Understanding supportive psychotherapy
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 stability, 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” (Figure).
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.
Supportive psychotherapy practice
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.
A strong therapeutic alliance 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.
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.