualized form of
Advances in psychiatric treatment (2010), vol. 16, 184–192 doi: 10.1192/apt.bp.107.003855 185
https://doi.org/10.1192/apt.bp.107.003855 Published online by Cambridge University Press
Bedi & Vassiliadis
Box 1 Aims of supportive psychotherapy The supportive relationship
The most important component of supportive
• To help the patient to reach and to maintain their best psychotherapy is the supportive relationship (also
level of psychological and social functioning sometimes termed the therapeutic alliance). This
• To reduce subjective distress relationship can be therapeutic in its own right,
• To reduce behavioural dysfunction but also acts as the matrix within which other
• To improve self-esteem more specific techniques can be implemented
(Novalis 1993). Many of the techniques are aimed
• To minimise relapses at building this supportive relationship, within
• To encourage and enhance the patient’s strengths and which the patient trusts the therapist and feels
coping skills safe. Important in the therapist is a genuine, warm,
• To allow the patient to achieve the maximum possible respectful and nonjudgemental attitude. The
independence from services and to gain support from therapist works to be a ‘real figure’ and this may
other sources be facilitated by judicious selfdisclosure or use of
humour. Ruptures in the therapeutic alliance are
noted and repaired as quickly as possible.
therapy which is practiced in different ways and at Communication style
different levels by a variety of professionals’.
Conversation is twoway and responsive, with no
Aims and techniques anxietyprovoking long silences. The therapist
There is general agreement in the literature on the encourages the patient to talk, and listens actively,
aims and techniques of supportive psychother attempting to understand their story and to hear
apy. Some of the specific aims are listed in Box also what is not being said. Some interruption and
1. Broadly speaking, the aim is to bolster and to persistence is appropriate if important issues are
improve the patient’s psychological functions (or being avoided. Ventilation of feelings and expression
‘ego functions’), which are for some reason defi of affect can bring relief, but should be encouraged
cient. Applebaum (1989) draws parallels between only to the degree that the patient is able to manage.
supportive psychotherapy and a good early child– The therapist does not aim to uncover deeply
parent relationship: just as the parent fosters repressed material. Accurate empathic responses
development in the child, so a therapist aims to show that the patient is being understood and
foster psychological and emotional maturation in encourage further communication.
the patient. Transference and countertransference
Much can be written about the strategies and
techniques of supportive psychotherapy. Here, we Being a ‘real figure’ helps the therapist to prevent a
offer a brief overview, but highly recommend some strong positive or negative transference developing,
of the available literature (marked in the reference an approach some describe as ‘managing the
list by an asterisk) for a more detailed account, transference’. A mild degree of positive transference
including disorderspecific techniques. The key may help the therapeutic alliance and can be
techniques are listed in Box 2. left intact. However, if negative transference is
developing, the therapist may need to act to restore
the patient’s sense of reality. The therapist should
Box 2 Some techniques of supportive psychotherapy be aware of the countertransference, particularly
as the activetherapist stance necessarily involves
• Develop a strong therapeutic alliance • Psychoeducation and reality-testing making judgements. Again, ruptures in the
• Convey acceptance of the patient • Limit-setting, confrontation therapeutic alliance are noted and repaired as
• Convey empathy • Help manage affect quickly as possible.
• Offer containment and provide a secure • Cognitive–behavioural techniques (e.g.
base activity-scheduling, problem-solving, A secure base and containment
• Allow ventilation of feelings exposure work, challenging thoughts) The reliable and consistent clinician will come
• Enhance self-esteem • Manage the transference and to form a secure base for the patient and some
countertransference degree of necessary dependency may occur while
• Model behaviour
• Use interpretation sparingly the patient works towards greater longterm
• Offer reassurance when appropriate inde pendence. The therapist acts to contain the
• Provide medication and other treatments
• Offer advice when appropriate patient’s emotions, touched by them, but able to
• Environmental interventions
• Encourage use of external supports think about and manage them and to respond
therapeutically.
