The Supportive Component of Psychotherapy

In view of the fact that support is an important aspect of all models of psychotherapy, it is remarkable that beginning practitioners are not taught how to be supportive. Only limited attention has been paid to discussion of the principles underlying supportive interactions. It seems to be taken for granted that good sense, kindness, innate empathy and life experience will enable psychotherapists-and physicians in general-to meet their patients' needs for support by communicating interest, liking and understanding. Just as the literature on psychoanalysis is a source for much of what we know about the expressive component of therapy, the limited literature on supportive psychotherapy is a source for ideas pertinent to the supportive component.

The term "supportive therapy" has been widely accepted for many years, although without an agreed-upon definition (Winston et al., 1986). Supportive therapy usually refers to various activities intended to prevent relapse or deterioration and to overcome symptoms, but not to bring about personality change. This modality has been defined in various ways: in terms of its target population, i.e., those who are not suitable for, or not willing to participate in, more substantial therapy (Wolberg, 1954); by comparing and contrasting it to expressive therapy (Dewald, 1971); and in terms of objectives (Novalis et al., 1993).

In the literature and in clinical practice, supportive therapy is at times used as an inflated way to describe a supportive relationship, and sometimes it is used to indicate a stand-alone modality. Pinsker and Rosenthal (1988) define supportive therapy as:

"A dyadic treatment characterized by use of direct measures to ameliorate symptoms and to maintain, restore, or improve self-esteem, adaptive skills, and psychological function. To the extent necessary to accomplish these objectives, treatment may utilize examination of relationships, real or transferential, and both past and current patterns of emotional response or behavior."

Most dynamic psychotherapy entails both supportive and expressive (exploratory) elements, i.e., there isn't much "pure" supportive or pure expressive treatment. Most individual therapy is what Luborsky (1984) has characterized as expressive-supportive and supportive-expressive.

A supportive relationship is characterized by acceptance, respect and interest. Most people rely upon supportive relationships with family, friends and co-workers to help prevent emotional problems, and to help them cope with problems when, and if, they emerge. A supportive relationship must exist if any psychotherapy is to proceed, but a supportive relationship alone does not constitute psychotherapy.

The patient who is maintained by an occasional monitoring visit is usually benefiting from a supportive relationship and, although it cannot properly be called psychotherapy, it is a valuable medical activity. Sometimes, psychotherapy that was once productive fades away, leaving only a supportive relationship in its place. When the therapist recognizes that this has happened, he or she should consider the possibility that another source of support might be more appropriate.

The supportive style is conversational. It is not conversation when a therapist listens in silence, only utilizing facilitators such as "uh-huh" and "yes." Nor is it a conversation when questions are routinely parried. An interrogatory (i.e., history-taking) style with many "Why?" questions should be avoided because it can be perceived as an attack (Pinsker, 1997). When a question is asked, the therapist acknowledges the response before going on to another topic.

Following are different responses to the same situation. The therapist queries, "Your husband accuses you of being irritable, but the way you see it, you are responding to his correcting you all the time. Is that right?" The therapist is seeking feedback. The patient responds, "Yes. He's always at me."

The therapist following the expressive model might remain silent, not interfering with the associative process. Using an interrogatory style the therapist immediately asks another question, "When he corrects you, is he sometimes on target?" and will continue to ask one question after another.

The therapist employing the supportive style might say something like, "That can be wearing," thereby noncommittally acknowledging the patient's response before going on.

In supportive therapy, positive efforts are made to minimize anxiety and to enhance self-esteem. Phrases that convey criticism, although they may be part of everyday life, have no place in supportive therapy. Some examples of this include "Did you hear me?" which may be perceived as "You are ignoring what I just said," or "What are you trying to say?" which may be perceived as "you are unable to express yourself competently."

The abstinence necessary to allow an unimpeded flow of associations is a technical maneuver devised to further the objectives of expressive therapy, not an attribute of all psychotherapies. Speaking to a silent listener is anxiety-provoking for all but self-absorbed people, who may revel in therapeutically unproductive monologue.

Phrases that physicians routinely use, although intended to reassure or encourage, may be registered by a patient as contradiction, negation or argument. A familiar example is saying "You look better," to the patient who has just said, "I feel worse than ever." The explanation, "It's your imagination," is usually experienced as denigration or dismissal, not as reassurance. Similarly, "You can do better," may be experienced as a rebuke.