Supportive Psychotherapy: Giving Cinderella Her Due

Supportive psychotherapy is a form of psychotherapy that uses empirically and evidence-based techniques—that is, techniques that have been observed to work to

• promote a generally positive and nonconflictual therapist-patient relationship;

• enhance the patient’s strengths, coping skills, and capacity to use environmental supports;

• reduce the patient’s subjective distress and behavioral dysfunction;

• achieve for the patient the greatest practical degree of independence from his or her psychiatric illness; and

• foster the patient’s greatest possible degree of autonomy in treatment decisions.

Supportive psychotherapy has been called the Cinderella of psychotherapies because it does the mundane tasks in psychotherapy. With the increasing emphasis on evidence-based treatments, it has frequently been relegated to the status of a weak comparator in psychotherapy outcome studies. The American Association of Directors of Psychiatric Residency Training also strives to make residents competent in this field.

What are these mundane tasks, and how do they make life easier for Cinderella’s stepsisters, who are presumably practicing the more glamorous and specialized psychotherapies such as psychodynamic, cognitive, or interpersonal therapies? Does Cinderella keep the house clean so the stepsisters can entertain visitors (establish the frame and ground rules for therapy), take their coats so they can sit by a warm fire (help them to shed defenses in a warm and supportive patient-therapist relationship), and feed them some warm hors d’oeuvres (provide praise and encouragement when needed)? Does she deal with criticisms of the meal (negative transference reactions) or even convince them not to leave abruptly (prevent disruption or early termination of treatment)? And if she does all these things, maybe she can go on to provide the full meal (use supportive techniques as the core of treatment). In other words, supportive psychotherapy can be the treatment of choice for many patients, even the supposedly high-functioning ones, or at least the starting treatment that segues into a more specialized or advanced treatment.

Renewed interest in supportive psychotherapy is evidenced by the publication of several new books on supportive psychotherapy, and, we are pleased to say, including the second edition of our Clinical Manual of Supportive Psychotherapy. Therefore, as experts in the field of supportive psychotherapy, if you ask us what you ought to know about the field, we do have a few words of advice.

Preconceptions about supportive psychotherapy, many of which have fallen by the wayside in the past few years, include the belief that it is suited only for low-functioning patients or those in need of temporary crisis support. The fact is, times are changing. People are spending less time in long-term psychotherapy as well as in psychoanalysis. Expectations for psychotherapy are also changing. In addition, it is useful, if not important, to understand the effect of supportive interventions even during the supposedly different task of prescribing psychotropic or even somatic medications. Even without an expectation of psychotherapy, just talking to patients in any medical setting can involve supportive techniques.

Here are three other preconceptions that are disproved by current research:

• FALSE: That patients need long-term psychodynamic therapy to accomplish long-lasting change in personality.

• TRUE: That patients can achieve long-term personality change in a short time.

• FALSE: That proven specialized psychotherapies like mentalization-based therapy (MBT) now have a definitive advantage over supportive psychotherapy for borderline personality disorder (BPD).

• TRUE: Reviews of multiple studies in the past few years show that mentalization is certainly good but its superiority is still being debated, and one well-cited study showed “that both MBT and supportive treatment are highly effective in treating BPD when conducted by a well-trained and experienced psychodynamic staff in a well-organized clinic.”

• FALSE: That cognitive-behavioral therapy (CBT) works for everybody and everything.

• TRUE: A study published in the April 2013 Acta Psychiatrica Scandinavica by C.R. Jørgensen et al. sheds doubt on the value of CBT for depression, schizophrenia, and bipolar disorder. “CBT is no better than nonspecific control interventions in the treatment of schizophrenia and does not reduce relapse rates. It is effective in major depression, but the size of the effect is small in treatment studies. On present evidence, CBT is not an effective treatment strategy for prevention of relapse in bipolar disorder,” wrote the authors.

As you recall, we opened this discussion with the recognition that supportive psychotherapy is being used as a weak comparator in psychotherapy outcome studies. Pardon the pessimism, but everybody is trying to prove something, especially psychotherapy researchers and innovators. As research proceeds, we learn what psychotherapies have an edge and what methods have an edge with certain patients with certain characteristics. We certainly have no bias against using psychodynamic, CBT, or mindfulness techniques with certain patients, but our own examination of this field indicates that at the core of all psychotherapies works Cinderella, often maligned and denigrated, but keeping the house of psychotherapy running for the rest of the day’s activities.

Invoking one last metaphor, we describe supportive psychotherapy as the stem of the flower of psychotherapies—a slight improvement, we think, of the “Y-model,” which was previously proposed for it in “The Y Model: An Integrated, Evidence-Based Approach to Teaching Psychotherapy Competencies” (Journal of Psychiatric Practice, January 2009).

It is important to know it, even if your favorite flower has other petals grafted onto it. Supportive psychotherapy is not likely to fall by the wayside like many other “fashionable” therapies that have had their 15 minutes or 15 years of fame. So it is worth investing your time in learning it, and not just in learning what other people (like us) say about it. Learn some methods, practice them, and discover what works for you with your own particular personality, style, and clientele. ■