The aim of supportive psychotherapy is to reduce or to relieve the intensity of manifested or presenting symptoms, distress or disability. It also reduces the extent of behavioral disruptions caused by the patient's psychic conflicts or disturbances.[2] Unlike in psychoanalysis, in which the analyst works to maintain a neutral demeanor as a "blank canvas" for transference, in supportive therapy the therapist engages in a fully emotional, encouraging, and supportive relationship with the patient as a method of furthering healthy defense mechanisms, especially in the context of interpersonal relationships.
Supportive psychotherapy can be used as treatment for a variety of physical, mental, and emotional ailments, and consists of a variety of strategies and techniques in which therapists or other licensed professionals can treat their patients. The objective of the therapist is to reinforce the patient's healthy and adaptive patterns of thoughtbehaviors in order to reduce the intrapsychic conflicts that produce symptoms of mental disorders.
Evolution of Supportive Psychotherapy
Sigmund Freud, founder of psychoanalysis, holding a cigar. Photographed by his son-in-law, Max Halberstadt, c. 1921
In the late 19th century, Sigmund Freud began to develop the techniques of psychoanalysis, which served as a foundation for all the other psychotherapeutic modalities. Freud found that by letting people talk freely about whatever came to mind (free association), they eventually revealed the origins of their psychological conflicts in disguised form. Upon hearing these confessions revealed through free association, the therapist would then interpret the unconscious cause for the patient's symptoms.[3]
In the years following Freud's development of psychoanalysis, this approach was seen as the default in treating mental illness in patients. Psychotherapists faced the problem of patients who were unanalyzable: those without the reflective capacity to hear interpretations, or with “pseudoneurotic schizophrenia”.[4] These patients who would react negatively to psychoanalysis would then receive a more bolstering, “supportive” treatment. This therapy, which would later be recognized as the initial stages of supportive psychotherapy, was not the preferred mode of treatment, not for the preferred patients, and hence, was seen as pejorative from the onset.
Franz Alexander studied Freud, and although he was trained in classical psychoanalytic technique, he began to evolve his own ideas about what allowed the curative process to occur in therapy.[5]
Alexander noted that in classical psychoanalysis, the essential requirement for change was the insight the patient gained from interpretation of the transference neurosis. Alexander agreed with Freud that during psychoanalysis the patient underwent transference based on earlier life experience and emotional traumas. While Freud believed that the insight the patient gained from this was essential for healing to occur, Alexander felt the process of the patient feeling nurtured or comforted while reliving emotional traumas was also a curative force. He began to look at other factors that might be contributing to improvement, factors not related to insight but rather to the relationship of the patient with the psychoanalyst.[5]
The objective of supportive psychotherapy was not to change the patient's personality but to help the patient cope with symptoms, prevent relapse of serious mental illness, or help a relatively healthy person deal with a crisis or transient problem. As defined in earlier years, supportive psychotherapy is a body of techniques, such as praise, advice, exhortation, and encouragement, embedded in psychodynamic understanding and used to treat severely impaired patients.[6]
Over the next few decades and with ample studies to demonstrate efficacy, supportive psychotherapy gained momentum among professionals as a practical and efficacious method of therapy and supportive psychotherapy became recognized as the default treatment for patients with more severe psychological symptoms or those who couldn't withstand the rigors of psychoanalysis.
Context and History
Context
Supportive psychotherapy is often practiced for patients who are considered lower functioning, too fragile, or too unmotivated to participate in more demanding expressive therapy, which might have more chance of leading to personality change.[7]
As a dyadic treatment that is characterized by use of direct measures to ameliorate symptoms and to maintain, restore, or improve self-esteem, adaptive skills, and psychological (ego) function, the treatment itself works to observe relationships (real or transferential) and both current and past patterns of emotional or behavioral response.[8]
As supportive psychotherapy is introduced in environments less formal than a primary care office, supportive psychotherapy can appear as an expression of interest, attention to concrete services, encouragement and optimism. The relationship between the patient and the professional during supportive treatment exists solely to meet the needs of the patient, and it should not develop as a platonic relationship outside of professionalism.[9]
History
Supportive psychotherapy functions with the objective of reducing anxiety and maintaining a positive patient-therapist relationship with minimal focus on transference.[7] While this practice of therapy is seldom studied, it has since been identified and functions as an alternative to expressive therapy.[8]
Supportive psychotherapy and supportive treatment works well for patients who are anticipated to fail at expressive therapy, or who are generally difficult to treat with expressive therapy.[8]
An early documentation of supportive psychotherapy can be found in The Journal of Psychotherapy Practice and Research with contributions from David J. Hellerstein, M.D., Henry Pinsker, M.D., Richard N. Rosenthal, M.D., and Steven Klee, Ph.D. In their contributions to the study and exploration of supportive psychotherapy, These researchers note that with supportive and expressive falling on a continuum, the model for individual dynamic psychotherapy should be based on concepts from the supportive end of the continuum, rather than the expressive end.[7]
A summary of Otto F. Kernberg's definition of supportive psychotherapy is featured in The Journal of Psychotherapy Practice and Research and defines what supportive therapy does rather than what it is.[7] Kernberg's definition includes actions like:
reducing behavioral dysfunctions
reducing subjective mental distress
supporting and enhancing the patient's strengths, coping skills, and capacity to use environmental supports
maximizing treatment autonomy
facilitating maximum possible independence from psychiatric illness.
