Eugenio M. Rothe, MD

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 

, which allays anxiety, helps support the patient’s healthy defenses, and enhances adaptive skills; and 

. 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.

Most psychotherapies rely on the therapeutic alliance, but in supportive psychotherapy it is considered the most important element. When practicing supportive psychotherapy, one must negotiate a therapeutic alliance that preserves the authority, voice, and agency of the patient and ensures that he or she is active in the treatment. In patients who have chronic disorders, unsatisfactory living conditions, and little hope for change in their lives, the therapist represents a figure of 

, a contact with the outside world, and a representative of the broader world. Supportive psychotherapy stands in contrast to expressive therapies that seek to accomplish personality change through analysis of the relationship; exploration of previously unrecognized feelings, thoughts, needs, and conflicts; and development of insight. Supportive therapy includes some of these elements, so the therapist must move through a “psychotherapeutic continuum” (

The therapist takes into account the patient’s cognitive abilities, reality testing, thought process, capacity to organize behavior, affect regulation, and capacity to relate to others in order to determine the patient’s location on the continuum. Purely supportive interventions are chosen for patients with disorganized behavior, thought disorder or cognitive impairment, limited intelligence, and lower levels of education and socialization and for patients with personality disorders. With less impaired patients, expressive therapies are used. It is important for the therapist to be hopeful that the impaired patient can eventually move across to more psychodynamic supportive therapy and beyond.

Affect regulation is one of the most important goals of supportive psychotherapy. More regressed patients commonly have difficulties with affect regulation, which produces a state in which the patient cannot attend or think and which interferes with the capacity to self-reflect. The therapist must attend to the patient’s physical comfort in therapy and try to avoid interruptions and phone calls during the sessions; establish conditions of emotional safety, such as addressing issues of substance abuse, self-harm, and domestic abuse; and avoid an interrogation stance.

In contrast to more psychodynamic-oriented therapies, one must be careful not to be incisive when practicing supportive therapy with more vulnerable or regressed patients. Clarifications, interpretations, and confrontations may embarrass the patient, increase the patient’s anxiety to a level that he or she is incapable of modulating, and may reawaken memories of abuse. These interventions are more appropriate for treating patients with neurotic defenses that are analyzed and examined and the conflicts underlying the defenses identified.

 is fostered by conveying to the patient acceptance, interest, respect, and admiration for his or her accomplishments, thus supporting the patient’s self-esteem. Conscious problems are addressed, and defenses are questioned only when they are maladaptive. The patient is treated with honesty and respect.

Other important techniques used in supportive psychotherapy include behavior goal setting, encouragement, positive reinforcement, shaping behavior, and modeling. Children respond to the influence of their parents by imitating them and gradually by internalizing aspects of the parents by the process of identification. They later identify with other important figures in their lives. Some key aspects of these identifications include the development of a stable sense of self; a capacity to modulate anxiety so that it does not lead to defensive distortions of reality; a benevolent conscience that allows for a reasonable pursuit of pleasure without unreasonable guilt; and a capacity to love without fearing a loss of the self in experiences of fusion, or of excessive anxiety in the face of separations. For change to take place in therapy, interpretive work needs to occur with the patient’s increasing capacity for self-reflection, but modeling by the therapist provides some of the first and most fundamental building blocks for change.

Supportive therapy may include educating the patient and family members about the illness and about the patient’s potential and limitations, establishing realistic goals, addressing issues in the life of the patient that will reduce stress and anxiety, and helping the patient and the family improve their adaptive skills. It may also include limit setting and appropriate reward and punishment with children, and helping the patient, the family, and others involved to understand the patient’s functional and cognitive limitations.

It is important to take into account barriers to treatment such as economic, geographic, cultural, and stigma-related issues; distrust; and past persecutory experiences. 

 are the characteristic way in which members of different cultures describe what is wrong and which may differ from the expressions found in mainstream American culture. It is also very important to explore the patient’s history for adverse life events and to listen to the metaphors or therapeutic stories for adverse previous personal and medical experiences. In many cases, the patient’s “life-meaning story” is closely related to previous traumas that account for treatment resistance. In some cases, the patient fears a repetition of these traumas, such as in the case of psychiatric hospitalization, which may elicit fears of oppression, abuse, and incarceration.

