Supportive Psychotherapy: Ugly Duckling of Psychiatric Practice

I have often struggled to help residents I supervise appreciate the great value that supportive psychotherapy can have long term for patients.

Would-be therapists are eager and highly motivated to provide the deepest, most profound, and intellectually stimulating interpretations to their patients, in the belief that this will deliver wisdom and insight that will cause them to abruptly throw down their crutches and walk into the future neurosis-free, euthymic, and totally self-actualized.

What is hard to teach is the value of being with. Often denigrated as handholding, since it requires no particular intellectual sophistication on the part of the clinician, it also fails to justify itself as an action to many students and practitioners. In 1988, I read Doris Lessing’s The Making of the Representative for Planet 8 in preparation for watching Philip Glass’s operatic setting of this book by the Houston Grand Opera. In it, an emissary is dispatched to a doomed planet to witness and share the experience with those who live there. The book has stayed with me for decades as a reminder of the action and gift of being with. No doubt we all hope that our patients will eventually experience much happier results, yet there is ample opportunity, prior to remission, to witness and share an understanding of their condition and their struggle while diagnosing, treating, and waiting for results.

Being there or being with is an action—the decision to hear, accept, and reflect understanding of a patient’s internal experience during assessment and treatment. It does not automatically occur just by being in the room with a patient. To be heard, to feel understood, and to be accepted free a patient to accept the situation and to make any possible changes. Supportive psychotherapy is figurative handholding. It is also listening, caring, and pointing the way forward for those who need hopeful guidance.

Supportive psychotherapy is an important tool, not just for the psychotherapist, but for the psychopharmacologist as well. When we refer to a therapeutic alliance, we often emphasize the motivation and agreement aspect—we are working together, side by side, solely for the benefit of the patient. Perhaps we don’t stress enough the importance of being with that, along with positive expectations by the practitioner, can help a patient develop hope and stamina—“grit,” as is it is so commonly described today.

As most psychiatric conditions are chronic, treatment often results in long-term relationships. Underappreciating the value of supportive psychotherapy (particularly in psychopharmacological treatment or in cases of conditions such as schizophrenia with limited outcome expectations and contraindication for many other forms of psychotherapy) denies our patients the opportunity to experience the beauty of shared understanding and acceptance.

Psychotherapy can occur without any brilliant interpretations, behavioral assignments, or cognitive linkages. Thomas E. Steele, M.D., who best taught me the process, stressed that our job in psychotherapy is not to be “ardent detectives of psychopathology,” but to never underestimate the value of our goodwill, undivided attention, and common sense. ■