Additional techniques include self-esteem maintenance through the use of empathy (Luborsky, 1984), help in dealing with a severe conscience (Luborsky, 1984), modulating affect (Misch, 2000), developing a liking for the patient (Luborsky, 1984), facilitating the helping or working alliance (Luborsky, 1984), achieving emancipation from parents (Andreasen and Black, 1991), gratification of dependency needs (Kaplan and Sadock, 1985), reframing (Rockland, 1989), and many more.
It is important to distinguish between supportive techniques and supportive psychotherapy. The terms are often used interchangeably, leading to confusion. Almost all psychotherapies use some supportive techniques. For instance, the therapist's avoidance of value judgments, present in virtually all therapies, is very supportive for most patients. Only when a therapy is primarily composed of supportive techniques does it become supportive psychotherapy (Luborsky, 1984).
Considering the large and often disparate number of techniques described, therapists need a method or underlying theoretical formulation to guide them in their choice of appropriate supportive techniques, whether it is supportive or any other therapy.
Knight's original guideline, using techniques that will strengthen the patient's defenses, has remained intact (Knight, 1949). Recent additional guidelines tend to be similar to the one recommended by Misch (2000): Do for the patient what a good, mature and loving parent would do. These guidelines are useful; however, they are often insufficient.
The supportive psychotherapist is the gratifying therapist, as opposed to the psychoanalyst who, for the purpose of achieving an eventual cure, withholds from the patient and eschews fulfilling the patient's dependency needs. The supportive therapist is active, talks more to the patient, does things for the patient and engages in direct actions to help the patient. To accomplish this, a variety of techniques are used. I have found it helpful to conceptualize the techniques on a continuum, based on whether the therapist's activity is directed to environmental change or to improving the patient's adaptive capacity.
In this "Outer-Inner Continuum," there are five points (Figure). The range is from outer, which refers to the external world of the patient, to inner, which refers to the conscious thinking and feeling of the patient. The positive changes the patient is able to make based upon more adaptive ways of handling thoughts and feelings will have a greater therapeutic effect than will simply following the therapist's instructions. For some patients, however, there can be little doubt that frequent monitoring by a therapist is very beneficial.
At the outer end of the continuum the therapist is acting on behalf of the patient. This includes hospitalizing the patient, prescribing medication and advising the family to make environmental changes. The patient is primarily passive. All the activity is done for the patient, by the therapist.
At the next stage along the continuum, the therapist is not acting on behalf of the patient. The therapist is advising and guiding the patient to take actions the therapist believes will be beneficial. The therapist's activity is limited to directing the patient, but it is the patient who is performing the actions. The patient makes a behavioral change under the direction of the therapist.