I am grateful to David Lopez, MD, and Jennifer Downey, MD, of the 

American Academy of Psychoanalysis and Dynamic Psychiatry

 (AAPDP) for their invitation to write this article and for their review of the article. The AAPDP is the affiliate society of the American Psychiatric Association dedicated to all aspects of psychodynamic psychiatry. Its mission is to promote psychodynamic understanding when evaluating and treating patients in clinical practice, medical education, and residency training.

• Applebaum AH. Supportive psychotherapy. 

• Dohrenwend BP, Levav I, Shrou PE, et al. Socioeconomic status and psychiatric disorders: the causation- selection issue. 

• Lewis O. Culture of poverty. In: Moynihan DP, ed. 

On Understanding Poverty: Perspectives From the Social Sciences

• Pumariega A, Rothe EM, Mian A, et al. Practice parameters for cultural competence in child psychiatric practice. 

• Rothe EM. A psychotherapy model for treating child and adolescent refugees caught in the midst of catastrophic situations. 

. Arlington, VA: American Psychiatric Press; 2004. 

Dr. Rothe is Professor of Psychiatry and Public Health at the Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, and Immediate Past Chair of Scientific Programs, American Academy of Psychoanalysis and Dynamic Psychiatry.

Dr. Rothe reports no conflicts of interest concerning the subject matter of this article.

Articles

Supportive psychotherapy can serve as the first bridge out of social isolation and marginalization and addresses personality issues, such as deficits in character structure and defense mechanisms.

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

The American Academy of Psychoanalysis and Dynamic Psychiatry (

 (APA), will celebrate its 59th annual meeting on May14 to 16, 2015, at the 

 Hotel in Toronto. The mission of the AAPDP is to maintain psychotherapy as a fundamental part of the psychiatric profession and to integrate psychodynamic theory, neuroscience, and the humanities into the daily practice of psychiatry.

This year’s meeting offers a rich and varied program. In the opening plenary, Richard Brockman, MD, will revisit William Shakespeare in “Othello: Shame, Rage and Neurobiology,” reminding psychiatrists that much can be learned and rediscovered from the works of literature and the arts, especially in view of the recent scientific advances that help to further integrate psychodynamic theory and neurobiology.

The first day of the meeting will include a series of symposia and workshops that focus on new approaches to the construction of 

 assessments and formulations, treatment plans, the integration of psychodynamic concepts into psychopharmacology, and the therapeutic use of dreams. These interactive presentations are specifically designed to help clinicians address the practical, everyday realities faced by today’s psychiatrists.

They also aim at helping psychiatrists maintain their understanding of the patient as “a real person,” putting in place treatment plans that incorporate psychopharmacology and psychodynamics. The hope is that psychiatrists will develop stronger 

 that help to improve treatment adherence and treatment outcomes and avoid the reductionistic approaches that are often imposed by third-party payers.

In the humanistic tradition that characterizes the meetings of the AAPDP, Chuck Joy, MD, will share his poetry in the interactive workshop titled, “A Psychiatrist-Poet Invites You to Explore What His Poetry Evokes in You.” Later, Gregory Mahr, MD and Dennis Kuo, MD will explore the relationship between “Music, Mind, and Brain.”

Other presentations will focus on the relationship between the therapeutic alliance and somatization; 

; the therapist’s capacity of self-regulation when treating severely regressed patients; and unique 

 to the treatment of trauma in diverse patient populations, such as war veterans, victims of torture, and AIDS patients.

Two plenary addresses will feature, Graeme Taylor, MD, who will discuss, “Patients With a Paucity of Inner Experiences: Insights from Neuroscience and Empirical Research,” and Andrew Gerber, MD, PhD, who will talk about “The Essential Role of Neuroscience Research and the Future of Psychoanalysis.”

The second day of the meeting will include presentations on dealing with the death of a parent as a college student; violations in the treatment alliance; how metaphor creates an environment for change in psychotherapy; the Superego seen from the point of view of neurobiology; memory reconsolidation in psychotherapy; and the contributions of the Babylonian Talmud to the understanding of dreams, among others.

