Supportive psychotherapy

Sigmund Freud, founder of psychoanalysis, holding a cigar. Photographed by his son-in-law, Max Halberstadt, c. 1921

In the late 19th century, Sigmund Freud began to develop the techniques of psychoanalysis, which served as a foundation for all the other psychotherapeutic modalities. Freud found that by letting people talk freely about whatever came to mind (free association), they eventually revealed the origins of their psychological conflicts in disguised form. Upon hearing these confessions revealed through free association, the therapist would then interpret the unconscious cause for the patient’s symptoms.[3]

In the years following Freud’s development of psychoanalysis, this approach was seen as the default in treating mental illness in patients. Psychotherapists faced the problem of patients who were unanalyzable: those without the reflective capacity to hear interpretations, or with “pseudoneurotic schizophrenia”.[4] These patients who would react negatively to psychoanalysis would then receive a more bolstering, “supportive” treatment. This therapy, which would later be recognized as the initial stages of supportive psychotherapy, was not the preferred mode of treatment, not for the preferred patients, and hence, was seen as pejorative from the onset.

Franz Alexander studied Freud, and although he was trained in classical psychoanalytic technique, he began to evolve his own ideas about what allowed the curative process to occur in therapy.[5]

Alexander noted that in classical psychoanalysis, the essential requirement for change was the insight the patient gained from interpretation of the transference neurosis. Alexander agreed with Freud that during psychoanalysis the patient underwent transference based on earlier life experience and emotional traumas. While Freud believed that the insight the patient gained from this was essential for healing to occur, Alexander felt the process of the patient feeling nurtured or comforted while reliving emotional traumas was also a curative force. He began to look at other factors that might be contributing to improvement, factors not related to insight but rather to the relationship of the patient with the psychoanalyst.[5]

The objective of supportive psychotherapy was not to change the patient's personality but to help the patient cope with symptoms, prevent relapse of serious mental illness, or help a relatively healthy person deal with a crisis or transient problem. As defined in earlier years, supportive psychotherapy is a body of techniques, such as praise, advice, exhortation, and encouragement, embedded in psychodynamic understanding and used to treat severely impaired patients.[6]

Over the next few decades and with ample studies to demonstrate efficacy, supportive psychotherapy gained momentum among professionals as a practical and efficacious method of therapy and supportive psychotherapy became recognized as the default treatment for patients with more severe psychological symptoms or those who couldn’t withstand the rigors of psychoanalysis.

Supportive psychotherapy has been shown to be effective in a variety of psychiatric conditions including schizophrenia, bipolar disorder, depression, anxiety disorders, personality disorders, substance use disorders, eating disorders, and postpartum depression.

Supportive psychotherapy has also shown to be effective in a variety of medical conditions including breast cancer, ovarian cancer, diabetes, leukemia, heart disease, chronic bronchitis, emphysema, inflammatory bowel disease, back pain, and for hemodialysis patients.[10][11][12][13]

Additionally, supportive therapy is recognized as the treatment of choice for patients seen by psychiatrists and residents who are suffering from extra-psychic problems, such as poverty, social and political oppression, and abuses of power in relationships that threaten to overwhelm their coping capacities.[14]

Strategies and techniques associated with supportive psychotherapy include the following:[3]

In an extensive longitudinal study developed in the 1950s, the "Menninger Psychotherapy Research Project" compared patients receiving psychoanalysis, psychoanalytic psychotherapy, and supportive psychotherapy over a 23-year span. The main objective of the study was to critically examine the difference between psychoanalysis and psychoanalytic psychotherapy. The supportive psychotherapy arm of the study was placed more as a control condition than as a rigorous technique for comparison. The study results concluded there were no significant differences among the three different types of psychotherapy.[16]

In one 1978 study looking at treatment of agoraphobia, mixed phobias, or simple phobias, patients were randomly assigned to one of three treatment conditions: behavior therapy alone, behavior therapy plus imipramine (medication) treatment, or supportive therapy plus imipramine (medication) treatment. Therapists in the behavior therapy groups used a manualized, highly structured treatment protocol that included relaxation training and systematic desensitization in imagination, specific in vivo desensitization homework assignments, and assertiveness training (including modeling, role playing, behavior rehearsal, and in vivo homework assignments). The supportive therapy was nondirective; patients took the initiative in all discussions. The therapists doing supportive therapy were instructed to be empathic and non-judgmental and to encourage patients to ventilate feelings and discuss problems, anxieties, and interpersonal relationships. The researchers found that there were no significant differences between the therapy conditions and that patients did well in both.[17]

In a 2005 randomized controlled study looking at cognitive-behavioral therapy versus interpersonal therapy for anorexia nervosa, once again supportive psychotherapy was used as a control condition. In the cognitive-behavioral therapy arm of the study, the patients underwent several phases of treatment, including psychoeducation, motivational assessment, cognitive-behavioral skills (including thought restructuring and homework assignments), relapse prevention, and recovery strategies.[18]

Researchers Arnold Winston, M.D., Richard N. Rosenthal, M.D., and Laura Weiss Roberts, M.D., M.A. express the elusiveness of the field of supportive psychotherapy: it is not based on “rigorous and internally consistent or appealing theory, it does not offer solutions to intractable clinical problems, and the field itself has no conferences, stars, and relatively few books.”[6]

In Winston’s Rosenthal’s and Robert’s text, “Learning Supportive Psychotherapy, Second Edition: An Illustrated Guide,” these authors note that “The psychotherapist’s central task is learning to understand...the emotional experience of the patient” (Balsam and Balsam), which was presented universally in regards to teaching supportive psychotherapy.

This universal treatment provided little guidance in how to handle patients who were inarticulate or poorly educated, who have intractable social problems, severe behavioral problems, or those who only visited for a couple months at a time or visited biweekly.[5]

In 2012, Adam M. Brenner, M.D. advocated for a “much more sophisticated approach” to teaching health professionals and therapists about supportive psychotherapy, which focused on three important factors of supportive psychotherapy:

• Its relevance for common factors underlying all forms of psychotherapy
• Its role on a spectrum of psychodynamically informed psychotherapies
• Its value as a modality that includes specifically definable techniques and aims

Brenner also advocated for “teaching supportive psychotherapy in diverse clinical rotations, including inpatient and consultation-liaison services as well as ambulatory settings.”[6]

As the method of supportive psychotherapy grew in popularity among psychologists and healthcare professionals, backlash concerning the effectiveness or validity of nonpsychoanalytic techniques arose. With psychoanalysis, the theory was that once a person improved through gaining insight, he or she underwent a permanent and curative change of personality. By contrast, changes brought about through more supportive types of psychotherapy were seen by critics as behavioral, meaning more transient and specific to the symptoms and not indicative of permanent personality change, which resulted in psychoanalysts believing that supportive-type therapy was not psychotherapy at all.[3]

An additional criticism regarding supportive psychotherapy is that it addresses only problems and conflicts that the patient is aware of. Other types of psychotherapy rely on less direct measures, such as identifying unconscious conflicts. Supportive psychotherapy looks at abstract entities such as defense mechanisms only when they seem maladaptive.[9]

• Phenomenology
• Psychotherapy
• Expressive therapies
• Supportive communication