From Cinderella to Straw Man?
From Cinderella to Straw Man?
We are living in an evidence-based era in all fields of medicine, including psychiatry. For the most part, this represents progress because clinicians can start to base their interventions on treatments that have been supported by the results of research studies. Evidence-based practice is believed to be superior to various alternatives, humorously described as eminence-, vehemence-, and eloquence-based.1
There is a growing base of reliable data on psychopharmacology that we increasingly use to guide our clinical work. Psychotherapy has also striven to become evidence-based. Demonstrated effectiveness in prospective, randomized, controlled studies has become the sine qua non of a particular psychotherapy’s widespread adoption. Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), problem-solving therapy, dialectic behavior therapy (DBT), and a host of other new therapies have gained credibility because of positive findings in randomized clinical trials (RCTs).
In general, supportive psychotherapy (SPT) has been used as the comparator in RCTs. In virtually all of the comparisons, SPT (eg, nondirective supportive treatment, supportive counseling, Rogerian supportive therapy, nondirective therapy, social support treatment) has been deemed the loser.
A look at the “evidence”
If you look at the evidence uncritically, you may conclude that SPT really is less effective than other treatment approaches. A recent meta-analysis of studies that compared 7 psychotherapies for depression concluded that while there were no major differences in outcomes between treatments, IPT was most effective and SPT was the least effective.2
Although the authors hedge their findings, saying that IPT was found to be “somewhat more” and SPT was “somewhat less” effective than the other treatments, their conclusions come across loud and clear. A reasonable clinician, reading the articles, would be ready to abandon SPT as a treatment whose time has passed. Indeed, the evidence-based enthusiasts among us may be tempted to add “and good riddance!” with the assumption that SPT represents all that was bad in the prescientific era of psychiatry.
? SPT is the most commonly practiced form of psychotherapy. It has been demonstrated to be effective in treating a broad range of psychiatric disorders.
? In recent years, SPT has been used as a comparator for other psychotherapy approaches. However, the way in which SPT has been defined and practiced in such studies does not fairly represent well-practiced SPT. Instead, it is often a pseudotherapy in which common SPT approaches are forbidden.
? Results of studies are often misinterpreted to suggest that SPT is not effective and that other therapies have specific benefits for particular disorders. The results of such studies are flawed and therefore do not provide a sound basis for “evidence-based practice.”
Has there ever been a good time for SPT? In the 1950s, the heyday of psychoanalysis, Sullivan3 described SPT as the Cinderella of psychotherapies, aptly summarized by Holmes4 in 1995 as “the poor relation of the psychotherapies, a Cinderella stuck at home doing the routine psychiatric chores while her more glamorous psychotherapeutic sisters are away at the ball.” Now, in the heyday of evidence-based practice, SPT has gained only a bit of stature—enough to be considered a reliable comparator in RCTs. Unfortunately, the way that SPT is administered and practiced is such that a recent review has recharacterized it as a straw man in the age of evidence-based practice: “Instead of being the poor relation of psychotherapies in practice, supportive therapy has now become a cast-away for control trial treatments.”5
Ironically, SPT is still the most frequently used modality of psychotherapy in clinical practice.6 In the 1998 National Survey of Psychiatric Practice, 36% of patients treated by psychiatrists received SPT compared with 19% who received insightoriented therapy, 6% who received CBT, and 1% who were psychoanalyzed. Although psychiatrists now spend less time doing psychotherapy than they did a decade ago, the psychotherapy they perform is likely to be supportive therapy.
After research publications in the early 1990s began to document the benefits of SPT, the Psychiatry Residency Review Committee of the Accreditation Council for Graduate Medical Education mandated that competence in SPT is required of all psychiatry residents, along with CBT, psychodynamic therapy, brief therapy, and combined psychotherapy and psychopharmacology.7 A number of texts on SPT have been published in recent years, and there is an increasing cadre of young psychiatrists and other mental health clinicians who have been trained to administer one or another form of SPT.8-11 SPT includes psychodynamically focused, interpersonal, and atheoretical formulations. SPT, regardless of the form, is widely used because of its flexibility, adaptability, and acceptability to both patients and clinicians, as well as its humane and empathetic orientation.