CLINICAL PSYCHOLOGY

PSYCHOTHERAPY: PSYCHODYNAMIC, SUPPORTIVE, CLIENT-CENTERED

JAPNEET AHLUWALIA
Assistant Professor
Department of Clinical Psychology
MCOAHS

SUPPORTIVE PSYCHOTHERAPY

BASIC PRINCIPLES OF SUPPORTIVE PSYCHOTHERAPY

Origins
The concept of supportive psychotherapy was developed early in the twentieth century to describe a
treatment approach with objectives more limited than the objectives of psychoanalysis. The
objective of supportive treatment was not to change the patients personality/bring about any
fundamental change but to help the patient cope with symptoms in order to prevent relapse of
serious mental illness or, in the case of a relatively healthy person, to help him or her deal with a
transient problem. Earlier it was regarded as an inferior form of treatment and was recommended
only when no specific form of treatment was available. But the picture changed since the mid
1980s.

Definition
It is important to understand that in this form of treatment, the therapists support is a core
component. The derivation of the word support helps to clarify the type of therapy this is:
Supportare: Sup=Sub+portare-to carry (Oxford English Dictionary, 1978) i.e. the therapist carries
the patient; he helps to sustain him, to bolster him.
Thus supportive therapy can be defined as a form of psychological treatment provided to a patient
over an extended period, often years, in order to sustain him psychologically, because he is unable
to manage his life adequately without this long-term help.

The Psychotherapy Continuum

Individual psychotherapies are conceptualized as a spectrum or continuum that extends from
supportive psychotherapy to psychoanalysis (Figure 11). From left to right, the continuum begins
with supportive psychotherapy, traverses supportive-expressive psychotherapy, expressive-
supportive psychotherapy, and finally extends to psychoanalysis.
Aims of treatment
The aim here is to reduce or relieve the intensity of manifest and presenting symptoms, distress or
disability, and to reduce the extent of behavioural disruption caused by the patient's psychic
disturbances. It is summarised as follows:
i) To promote the patients best possible psychological and social adaptation.
ii) To bolster his self-esteem and self-confidence.
iii) To make him aware of the reality of what he can and cannot achieve.
iv) To forestall a relapse of his clinical condition and thus try to prevent deterioration or re-
hospitalization.
v) To provide adequate degree of professional support to prevent undue dependency.
vi) To transfer the source of support from professionals to relatives and/or friends.

Goals of treatment
To improve the patient's adaptation by whatever means are available and to focus the therapy at the
level of manifest stress or disability. In some instances the hope is for significant improvement. In
some cases the goal may be to prevent further disruption and maintain status quo; or even primarily
to help the patient remain outside of a hospital.

Underlying Assumptions
Supportive psychotherapy relies on direct measures. It is not assumed that improvement will
develop as a by-product of gaining insight. A major tenet of psychoanalytic psychotherapy was that
the unconscious conflict that produced the symptom would become conscious and be worked
through and that the symptom would disappear because it was no longer psychologically necessary.
In supportive psychotherapy, conscious problems or conflicts are addressed; however, underlying
unconscious conflicts and personality distortions are not (Dewald 1964, 1971).

Therapeutic Alliance
From the supportive vantage point, the relationship between patient and therapist is a relationship
between two adults with a common purpose. The professional person, the therapist, owes the patient
or client respect, full attention, honesty, and vigorous efforts to accomplish the stated purpose by
using the knowledge and skills of the profession. Thus, the professional psychotherapeutic
relationship is unique here. It is not based on reciprocal equality. It exists solely to meet the needs of
the patient or client. However it is not the nonspecific support provided to patients with medical or
surgical professionals as this is more structured and focused.

Levels of consciousness
In supportive psychotherapy the focus is on those issues that are already conscious for the
patient, and attempts to reduce defenses or to bring previously unconscious material to
awareness are not encouraged.
Not only bland or reassuring mental content is discussed, but only those issues, problems,
emotions, or conflicts that are already conscious should be brought into the therapeutic
dialogue and interchange.

Identification with the therapist

In supportive psychotherapy identification with the therapist is encouraged, in as much as
the therapist, will be a more stable, mature, and capable model for the patient than had been
the individuals with whom he/she has identified in the past.
The therapist may provide personal information and responses
May advise or suggest ways of resolving problems
May encourage imitation of the therapist's judgment and values
May provide active alternative understanding of situations.
In this way the therapist provides an active teaching parental figure from whom the patient
learns to adopt new methods of adaptation.

Management of resistance and defense

In supportive psychotherapy defenses are for the most part unchallenged and are maintained
or even strengthened to promote more comfortable or solid adaptation to otherwise
unexpressed or unacceptable conflict.
If the resistances and defenses used by the patient threaten the patient's external adjustment
or the therapeutic relationship, new and substitute defenses are suggested and are
encouraged to take the place of the disruptive ones.

