Supportive psychotherapy
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Supportive psychotherapy is a
psychotherapeutic approach Clinical psychology is an integration of social science, theory, and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically based distress or dysfunction and to promote subjective well-being and persona ...
that integrates various therapeutic schools such as
psychodynamic Psychodynamics, also known as psychodynamic psychology, in its broadest sense, is an approach to psychology that emphasizes systematic study of the psychological forces underlying human behavior, feelings, and emotions and how they might relate t ...
and cognitive-behavioral, as well as interpersonal conceptual models and techniques. The aim of supportive psychotherapy is to reduce or to relieve the intensity of manifested or presenting symptoms, distress or disability. It also reduces the extent of behavioral disruptions caused by the patient's psychic conflicts or disturbances. Unlike in
psychoanalysis PsychoanalysisFrom Greek: + . is a set of theories and therapeutic techniques"What is psychoanalysis? Of course, one is supposed to answer that it is many things — a theory, a research method, a therapy, a body of knowledge. In what might b ...
, in which the analyst works to maintain a neutral demeanor as a "blank canvas" for
transference Transference (german: Übertragung) is a phenomenon within psychotherapy in which the "feelings, attitudes, or desires" a person had about one thing are subconsciously projected onto the here-and-now Other. It usually concerns feelings from a ...
, in supportive therapy the therapist engages in a fully emotional, encouraging, and supportive relationship with the patient as a method of furthering healthy
defense mechanisms In psychoanalytic theory, a defence mechanism (American English: defense mechanism), is an unconscious psychological operation that functions to protect a person from anxiety-producing thoughts and feelings related to internal conflicts and o ...
, especially in the context of
interpersonal relationships The concept of interpersonal relationship involves social associations, connections, or affiliations between two or more people. Interpersonal relationships vary in their degree of intimacy or self-disclosure, but also in their duration, in t ...
. Supportive psychotherapy can be used as treatment for a variety of physical, mental, and emotional ailments, and consists of a variety of strategies and techniques in which therapists or other licensed professionals can treat their patients. The objective of the
therapist Therapist is a person who offers any kinds of therapy A therapy or medical treatment (often abbreviated tx, Tx, or Tx) is the attempted remediation of a health problem, usually following a medical diagnosis. As a rule, each therapy has indi ...
is to reinforce the patient's healthy and adaptive patterns of thought
behaviors Behavior (American English) or behaviour (British English) is the range of actions and mannerisms made by individuals, organisms, systems or artificial entities in some environment. These systems can include other systems or organisms as wel ...
in order to reduce the intrapsychic conflicts that produce symptoms of
mental disorder A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitt ...
s.


Evolution of Supportive Psychotherapy

In the late 19th century,
Sigmund Freud Sigmund Freud ( , ; born Sigismund Schlomo Freud; 6 May 1856 – 23 September 1939) was an Austrian neurologist and the founder of psychoanalysis, a clinical method for evaluating and treating pathologies explained as originating in conflicts ...
began to develop the techniques of
psychoanalysis PsychoanalysisFrom Greek: + . is a set of theories and therapeutic techniques"What is psychoanalysis? Of course, one is supposed to answer that it is many things — a theory, a research method, a therapy, a body of knowledge. In what might b ...
, 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. 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”. 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 Franz Gabriel Alexander (22 January 1891 – 8 March 1964) was a Hungarian-American psychoanalyst and physician, who is considered one of the founders of psychosomatic medicine and psychoanalytic criminology. Life Franz Gabriel Alexander, in ...
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. 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. 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. 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.