Additionally, supportive therapy is recognized as the treatment of choice for patients seen by psychiatrists and residents who are suffering from extra-psychic problems, such as poverty, social and political oppression, and abuses of power in relationships that threaten to overwhelm their coping capacities.[14]
Strategies and Techniques
Strategies and techniques associated with supportive psychotherapy include the following:[3]
Listening
Argued by author John Battaglia as “the most powerful skill of supportive psychotherapy”,[3] the element of listening in regards to supportive psychotherapy helps patients feel “heard” by their therapists or health professionals. Effective listening “includes careful attentiveness to the body language, emotional tone, and overall bearing of patients in the sessions.”
Plussing
Plussing is defined as “promoting a positive atmosphere in the therapy by finding the good in the patient and accentuating the positive in the patient’s situation.” Battaglia compares this supportive psychotherapy strategy to “putting on rose-colored glasses and seeing what the patient presents as half full,” and assisting patients with finding a positive outlook even if it appears difficult to find.
Explaining Behavior or Advice
Using the explaining behavior strategy within supportive psychotherapy allows for therapists and health professionals to lead patients to areas of comfort or security as they navigate complex and overwhelming emotions or compulsions. With this technique, the behavioral explanations brought forth by the professional should aim to make sense to the patient and help them feel supported.
Advice is another supportive psychotherapy strategy that branches from the explaining behavior technique. Advice is effective usually when the patient is able to connect it to their goals.[15]
Confrontation and Reframing
Confrontation is essentially allowing the patient to reflect and comprehend how their patterns of behavior are contributing to their suffering. Therapists and professionals help guide patients to understanding how repeated behaviors or emotions contribute to their mental health and symptoms.
Reframing is related to the technique of confrontation as reframing involves looking at something in a different light or different angle and can provide patients with a new perspective as they undergo supportive psychotherapy.[15]
Encouragement or Praise
Encouragement or Praise is often used in doses that are based on preexisting elements of the patient, such as their history, strengths, and weaknesses. Encouragement should be used sparingly in order to avoid the patient experiencing emotions of falling short to what their therapist expected of them. Using encouragement in this environment combines opportunities for education and movement in order to bring patients upward in their treatment or outside of their comfort zone.
Additionally, this technique can be used to reinforce accomplishments or positive changes in behavior, and can be positioned as the reinforcement of the patient's steps towards achieving their stated goals.[15]
Hope
Very similarly to encouragement, hope is to be used sparingly and appropriately by therapists and health professionals in order to “provide enough hope for the patient to see change as a realistic opportunity.”
Metaphor
The use of metaphors is a stimulating element of supportive psychotherapy that “[utilizes] different parts of the patient’s brain than those stimulated by many of the other more language based techniques.” A metaphor is said to “stick” in a patient's head in a “very durable way.”
Coping Skills
Therapists and health professionals assisting patients with developing cognitive and behavioral coping skills is another technique used for supportive psychotherapy. These techniques range in complexity, and can consist of mantras or coping plans for the patient.
Self-soothing
Giving patients the tools necessary to develop self-soothing habits in opposition to unhealthy acting-out behavior, such as extreme mood swings, substance abuse, or acting out.
Creative Opportunities
Creative opportunities allow for therapists and health professionals to introduce their patients to creative outlets in order to express their emotions. Some of these techniques within this strategy include storytelling, journaling, and writing letters they won't send.
Some techniques identified, but generally avoided and used with caution are humor and comparing pain.