The use of medication

Medication is much more commonly and frequently used as an adjunct in the control of
symptoms and the alleviation of distressing behaviours.

Insight
Insight is considered less important and mainly reflects understanding that is already
conscious in the patient.
Such understanding is predominantly organized in keeping with secondary-process logic,
rational thought, and reasoning.

Self-Esteem
One person helps the self-esteem of another person by conveying acceptance, approval, interest,
respect, or admiration. The patient who cannot form relationships with others, is avoided by others,
or perceives (perhaps correctly) that people look at him or her disapprovingly finds in the therapist a
person who is accepting and interested. The therapists acceptance and trust are unspoken. The
therapist communicates his or her interest in the patient by making it evident that he or she
remembers their conversations, remembers what the patient has said, and is aware of the patients
likes, dislikes, and attitudes. Acceptance is communicated by avoidance of arguing, denigrating, and
criticizingverbal interactions common to most relationships and, unfortunately, many contacts
between patients and health care providers:

Therapist 1: It doesnt make any sense to get an MRI [magnetic resonance image] just because you
forget peoples names. (Argument)
Therapist 2: What are you trying to say? (Denigration)
Therapist 3: Didnt they tell you to take it every day? (Criticism)
Here are the responses in more congenial language:
Therapist 1: Forgetting names is usually the first defect in memory that normal people experience. If
that is the only problem, its not caused by the sort of thing that shows up on an MRI.
Therapist 2: I dont understand.
Therapist 3: A lot of the effect is lost if you dont take it every day. If the dose is too large, we
should discuss it. A smaller dose might be the answer.

(Pinsker 1997). In the course of growing up, most people learn that the question Why did you do
it? is not so much a search for information as a rebuke for having done the particular action.
Similarly, Why didnt you do it? means You should have done it. Attack is inimical to self-
esteem. Alternatives to Why? can be created:
Therapist 1: Can you explain how it was that you did it that way?
Therapist 2: When you dropped out of school, what was the reason?
Therapist 3: Was there something about your behavior that made them think it was necessary to call
the police?

GENERAL FRAMEWORK OF SUPPORTIVE PSYCHOTHERAPY

Supportive Psychotherapy is useful for

People who have difficult, unstable, or limited interpersonal relationships
For those who are not introspective or curious about themselves and their psychological
functioning
For patients whose reality resources preclude the necessary frequency or expense of
intensive psychotherapy.
For those whose interest is predominantly in symptomatic change and whose capacity for
self-initiating behavior is limited.
Patients who in the past have suffered major psychotic episodes or required long periods of
hospitalization are usually candidates for supportive treatment.

Indications
The indications for supportive psychotherapy conceptually fall into two groups, which are not really
discrete:
1) Crisis - which includes acute illnesses that emerge with the overwhelming of the patients
defenses in the context of intense physical or psychological stress e.g. loss of life from a life-
threatening illness (breast cancer, HIV), loss of personal or public safety (terrorist attacks) or loss of
a loved one.
2) Chronic illness - e.g. medical or psychiatric (chronic schizophrenia, bipolar disorder, severe
personality disorders) with concomitant impairment of adaptive skills and psychological functions.

Contraindications
Because supportive psychotherapy is based on the factors common to all psychotherapies, there are
relatively few circumstances in which it is contraindicated (Frank 1975; Pinsker et al. 1996).
Supportive psychotherapy is the appropriate default approach to psychotherapy (Hellerstein et al.
1994) thus can be applied over a wide range of psychopathology and situations. Novalis et al.
(1993) suggested that supportive psychotherapy is unlikely to be effective in delirium states, other
organic mental disorders, drug intoxication, and later stages of dementia, but these are conditions in
which any psychotherapy could be expected to fail. Help-rejecting complainers, because they are
wedded to the victim role and are not invested in becoming more adaptive, do not make good use of
supportive interventions but rather become worse as they confirm that the goodwill and concrete
advice of the therapist are not useful. Con artists and others who lie or malinger as a matter of
course do as poorly in this treatment as in other treatments.

Initiation of Treatment
If the therapist determines that supportive psychotherapy is the treatment of choice, he or she will
make that determination during the first session. During the initial sessions, the ground rules of
supportive psychotherapy should be made explicit. It is important to obtain the patients agreement
about these ground rules.

Therapy Arrangement
Seating for supportive psychotherapy is best arranged in a manner that is welcoming, friendly,
comfortable, and professionaljust like the treatment itself. Thus, one should provide adequate but
not harsh lighting, and comfortable chairs that are not too close but also not too far away, so that
participants can sit upright and see and hear each other easily. The therapist can then pick up
nuances of verbal tone, facial expression, and body language.

Initiation and Termination of Sessions

The therapist is expected to begin and end sessions on time. This temporal framing of sessions is out
of respect both for the patient and for the psychotherapist. Occasional lateness is not a typical issue
to be focused on in supportive psychotherapy. When a patient demonstrates a pattern of lateness, the
pattern can be explored within the supportive framework. A pattern of missing sessions can be
addressed in the same way.