The presidential address will be given by Elizabeth Auchincloss, MD, who will discuss “New Developments in the Therapeutic Alliance and Its Implications for the Future of Psychotherapy and Psychoanalysis.” The meeting will include presentations; paper sessions; and a luncheon for residents and medical students, who are invited to attend the meeting free of charge upon presenting a valid ID.

The AAPDP invites all psychiatrists, residents, and medical students interested in psychodynamic therapy to register and attend this stimulating and exciting meeting, which takes place immediately before the APA, by logging on to 

Dr Rothe is Chair of Scientific Programs for the American Academy of Psychoanalysis and Dynamic Psychiatry.

The American Academy of Psychoanalysis and Dynamic Psychiatry meeting will include a series of symposia and workshops that focus on new approaches to psychotherapy.

Psychodynamic Psychiatrists to Meet in Toronto Alongside the APA

San Francisco will host the 57th annual meeting of the 

American Academy of Psychoanalysis and Dynamic Psychiatry (AAPDP)

, which will take place concurrently with the American Psychiatric Association (APA) annual meeting from May 16 to 18, 2013. The chosen location will be at the Westin St. Francis Hotel at 335 Powell Street with easy access to many of the city’s main attractions.

The AAPDP welcomes all psychiatrists interested in psychotherapy and psychodynamics and has as its mission keeping psychodynamic therapy as an integral part of the psychiatric profession. This year’s meeting will highlight the topic of Suicide and the Opening Speaker will be Mardi Horowitz, MD, who will present on 

The Keynote Address will be given by APA President, 

Wisdom: From Psychology to Neuroscience. 

The Friday morning program will consist of 2 symposia-

On the Nature of the Clinical Applications of Psychodynamics 

Transcultural and Intergenerational Aspects of Suicide

. These will befollowed by a resident’s workshop sponsored by the New York Medical College Psychoanalytic Institute and titled

, Clinical Dilemmas and Therapeutic Issues.

 It will feature a rich and diverse collection of their own clinical experiences presented by residents and discussed by the masters.

Friday’s noon workshops will address the paradoxes of, 

Suicide as Impact of Trauma and Trauma as Impact of Suicide, 

Relational Suicide Assessment With Particular Attention to Medical Students. 

The afternoon will start with a presentation of a 90-minute documentary film titled 

 followed by an interview with the documentary author-filmmaker Michael Stutz, conducted by AAPDP President, Michael Blumenfield, MD, followed by a question and answer session with the audience.

Psychodynamic Psychotherapy With Persons that have Medical Illnesses,

States of Mind Preceding Near Lethal Suicide Attempts.

 Workshops will continue on Saturday and will address such tiles as: 

Trauma and Identity in a Psychological Autopsy

 and other symposia addressing novel approaches of the psychodynamic treatment of PTSD, countertransference issues in suicide, treatment of the suicidal adolescent, the psychodynamics of physician-assisted suicide, suicide issues in the military, the therapeutic use of dreams, Jungian perspectives on suicide, a pharmacology peer supervision workshop, and a workshop for residents and medical students.

The meeting will also feature a live interview with one of the masters of the AAPDP covering the life and work of Leah Davison, MD. The meeting will conclude with the Presidential address given by former APA president Herb Pardes, MD, who will discuss 

Psychodynamics in a Turbulent World of Health Reform

The American Academy of Psychoanalysis and Dynamic Psychiatry welcomes all psychiatrists interested in psychotherapy and psychodynamics and has as its mission keeping psychodynamic therapy as an integral part of the psychiatric profession.

Psychodynamic Psychiatrists to Meet Alongside the APA in San Francisco

Philadelphia will host this year’s annual 56th Annual Meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry (

), which will take place from May 3 to 5, 2012. The chosen location will be at the Loews Philadelphia Hotel at 1200 Market Street, with easy access to many of the city’s main attractions.

In what now has become a tradition and a statement about our strong ties with the American Psychiatric Association (APA), the Opening Speaker will be APA President John Oldham, MD, who will inform us about “Personality Disorders and DSM-5.” Thanks to the efforts of co-chairs Eugene Della Badia, DO, and Kimberly Best, MD, the meeting will highlight a Plenary Session with Henri Parens, MD, a child survivor of the holocaust and Professor of Psychiatry at Jefferson Medical College, who will present autobiographical material and discuss the topic of “Resiliency.” The Keynote Address will be delivered by Salman Akhtar, MD, also a Professor at Jefferson, who will present on “Psychoanalytic Perspectives on Human Goodness: Theory and Technique.”