Studies on Supportive Psychotherapy
In an extensive longitudinal study developed in the 1950s, the "Menninger Psychotherapy Research Project" compared patients receiving psychoanalysis, psychoanalytic psychotherapy, and supportive psychotherapy over a 23-year span. The main objective of the study was to critically examine the difference between psychoanalysis and psychoanalytic psychotherapy. The supportive psychotherapy arm of the study was placed more as a control condition than as a rigorous technique for comparison. The study results concluded there were no significant differences among the three different types of psychotherapy.[16]
In one 1978 study looking at treatment of agoraphobia, mixed phobias, or simple phobias, patients were randomly assigned to one of three treatment conditions: behavior therapy alone, behavior therapy plus imipramine (medication) treatment, or supportive therapy plus imipramine (medication) treatment. Therapists in the behavior therapy groups used a manualized, highly structured treatment protocol that included relaxation training and systematic desensitization in imagination, specific in vivo desensitization homework assignments, and assertiveness training (including modeling, role playing, behavior rehearsal, and in vivo homework assignments). The supportive therapy was nondirective; patients took the initiative in all discussions. The therapists doing supportive therapy were instructed to be empathic and non-judgmental and to encourage patients to ventilate feelings and discuss problems, anxieties, and interpersonal relationships. The researchers found that there were no significant differences between the therapy conditions and that patients did well in both.[17]
In a 2005 randomized controlled study looking at cognitive-behavioral therapy versus interpersonal therapy for anorexia nervosa, once again supportive psychotherapy was used as a control condition. In the cognitive-behavioral therapy arm of the study, the patients underwent several phases of treatment, including psychoeducation, motivational assessment, cognitive-behavioral skills (including thought restructuring and homework assignments), relapse prevention, and recovery strategies.[18]
Teaching Supportive Psychotherapy
Researchers Arnold Winston, M.D., Richard N. Rosenthal, M.D., and Laura Weiss Roberts, M.D., M.A. express the elusiveness of the field of supportive psychotherapy: it is not based on “rigorous and internally consistent or appealing theory, it does not offer solutions to intractable clinical problems, and the field itself has no conferences, stars, and relatively few books.”[6]
In Winston's Rosenthal's and Robert's text, “Learning Supportive Psychotherapy, Second Edition: An Illustrated Guide,” these authors note that “The psychotherapist’s central task is learning to understand...the emotional experience of the patient” (Balsam and Balsam), which was presented universally in regards to teaching supportive psychotherapy.
This universal treatment provided little guidance in how to handle patients who were inarticulate or poorly educated, who have intractable social problems, severe behavioral problems, or those who only visited for a couple months at a time or visited biweekly.[5]
In 2012, Adam M. Brenner, M.D. advocated for a “much more sophisticated approach” to teaching health professionals and therapists about supportive psychotherapy, which focused on three important factors of supportive psychotherapy:
Its relevance for common factors underlying all forms of psychotherapy
Its role on a spectrum of psychodynamically informed psychotherapies
Its value as a modality that includes specifically definable techniques and aims
Brenner also advocated for “teaching supportive psychotherapy in diverse clinical rotations, including inpatient and consultation-liaison services as well as ambulatory settings.”[6]
Criticism about supportive psychotherapy
As the method of supportive psychotherapy grew in popularity among psychologists and healthcare professionals, backlash concerning the effectiveness or validity of nonpsychoanalytic techniques arose. With psychoanalysis, the theory was that once a person improved through gaining insight, he or she underwent a permanent and curative change of personality. By contrast, changes brought about through more supportive types of psychotherapy were seen by critics as behavioral, meaning more transient and specific to the symptoms and not indicative of permanent personality change, which resulted in psychoanalysts believing that supportive-type therapy was not psychotherapy at all.[3]
An additional criticism regarding supportive psychotherapy is that it 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.[9]
Psychoanalysis is a set of theories and therapeutic techniques that deal in part with the unconscious mind, and which together form a method of treatment for mental disorders. The discipline was established in the early 1890s by Sigmund Freud, whose work stemmed partly from the clinical work of Josef Breuer and others. Freud developed and refined the theory and practice of psychoanalysis until his death in 1939. In an encyclopedic article, he identified the cornerstones of psychoanalysis as "the assumption that there are unconscious mental processes, the recognition of the theory of repression and resistance, the appreciation of the importance of sexuality and of the Oedipus complex." Freud's colleagues Alfred Adler and Carl Gustav Jung developed offshoots of psychoanalysis which they called individual psychology (Adler) and analytical psychology (Jung), although Freud himself wrote a number of criticisms of them and emphatically denied that they were forms of psychoanalysis. Psychoanalysis was later developed in different directions by neo-Freudian thinkers, such as Erich Fromm, Karen Horney, and Harry Stack Sullivan.