Context and History


''Context''

Supportive psychotherapy is often practiced for patients who are considered lower functioning, too fragile, or too unmotivated to participate in more demanding expressive therapy, which might have more chance of leading to personality change. As a dyadic treatment that is characterized by use of direct measures to ameliorate symptoms and to maintain, restore, or improve self-esteem, adaptive skills, and psychological (ego) function, the treatment itself works to observe relationships (real or transferential) and both current and past patterns of emotional or behavioral response. As supportive psychotherapy is introduced in environments less formal than a primary care office, supportive psychotherapy can appear as an expression of interest, attention to concrete services, encouragement and optimism. The relationship between the patient and the professional during supportive treatment exists solely to meet the needs of the patient, and it should not develop as a platonic relationship outside of professionalism.


''History''

Supportive psychotherapy functions with the objective of reducing anxiety and maintaining a positive patient-therapist relationship with minimal focus on transference. While this practice of therapy is seldom studied, it has since been identified and functions as an alternative to expressive therapy. Supportive psychotherapy and supportive treatment works well for patients who are anticipated to fail at expressive therapy, or who are generally difficult to treat with expressive therapy. An early documentation of supportive psychotherapy can be found in ''The Journal of Psychotherapy Practice and Research'' with contributions from David J. Hellerstein, M.D., Henry Pinsker, M.D., Richard N. Rosenthal, M.D., and Steven Klee, Ph.D. In their contributions to the study and exploration of supportive psychotherapy,  These researchers note that with supportive and expressive falling on a continuum, the model for individual dynamic psychotherapy should be based on concepts from the supportive end of the continuum, rather than the expressive end. A summary of Otto F. Kernberg’s definition of supportive psychotherapy is featured in ''The Journal of Psychotherapy Practice and Research'' and defines what supportive therapy does rather than what it is. Kernberg’s definition includes actions like: * reducing behavioral dysfunctions * reducing subjective mental distress * supporting and enhancing the patient’s strengths, coping skills, and capacity to use environmental supports * maximizing treatment autonomy * facilitating maximum possible independence from psychiatric illness.


Uses

Supportive psychotherapy has been shown to be effective in a variety of psychiatric conditions including
schizophrenia Schizophrenia is a mental disorder characterized by continuous or relapsing episodes of psychosis. Major symptoms include hallucinations (typically hearing voices), delusions, and disorganized thinking. Other symptoms include social wit ...
,
bipolar disorder Bipolar disorder, previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that last from days to weeks each. If the elevated mood is severe or associated with ...
, depression, anxiety disorders,
personality disorder Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture ...
s, substance use disorders, eating disorders, and
postpartum depression Postpartum depression (PPD), also called postnatal depression, is a type of mood disorder associated with childbirth, which can affect both sexes. Symptoms may include extreme sadness, low energy, anxiety, crying episodes, irritability, and cha ...
. Supportive psychotherapy has also shown to be effective in a variety of medical conditions including
breast cancer Breast cancer is cancer that develops from breast tissue. Signs of breast cancer may include a lump in the breast, a change in breast shape, dimpling of the skin, milk rejection, fluid coming from the nipple, a newly inverted nipple, or a r ...
,
ovarian cancer Ovarian cancer is a cancerous tumor of an ovary. It may originate from the ovary itself or more commonly from communicating nearby structures such as fallopian tubes or the inner lining of the abdomen. The ovary is made up of three different c ...
,
diabetes Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...
,
leukemia Leukemia ( also spelled leukaemia and pronounced ) is a group of blood cancers that usually begin in the bone marrow and result in high numbers of abnormal blood cells. These blood cells are not fully developed and are called ''blasts'' or ...
, heart disease,
chronic bronchitis Bronchitis is inflammation of the bronchi (large and medium-sized airways) in the lungs that causes coughing. Bronchitis usually begins as an infection in the nose, ears, throat, or sinuses. The infection then makes its way down to the bronchi. ...
, emphysema, inflammatory bowel disease,
back pain Back pain is pain felt in the back. It may be classified as neck pain (cervical), middle back pain (thoracic), lower back pain (lumbar) or coccydynia (tailbone or sacral pain) based on the segment affected. The lumbar area is the most common ...
, and for
hemodialysis Hemodialysis, also spelled haemodialysis, or simply dialysis, is a process of purifying the blood of a person whose kidneys are not working normally. This type of dialysis achieves the extracorporeal removal of waste products such as creatinin ...
patients. 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.


