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.
1. Isaacs D, Fitzgerald D. Seven alternatives to evidence based medicine. BMJ. 1999;319:1618.
2. Cuijpers P, van Straten A, Andersson G, van Oppen P. Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. J Consult Clin Psychol. 2008;76:909-922.
3. Sullivan HS. The Interpersonal Theory of Psychiatry. New York: Norton; 1953.
4. Holmes J. Supportive psychotherapy. The search for positive meanings. Br J Psychiatry. 1995;167:439-445.
5. Budge S, Baardseth TP, Wampold BE, Flückiger C. Researcher allegiance and supportive therapy: pernicious affects on results of randomized clinical trials. Eur J Counsel Psychother. 2010;12:23-39.
6. Tanielian TL, Marcus SC, Suarez AP, Pincus HA. Datapoints: trends in psychiatric practice, 1988-1998: II. Caseload and treatment characteristics. Psychiatr Serv. 2001;52:880.
7. ACGME, Residency Review Committee for Psychiatry. Program Requirements for Residency Training in Psychiatry. February 2000, effective January 2001. http://www.acgme.org/acwebsite/rrc_400/400_prindex.asp. Accessed July 11, 2011.
8. Novalis PN, Rojcewicz SJ, Peele R. Clinical Manual of Supportive Psychotherapy. Washington, DC: American Psychiatric Press; 1993.
9. Pinsker H. A Primer of Supportive Therapy. Hillside, NJ: Analytic Press; 1997.
10. Winston A, Rosenthal RN, Pinsker H. Introduction to Supportive Psychotherapy: Core Competencies in Psychotherapy. Washington, DC: American Psychiatric Publishing; 2004.
11. Rockland LH. Supportive Therapy: A Psychodynamic Approach. New York: Basic Books; 1989.
12. Foa EB, Rothbaum BO, Riggs DS, Murdock TB. Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive-behavioral procedures and counseling. J Consult Clin Psychol. 1991;59:715-723.
13. Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007;164:922-928.
14. Hellerstein DJ, Rosenthal RN, Pinsker H, et al. A randomized prospective study comparing supportive and dynamic therapies. Outcome and alliance. J Psychother Pract Res. 1998;7:261-271.
15. Rosenthal RN, Muran JC, Pinsker H, et al. Interpersonal change in brief supportive psychotherapy. J Psychother Pract Res. 1999;8:55-63.
16. Behar ES, Borkovec TD. Psychotherapy outcome research. Handbook of Psychology. Wiley Online Library; 2003:213-240. http://onlinelibrary.wiley.com/doi/10.1002/0471264385.wei0209/full.
17. Aviram RB, Hellerstein DJ, Gerson J, Stanley B. Adapting supportive psychotherapy for individuals with borderline personality disorder who self-injure or attempt suicide. J Psychiatr Pract. 2004;10:145-155.
18. Hellerstein DJ. Combining supportive psychotherapy with medication. In: Gabbard GO, ed. The American Psychiatric Publishing Textbook of Psychotherapeutic Treatments in Psychiatry. Washington, DC: American Psychiatric Press; 2008:595-629.