Psychotherapy is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome problems. Psychotherapy aims to improve an individual's well-being and mental health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions, and to improve relationships and social skills. Numerous types of psychotherapy have been designed either for individual adults, families, or children and adolescents. Certain types of psychotherapy are considered evidence-based for treating some diagnosed mental disorders; other types have been criticized as pseudoscience.
Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group. The term can legitimately refer to any form of psychotherapy when delivered in a group format, including art therapy, cognitive behavioral therapy or interpersonal therapy, but it is usually applied to psychodynamic group therapy where the group context and group process is explicitly utilized as a mechanism of change by developing, exploring and examining interpersonal relationships within the group.
Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideation as well as for changing behavioral patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies and ultimately balance and synthesize them—comparable to the philosophical dialectical process of thesis and antithesis, followed by synthesis.
Transference is a phenomenon within psychotherapy in which repetitions of old feelings, attitudes, desires, or fantasies that someone displaces are subconsciously projected onto a here-and-now person. Traditionally, it had solely concerned feelings from a primary relationship during childhood.
Psychodynamic psychotherapy and psychoanalytic psychotherapy are two categories of psychological therapies. Their main purpose is revealing the unconscious content of a client's psyche in an effort to alleviate psychic tension, which is inner conflict within the mind that was created in a situation of extreme stress or emotional hardship, often in the state of distress. The terms "psychoanalytic psychotherapy" and "psychodynamic psychotherapy" are often used interchangeably, but a distinction can be made in practice: though psychodynamic psychotherapy largely relies on psychoanalytical theory, it employs substantially shorter treatment periods than traditional psychoanalytical therapies. Psychodynamic psychotherapy is evidence-based; the effectiveness of psychoanalysis and its relationship to facts is disputed.
Play therapy refers to a range of methods of capitalising on children's natural urge to explore and harnessing it to meet and respond to the developmental and later also their mental health needs. It is also used for forensic or psychological assessment purposes where the individual is too young or too traumatised to give a verbal account of adverse, abusive or potentially criminal circumstances in their life.
Intensive short-term dynamic psychotherapy (ISTDP) is a form of short-term psychotherapy developed through empirical, video-recorded research by Habib Davanloo.
Franz Gabriel Alexander was a Hungarian-American psychoanalyst and physician, who is considered one of the founders of psychosomatic medicine and psychoanalytic criminology.
Frieda Fromm-Reichmann was a German psychiatrist and contemporary of Sigmund Freud who immigrated to America during World War II. She was a pioneer for women in science, specifically within psychology and the treatment of schizophrenia. She is known for coining the now widely debunked term Schizophrenogenic mother. In 1948, she wrote "the schizophrenic is painfully distrustful and resentful of other people, due to the severe early warp and rejection he encountered in important people of his infancy and childhood, as a rule, mainly in a schizophrenogenic mother".
Resistance, in psychoanalysis, refers to the client's defence mechanisms that emerge from unconscious content coming to fruition through process. Resistance is the repression of unconscious drives from integration into conscious awareness.
In applied psychology, interventions are actions performed to bring about change in people. A wide range of intervention strategies exist and they are directed towards various types of issues. Most generally, it means any activities used to modify behavior, emotional state, or feelings. Psychological interventions have many different applications and the most common use is for the treatment of mental disorders, most commonly using psychotherapy. The ultimate goal behind these interventions is not only to alleviate symptoms but also to target the root cause of mental disorders.
The therapeutic relationship refers to the relationship between a healthcare professional and a client or patient. It is the means by which a therapist and a client hope to engage with each other and effect beneficial change in the client.
Child psychotherapy, or mental health interventions for children refers to the psychological treatment of various mental disorders diagnosed in children and adolescents. The therapeutic techniques developed for younger age ranges specialize in prioritizing the relationship between the child and the therapist. The goal of maintaining positive therapist-client relationships is typically achieved using therapeutic conversations and can take place with the client alone, or through engagement with family members.
