Psychiatry residents who have been offered only the expressive model of psychotherapy may come to believe that the assumptions and technical maneuvers of expressive therapy are the model for all types of psychotherapy, and thus be unrealistically hesitant about "gratifying" the patient. According to what they have learned from therapy theories, supportive interventions may "reflect countertransference problems, theoretical misunderstanding or misguided technique" (Langs, 1973). The therapist who has been steeped in the analytic approach may assume that a departure from this model requires primarily that he or she be "warm and casual" (Berger, 1997), not appreciating that supportive therapy and supportive-expressive therapy are disciplined applications of definable techniques.
Definable supportive techniques include such direct measures as praise, encouragement, reassurance, advice, instruction and anticipatory guidance. Praise must be sincere, pertinent to what the patient believes is praiseworthy and supported by facts. Judgmental praise such as, "That's good!" is appropriate with low-functioning patients and has a limited role with higher-functioning patients. The most meaningful praise is related to the patient's goals and reinforces improvement of adaptive skills. "You have been talking about getting more exercise; it's good that you were able to follow through and do it. Do you agree?" (The psychotherapeutic issue is following through, not exercise, and soliciting feedback is important.)
As psychotherapeutic techniques, advice or reassurances are valid and appropriate only within the area of the therapist's expertise. For example, the therapist may say "You have always done well, even though you worry" (if the data support the statement). But he or she should not say "I'm sure you will do well."
Advice must be clearly connected to psychological, emotional or adaptive issues. The therapist should not ordinarily offer advice that is based solely on his or her wisdom, experience and personal prejudice. Advising a disabled patient who has difficulty meeting the requirements of a rehabilitation program to refrain from going on job interviews is expert advice reflecting the therapist's understanding of the patient's deficiencies and concern about the impact of rejection on her self-esteem. Advising a working person that he should not sell his apartment and move to the suburbs is likely to be a reflection of the therapist's personal preferences. Although Freud gave advice about where to live, what job to take or whom to marry (Lynn and Vaillant, 1998), that does not make it good practice.
Clarification (summarizing, paraphrasing and organizing the patient's statements without elaboration or inference) and confrontation (bringing to the patient's attention a pattern of behavior, ideas or feelings that has not been recognized or that is being avoided) are employed. Interpretation of the genetic origins of problems is not an objective of supportive work. Defenses are challenged only when they are clearly maladaptive. Unrealistic grandiosity or pathological projections are not endorsed. Rationalization and denial may go unmentioned, but not unnoticed. Transference issues are discussed only when they threaten to disrupt the treatment. The therapist should be able to recognize manifestations of transference or countertransference, but conversation about these issues has little place in the supportive mode.Balance Between Supportive and Expressive Approaches
Supportive approaches do not require adherence to psychodynamic theory (Pinsker, 1994), but they are compatible with it, as they are also compatible with cognitive-behavioral therapy and medical practice in general. Addressing the topic of how to determine the balance between supportive and expressive techniques, Wachtel (1993) advised, "Be as supportive as you can be so that you can be as expressive [or exploratory] as you will need to be."
When psychotherapy is based on the expressive model (i.e., the assumptions, premises and techniques of expressive therapy), the therapist only gives up as much neutrality as necessary. In the supportive therapy model, however, the therapist is no more neutral than necessary. My colleagues and I have proposed that instead of applying the expressive model to all but the most supportive end of the psychotherapy spectrum, the supportive model should be paramount in all but the most expressive treatment (Hellerstein et al., 1994).
The supportive component of expressive-supportive treatment entails being alert for opportunities to offer praise and encouragement, solicit feedback and explicitly define the agenda. Efforts to minimize or prevent anxiety are appropriate with most patients. At the middle of the psychotherapy spectrum, the therapist must determine for each patient whether to utilize transferential aspects of the relationship, or to keep it to himself or herself.
As the patient's condition and goals change, the role of expressive elements may become greater. At all times, however, therapy should be coherent and consistent. One does not make transference interpretations one day and not the next, or alternate between ignoring or challenging defenses. And although discovery of unconscious forces is not an objective when the supportive component is prominent, it is important that the therapist be aware of the ways that the unconscious process and transference can affect the patient, the therapist and the therapeutic relationship. Unconscious forces do not cause all the mental disorders once attributed to them, but they often determine the outcome of treatment.Supportive Therapy and the Common Factors
Because psychotherapy research has generally failed to demonstrate that any one type of psychotherapy is more effective than another, it has been hypothesized that the effects of psychotherapy might be related to factors common to all therapies.
Lambert and Bergin (1994) listed 32 factors common across therapies that are associated with positive outcomes. They included: reassurance, structure, empathy, advice, cognitive learning, changing expectations for personal effectiveness, cognitive mastery, modeling and success experience. Weinberger (1995), Frank and Frank (1991), and Winston and Muran (1996) all concluded that the therapeutic relationship is a major factor in determining outcome. deJonghe et al. (1992) stated: "Without minimizing the importance of the interpretation-insight factor, we contend that the support-experience factor is the mute and underestimated power of psychoanalysis; it is its silent force."
If the therapeutic relationship and provision of support are, in fact, the active ingredients in psychotherapy, attention by all therapists to this aspect of their work would seem to be worthwhile.Education
Treatment techniques have traditionally been presented to students as derivatives from theories about personality-development and symptom-formation. Supportive psychotherapy has not been derived from theory; perhaps this is one of the reasons why supportive techniques are not usually part of the curriculum. Education about supportive therapy ought to be part of residency training. Although most residents develop a repertoire of supportive skills, specific instruction about supportive therapy and supportive techniques would surely bene-fit patients treated by residents and other trainees in the early years of their careers.
It may be comforting to think of dropout and noncompliance as expressions of a patient's psychopathology. However, the practitioner who is skillful at establishing and maintaining relationships will have fewer dropouts and better compliance. Because the ability to be supportive has been vaguely assumed to be a personality attribute of the therapist rather than as a skill to be learned, attention to the supportive component of therapy might have been seen as an admission of personal deficiency rather than the pursuit of technical prowess.Conclusion
The supportive component of psychotherapy involves deliberate efforts to enhance the therapist-patient relationship, to minimize anxiety and to enhance the patient's self-esteem. When the patient is severely impaired, the supportive component is paramount. With the patient who functions at a higher level and whose treatment is supportive-expressive or expressive-supportive, supportive measures may be most important for a successful outcome.
Psychotherapy research has generally not found that "pure" expressive therapy is more effective than other therapies. Even if it were possible to demonstrate unique benefits from expressive therapy, it would not alter the reality that most medical psychotherapy today is supportive-expressive or supportive in conjunction with other modalities.