The Friday program will begin with two concurrent panels: the first will be chaired by Andres Pumariega, MD, Chairman of Psychiatry at the Cooper Medical School in Camden, New Jersey, and will focus on “Psychotherapy Approaches with Children and Families of Underprivileged and Culturally Diverse Backgrounds.” The concurrent panel “New Frontiers in Psychodynamic Psychiatry,” will be chaired by Gail Berry, MD, with Gerald P. Perman, MD, as discussant. This will be a rich and diverse collection of presentations covering applied psychodynamics, politics and neuroscience.

Friday’s noon workshops will consist of Cesar Alfonso, MD, and Silvia Olarte, MD’s “The Psychiatrist as Internist of the Mind,” concurrently with Crittenden Brookes, MD, PhD, and Clay Whitehead, MD’s ongoing and exciting discussion group, “Theoretical Models of Psychotherapy.” The afternoon will offer a series of very exciting consecutive presentations, all in the same room, in order to allow the members to interact as a group and be able to attend all the presentations without having to make difficult choices. The session will start out with Erminia Scarcella, MD’s “The Red Book of C.J. Jun,” and Sheila Hafter-Gray, MD, as discussant, followed by Samuel Slipp, MD, who will present on “How Freud’s Fight Against Anti-semitism Split the Psychoanalytic Movement.” Later, Buddy Glucksman, MD, and Milton Kramer, MD, will present on “Initial and Manifest Dream Reports of Patients in Psychodynamically-Oriented Psychotherapy,” ending with Greg Mahr, MD, of Michigan, who will present on “The Overdiagnosis of Bipolar Disorder: Countertransference Aspects.”

The Saturday morning program will begin with two concurrent panels. One will focus on the “The Interface between Psychodynamics and Biologic Psychiatry,” including topics such as evidence-based findings on adherence to medication, splitting treatment with psychologists and social workers, and the use of MRI’s and genetic testing in psychodynamic psychiatry. The other panel will focus on “Child and Adolescent Psychiatry,” and it will cover such topics as psychodynamic reactions to foster care; psychotherapy with persons who are adopted; childhood precursors to personality disorders; and an international perspective on attachment. The noon program will present attendees with two consecutive and very difficult choices. The first two workshops will focus on “Neurodynamics and Psychodynamics of Narrative,” by Richard Brockman, MD, and “Transcultural and Psychodynamic Psychiatry in the Era of Globalization” chaired by Cesar Alfonso, MD, and Antonio Bullon, MD. These are followed by another very difficult choice for the attendees: “Narratives and Brain Processing” with Andrei Novac, MD, and Barton Blinder, MD, of Newport Beach, California, concurrently with a workshop titled: “Interfacing with the Academy Journal: Psychodynamic Psychiatry,” which will introduce members to the new Academy Journal, including instructions and coaching on how to publish articles in the journal. This workshop will be chaired by Richard Friedman, MD; Jennifer Downey, MD; Cesar Alfonso, MD; and Joseph Silvio, MD. In the meantime, that same day at noon, Kim Best will be chairing the “Residents Luncheon” in which psychiatry resident Heather Forouhar-Graff, MD, will present “The Nocebo Effect: Reviewing the Literature from a Medical Student’s Perspective.”

Saturday afternoon will consist of a three-hour panel, concurrently with three successive paper sessions on education, taking place in the adjacent room. The panel, “Update in HIV and AIDS Psychiatry,” will be chaired by Mary Ann Cohen, MD, and will encompass 5 distinguished presenters who will provide a comprehensive and up-to-date focus on these conditions. In the other room, Joseph Silvio, MD, and Peter Collori, MD, will present on “Rediscovering Psychodynamics in Modern Residency Programs: Experiential Training for PGY-I and Beyond,” followed another presentation focusing on psychiatric education titled, “Experientally Engaging Psychiatric Trainees in Reflection, Psychotherapy and Organizational Dynamics Using Balint Style Group Facilitation: The Dudley Model,” by Faisal Shafi Shaikh, MRCPsych, of the United Kingdom. The Faculty of the Psychoanalytic Institute of New York Medical College will sponsor the 3rd and final presentation of the afternoon titled, “Dilemmas in Clinical Practice,” and consisting of work with patients done by residents and with contributions by Scott Schwartz, MD. A rich discussion by Doug Ingram, MD; Joe Silvio, MD; Sherry Katz-Bearnot, MD; Buddy Glucksman, MD; and Silvia Olarte, MD, will follow.