Strategies and Techniques

Strategies and techniques associated with supportive psychotherapy include the following:


''Listening''

Argued by author John Battaglia as “the most powerful skill of supportive psychotherapy”, the element of listening in regards to supportive psychotherapy helps patients feel “heard” by their therapists or health professionals. Effective listening “includes careful attentiveness to the body language, emotional tone, and overall bearing of patients in the sessions.”


''Plussing''

Plussing is defined as “promoting a positive atmosphere in the therapy by finding the good in the patient and accentuating the positive in the patient’s situation.” Battaglia compares this supportive psychotherapy strategy to “putting on rose-colored glasses and seeing what the patient presents as half full,” and assisting patients with finding a positive outlook even if it appears difficult to find.


''Explaining Behavior or Advice''

Using the explaining behavior strategy within supportive psychotherapy allows for therapists and health professionals to lead patients to areas of comfort or security as they navigate complex and overwhelming emotions or compulsions. With this technique, the behavioral explanations brought forth by the professional should aim to make sense to the patient and help them feel supported. Advice is another supportive psychotherapy strategy that branches from the explaining behavior technique. Advice is effective usually when the patient is able to connect it to their goals.


''Confrontation and Reframing''

Confrontation is essentially allowing the patient to reflect and comprehend how their patterns of behavior are contributing to their suffering. Therapists and professionals help guide patients to understanding how repeated behaviors or emotions contribute to their mental health and symptoms. Reframing is related to the technique of confrontation as reframing involves looking at something in a different light or different angle and can provide patients with a new perspective as they undergo supportive psychotherapy.


''Encouragement or Praise''

Encouragement or Praise is often used in doses that are based on preexisting elements of the patient, such as their history, strengths, and weaknesses. Encouragement should be used sparingly in order to avoid the patient experiencing emotions of falling short to what their therapist expected of them. Using encouragement in this environment combines opportunities for education and movement in order to bring patients upward in their treatment or outside of their comfort zone. Additionally, this technique can be used to reinforce accomplishments or positive changes in behavior, and can be positioned as the reinforcement of the patient's steps towards achieving their stated goals.


''Hope''

Very similarly to encouragement, hope is to be used sparingly and appropriately by therapists and health professionals in order to “provide enough hope for the patient to see change as a realistic opportunity.”


''Metaphor''

The use of metaphors is a stimulating element of supportive psychotherapy that “ tilizesdifferent parts of the patient’s brain than those stimulated by many of the other more language based techniques.” A metaphor is said to “stick” in a patient's head in a “very durable way.”  


''Coping Skills''

Therapists and health professionals assisting patients with developing cognitive and behavioral coping skills is another technique used for supportive psychotherapy. These techniques range in complexity, and can consist of mantras or coping plans for the patient.


''Self-soothing''

Giving patients the tools necessary to develop self-soothing habits in opposition to unhealthy acting-out behavior, such as extreme mood swings, substance abuse, or acting out.


''Creative Opportunities''

Creative opportunities allow for therapists and health professionals to introduce their patients to creative outlets in order to express their emotions. Some of these techniques within this strategy include storytelling, journaling, and writing letters they won’t send. Some techniques identified, but generally avoided and used with caution are humor and comparing pain.


Studies on Supportive Psychotherapy

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. 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. 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.


Teaching Supportive Psychotherapy

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.” 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. 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.”


Criticism about supportive psychotherapy

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. 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.


See also

*
Phenomenology Phenomenology may refer to: Art * Phenomenology (architecture), based on the experience of building materials and their sensory properties Philosophy * Phenomenology (philosophy), a branch of philosophy which studies subjective experiences and a ...
* Psychotherapy * Expressive therapies * Supportive communication


References

{{reflist Psychotherapies