Interpersonal psychotherapy (IPT) is a brief, attachment-focused psychotherapy that centers on resolving interpersonal problems and symptomatic recovery. It is an empirically supported treatment (EST) that follows a highly structured and time-limited approach and is intended to be completed within 12–16 weeks. IPT is based on the principle that relationships and life events impact mood and that the reverse is also true. It was developed by Gerald Klerman and Myrna Weissman for major depression in the 1970s and has since been adapted for other mental disorders. IPT is an empirically validated intervention for depressive disorders, and is more effective when used in combination with psychiatric medications. Along with cognitive behavioral therapy (CBT), IPT is recommended in treatment guidelines as a psychosocial treatment of choice for depression.
Mentalization-based treatment (MBT) is an integrative form of psychotherapy, bringing together aspects of psychodynamic, cognitive-behavioral, systemic and ecological approaches. MBT was developed and manualised by Peter Fonagy and Anthony Bateman, designed for individuals with borderline personality disorder (BPD). Some of these individuals suffer from disorganized attachment and failed to develop a robust mentalization capacity. Fonagy and Bateman define mentalization as the process by which we implicitly and explicitly interpret the actions of oneself and others as meaningful on the basis of intentional mental states. The object of treatment is that patients with BPD increase their mentalization capacity, which should improve affect regulation, thereby reducing suicidality and self-harm, as well as strengthening interpersonal relationships.
Insight-oriented psychotherapy is a category of psychotherapies that rely on conversation between the therapist and the client. It involves developing the patient's understanding of past and present experiences, how they are related to each other and the effect they have on the patient's interpersonal relationships, emotions and symptoms. Insight-oriented psychotherapy can be an intensive process, wherein the client must spend multiple days per week with the therapist.
The mainstay of management of borderline personality disorder is various forms of psychotherapy with medications being found to be of little use.
Schema therapy was developed by Jeffrey E. Young for use in treatment of personality disorders and chronic DSM Axis I disorders, such as when patients fail to respond or relapse after having been through other therapies. Schema therapy is an integrative psychotherapy combining theory and techniques from previously existing therapies, including cognitive behavioral therapy, psychoanalytic object relations theory, attachment theory, and Gestalt therapy.
Elvin Semrad (1909-1976) was a prominent American psychoanalytic psychiatrist. He was noted for his ability to establish a rapport with deeply troubled individuals. He was one of the most influential teachers of psychotherapy in his time and he had been trained by a close associate of Freud.
References
↑ Werman, David S. (1964). The Practice of Supportive Psychotherapy. New York, New York: Psychology Press.
1 2 3 Margolin, Sidney G. (July 1946). "ALEXANDER, FRANZ, AND FRENCH, THOMAS: Psychoanalytic Therapy. New York, Ronald Press Company, 1946, 353 pp. $5.00". Psychosomatic Medicine. 8 (4): 285–296. doi:10.1097/00006842-194607000-00010.
↑ Rockland, Lawrence H. (November 1993). "A Review of Supportive Psychotherapy, 1986-1992". Psychiatric Services. 44 (11): 1053–1060. doi:10.1176/ps.44.11.1053. PMID8288173.
↑ Manne, Sharon L.; Rubin, Stephen; Edelson, Mitchell; Rosenblum, Norman; Bergman, Cynthia; Hernandez, Enrique; Carlson, John; Rocereto, Thomas; Winkel, Gary (August 2007). "Coping and communication-enhancing intervention versus supportive counseling for women diagnosed with gynecological cancers". Journal of Consulting and Clinical Psychology. 75 (4): 615–628. doi:10.1037/0022-006X.75.4.615. PMID17663615.
↑ Wallerstein, Robert S. (1989). "The Psychotherapy Research Project of the Menninger Foundation: An overview". Journal of Consulting and Clinical Psychology. 57 (2): 195–205. doi:10.1037/0022-006x.57.2.195. PMID2708605.
↑ Zitrin, Charlotte Marker (1 March 1978). "Behavior Therapy, Supportive Psychotherapy, Imipramine, and Phobias". Archives of General Psychiatry. 35 (3): 307–316. doi:10.1001/archpsyc.1978.01770270057005. PMID31847.
↑ McIntosh, Virginia V.W.; Jordan, Jennifer; Carter, Frances A.; Luty, Suzanne E.; McKenzie, Janice M.; Bulik, Cynthia M.; Frampton, Christopher M.A.; Joyce, Peter R. (April 2005). "Three Psychotherapies for Anorexia Nervosa: A Randomized, Controlled Trial". American Journal of Psychiatry. 162 (4): 741–747. doi:10.1176/appi.ajp.162.4.741. PMID15800147.
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