186 Advances in psychiatric treatment (2010), vol. 16, 184–192 doi: 10.1192/apt.bp.107.003855
https://doi.org/10.1192/apt.bp.107.003855 Published online by Cambridge University Press
Bedi & Vassiliadis Supervised case experience in supportive psychotherapy
Focus on current problems For example, the supportive therapist may delay
The focus of the work is largely the present, the interpretation until after the emotional tension
helping the patient to examine and manage current has cooled – an approach described by Pine (1986)
difficulties. Goals are agreed collaboratively. Self as ‘strike while the iron is cold’. Some use a partial
esteem and sense of mastery may be improved by (inexact) interpretation, which offers an account
encouragement and praise. The therapist may teach that is only partly accurate, or a benign projection
problemsolving skills and support the patient in that attributes the problem to something outside
using their own resources to solve problems. If the patient’s control.
this is not successful, then more direct suggestion Other techniques
or advice may be necessary. Reassurance is
appropriate if the patient has unrealistic fears, Many authors see prescribing of medication and
but should be offered only once these have been environmental interventions as techniques of
adequately explored. supportive psychotherapy.
Behaviour The research
The therapist helps the patient to increase functional The literature on supportive psychotherapy
and reduce dysfunctional behaviours, although in contains many small studies and case reports.
the spirit of working with a patient’s strengths, A few randomised trials include supportive
minor problematic behaviours could be selectively psychotherapy, but usually as a control rather
ignored. Functional behaviours can be encouraged than a modality to be investigated in its own right.
through praise. An uncritical but questioning We have not attempted a comprehensive review
attitude towards dysfunctional behaviours may of the research, but outline some of the more
lessen these. If behaviour is unacceptable, non recent randomised trials. Methodologically, these
negotiable limitsetting is sometimes required. are all fairly robust studies, although they have
These limits may serve to contain the patient and the usual difficulties associated with conducting
shape harmful behaviours into more appropriate psychotherapy research. A specific problem in
ones. Patients who have difficulty in managing interpreting the research in this area is that
affect and controlling impulses may be assisted in different researchers use slightly differing models
recognising these patterns and trying alternative of ‘supportive psychotherapy’.
strategies.
The therapist can model behaviour such as Anxiety disorders
being on time and maintaining boundaries. Klein et al (1983) describe a randomised trial
The selfcritical patient can learn from the in outpatients comparing the combinations of
compassionate therapist how they might be kinder behaviour therapy and imipramine with supportive
† †
to themselves. psychotherapy and imipramine. Therapy sessions Compassion in patient and
occurred weekly for 26 sessions. Supportive therapist are discussed in
Reality testing psychotherapy was found, surprisingly, to be as Gilbert P (2009) Introducing
compassion-focused therapy.
The patient is assisted in reality testing. effective as behaviour therapy. Advances in Psychiatric Treatment
Psychoeducation can help greatly in correcting In a randomised trial involving older outpatients 15: 199–207. Ed.
inaccurate views of the illness. Basic cognitive and with a range of anxiety disorders, Barrowclough
behavioural techniques can be used to help the et al (2001) treated one group with cognitive–
patient to identify and challenge distorted thinking, behavioural psychotherapy and the other with
and to experiment with changing behaviours. supportive psychotherapy. Three different anxiety
scales were used to measure outcome. At the end of
Defence mechanisms and interpretation treatment, changes in anxiety symptoms measured
The emphasis of supportive psychotherapy is on by one of the scales demonstrated a significant
respecting defence mechanisms and acknowledging benefit of cognitive–behavioural psychotherapy
their possible protective functions for the patient. over supportive psychotherapy, but changes on the
Some healthy defences may be encouraged (for other two scales suggested that the two treatments
example, the sublimation of rage into exercise). were broadly equal in effect.
Harmful defence mechanisms may, however, Depression
need to be challenged (for example, denial of a
medical problem preventing appropriate help Shortterm psychoanalytic supportive psycho
seeking). There may be a place for some forms of therapy (SPSP), usually offered as 16 sessions
interpretation, but the aim is to reduce anxiety over 6 months, was developed as a treatment for
and not to uncover deeply unconscious feelings. depression (de Jonghe 1994). A megaanalysis of
Advances in psychiatric treatment (2010), vol. 16, 184–192 doi: 10.1192/apt.bp.107.003855 187
https://doi.org/10.1192/apt.bp.107.003855 Published online by Cambridge University Press
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