The closing of the meeting will take place with the Presidential Address. Academy President Cesar Alfonso, MD, has chosen Debra Katz, MD, of the University of Kentucky, to deliver the presentation titled, “Inspiring Interest in Psychodynamic Psychiatry and Psychoanalysis: National Survey Data and Implications for the Future.”

There is a term in Latin that is used in judicial circles to define a situation that is so clear and of such common agreement, that it requires no argument. It’s “Res Ipsa Loquitur,”meaning: “the thing speaks for itself.” This is the most fitting description of the level of quality of our upcoming annual meeting. We hope to see you all in Philadelphia. Registration and contact information at 

Philadelphia will host this year’s annual meeting that will take place from May 3 to 5, 2012. The chosen location will be at the Loews Philadelphia Hotel at 1200 Market Street, with easy access to many of the city’s main attractions.

AAPDP Annual Meeting Offers a Rich and Exciting Program

A few years ago, the eminent professor of psychiatry, Dr Ronald Pies, wrote a commentary for 

 titled, “Are We Misreading the Signs in Psychiatry?”

 In that article, Dr Pies discussed the need for the comprehensive evaluation of patients in order to arrive at the correct diagnosis. We want to take from his premise that this concept should be expanded to include that among patients presenting with substance abuse as a primary diagnosis, other co-existing Axis I diagnoses should be considered. 

The recent passing of the famous British singer Amy Winehouse highlights once again the question: Is substance abuse a form of self-medication in some of the most well-known cases of public self-destruction? A 

 reads:“Amy Winehouse Died from Alcohol Withdrawal, Says Family.” Several London newspapers previously speculated about a heroin overdose. Whatever the cause of death, the demise of Amy Winehouse again sparks the debate about public figures who die from “yet another addiction,” leaving open the possibility that other co-existing Axis I diagnoses are being ignored and untreated.

As psychiatrists, we are well aware of the co-morbidity of substance abuse with major mental illness. Long before Mickey Mantle declared that he always needed several shots of liquor to face the press (social anxiety?), we have been aware that Vincent Van Gogh, Charles Dickens, Lord Byron, Salvador Dali, Sylvia Plath, and many other famous artists have struggled with mental illness and co-existing substance abuse disorders.

We have also seen the other side of the coin, for example, when clear cut alcohol or opiate abusers present with racing thoughts and irritable mood upon interrupting the abuse of their substance of choice and a diagnosis of bipolar disorder is made, only to discover later that such presentation was part of the withdrawal syndrome.

We venture to speculate that we, as psychiatrists, are not the ones misreading the signs, but that it is the media who miss the signs and misinform the public. It is our responsibility as psychiatrists to educate the media and the public in general about the danger of oversimplification and of the possibility that behind egregious and self-destructive substance abuse, there is often a co-existing psychiatric diagnosis.

1. Pies R. Are we misreading the signs in psychiatry? 

 2006;23(2):15-16.
2. Nudd T. Amy Winehouse died from alcohol withdrawal, says family. 

 Available at: http://www.people.com/people/article/0,,20513558,00.html. Accessed August 15, 2011.

It is our responsibility as psychiatrists to educate the media and the public in general.

Are the Media and the Public Still Missing the Clues?

Why Are Vampires So Popular in Our Culture?

That unusual topic was addressed by Dr Eugenio Rothe at a symposium at the recent 

. We’ve invited Dr Rothe to talk briefly about the appeal of vampires and what their popularity reveals about the human psyche. Dr Rothe is Professor of Psychiatry and Public Health at the Herbert Wertheim College of Medicine, Florida International University, and Chair of the Scientific Programs, of the 

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That unusual topic was addressed by Dr Eugenio Rothe at a symposium at the recent APA meeting in Honolulu.