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Supportive Psychotherapy in Everyday Clinical Practice: It’s Like Riding a Bicycle

Supportive Psychotherapy in Everyday Clinical Practice: It’s Like Riding a Bicycle

Levels of psychological impairmentFigure. Levels of psychological impairment

Supportive psychotherapy occurs in almost every doctor-patient encounter and is the psychotherapy provided to the vast majority of patients who are seen in psychiatric clinics and mental health centers. Yet very few scholarly articles are written that help explain its principles or how it works.

In the late 19th century, Freud began to develop the techniques of psychoanalysis, which served as a foundation for all the other psychotherapeutic modalities. Most of Freud’s patients were members of the upper classes of Viennese society and had significant ego strengths, and their problems were mainly intra-psychic. In contrast, many of the patients seen by psychiatrists and residents today suffer from extra-psychic problems, such as poverty, social and political oppression, and abuses of power in relationships that threaten to overwhelm their coping capacities. For these patients, supportive therapy is the treatment of choice.

Supportive psychotherapy is a dyadic treatment that uses direct measures to ameliorate symptoms and to maintain, restore, or improve self-esteem, ego functions, and adaptive skills. It was developed in the early 20th century, and its objectives are more limited than those of the psychodynamic therapies. This therapeutic modality focuses especially on developing adaptive capacities that take into account the patient’s limitations, including:

• Personality issues, such as deficits in character structure and defense mechanisms

• Native ability (eg, impaired reality testing, decreased cognitive functioning, lower IQ, learning disabilities)

• Problems associated with life circumstances (eg, lower levels of education, low socioeconomic status, limited social support systems, problems related to migration)

The connection between mental illness and poverty

There is a 2-way connection between mental illness and poverty. Poverty increases the risk of mental illness, and mental illness is often a person’s path into poverty. In 1965, the sociologist Oscar Lewis published the controversial document “The Culture of Poverty,” in which he argued that to adapt to their environment, people who live in poverty for a long time develop a series of coping mechanisms that become engrained and paralyzing and that affect the individual, the family, the slum community, and the community in relation to society.

Supportive therapy can serve as the first bridge out of social isolation and marginalization, since the 2 most important elements of supportive therapy are the therapeutic alliance, which allays anxiety, helps support the patient’s healthy defenses, and enhances adaptive skills; and conversational style. This style avoids analytic abstinence and engages the patient in a collaborative discussion that decreases the power differential.

Supportive therapy is also the treatment of choice in individuals with severe personality disorders, at least in the initial phases of treatment. Many individuals with personality disorders resent and fear the power differential that results from a more analytic stance, given that many of them have experienced abuses of power in early life. If the power differential is not addressed early in the treatment, it can destroy the therapeutic relationship.

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