Timing and Intensity of Treatment

The timing and intensity of treatment should be set through agreement of the patient and therapist,
with the provision that these aspects may change on the basis of clinical needfor example, when a
crisis arises. Setting a specific, repeated time to meet tends to reduce anxiety, which is an intention
of supportive treatment. Similarly, the length of a session should generally be fixed but be subject to
variation when clinically appropriate and when the therapist can accommodate.

Phases of Treatment
Beginning
During the beginning of therapy, the therapist pays specific attention to supporting the formation of
a therapeutic alliance, because such an alliance increases the likelihood that the patient will remain
in treatment and will have a good outcome (Gunderson et al. 1984; Hartley and Strupp 1983). Over
the first few sessions, the therapist should attempt to come to a reasonable understanding of the
patients target complaints and presenting symptoms and to acquire a working knowledge of the
patients general level of ego function as well as his or her adaptive strengths and deficits. From
these data, the therapist synthesizes a case formulation and hypothesizes areas of acute and chronic
deficit in defensive operations, adaptive skills, and ego functioning that supportive interventions
should directly address. Once the goals and objectives of therapy are agreed on, the therapist must
consider issues of acuity and timing.
Middle Stages
The therapist continues to monitor the alliance with the patient during the course of treatment and
attempts to optimize that alliance using the same attention he or she used in the initial sessions of
the treatment. This type of therapeutic attunement to the patient contributes to the patients
experience of being understood and supported by the therapist. In the middle phase of therapy, if
therapy is proceeding well, the patient begins to accept that the therapist is truly capable of
understanding and supporting him or her, and this acceptance can serve as a corrective emotional
experience.
Termination
A formal termination process is not part of supportive psychotherapy. Therapy ends when the goals
of treatment have been reached or when the patient elects not to continue. At the end of formal
treatment, gains are summarized and an agenda is articulated for the patients continued work
without regular visits to the therapist. It is important for the patient to reflect on and celebrate
important milestones that he or she has been able to achieve (Rosenthal 2002). The patient is always
told that he or she should feel free to come back should the need arise.

Long-Term Versus Brief Therapy

For patients with chronic mental disorders, for whom supportive psychotherapy is mostly aimed at
maintaining adaptive and ego functioning, treatment is likely to be framed as an ongoing
relationship without a time limit, unless constrained by external factors, such as the patients
financial resources, insurance coverage, or continued-stay criteria in a mental health clinic.
Brief therapy is typically indicated when the psychopathology is expected to be time limited, such
as in an adjustment disorder, in a terminal illness, or when an acute loss or a crisis overwhelms a
patients defenses and he or she becomes symptomatic. Treatment is complete when symptoms have
been reduced to comfortable levels or when more-competent coping strategies have been developed.

Evaluation of treatment results

Evaluation of the success of therapy must be done in keeping with the original goals that
were set and perhaps modified during the course of the therapeutic experience.
The mere relief of symptoms or modification of behavior without underlying significant
personality modification, might not be adequate for a positive assessment of expressive
psychotherapy, but it might be a sign of success of a supportive psychotherapy.
The assessment of results needs to be done by keeping in mind what the original aim of the
treatment experience was.
A major issue in assessment is the question of how lasting the therapeutic progress is.
Adequate assessment requires a significant interval after termination has occurred.
The structure of the termination process is arranged to minimize the stress and loss, as well
as minimize the impact which this element of the treatment relationship has upon the
patient's adaptation.
 Weaning" (whereby the frequency and duration of the treatment sessions are gradually
reduced) are instituted.
Active encouragement and reassurance are offered, and efforts at continuing the sense of a
relationship after the interruption occurs are encouraged.

Components of Supportive Therapy (Strategies and Techniques)

1. Reassurance
a) By removing doubts and misconceptions
b) By pointing to their assets
2. Explanation
It focuses on:
a) Day-to-day practical questions
b) Current and external reality with which the patient contends
These may include the nature of the symptoms, the reason for taking medication, the reason
for relapse etc. The goal is to enhance the ability of the patient to cope and deal with these.
3. Guidance
This involves guiding the patient in a range of situations (practical issues, issues with respect
to work, family etc.) mainly through direct advice. The goal is to teach him requisite skills
for coping with other similar problems.
4. Suggestion
The therapist aims to induce change in patients behaviour by influencing him implicitly or
explicitly e.g. The way you stood up for yourself was terrific.
5. Encouragement
Injections of courage to combat feelings of inferiority, to promote self-esteem, and to urge
the patient to adopt courses of action or behaviours of which he is hesitant or anxious.
6. Effecting changes in the patients environment
Stressful factors need to be carefully assessed so that they can be suitably modified. There
are two dimensions to this strategy:
a) Working directly with the patient by helping him
b) Working with people who are important to the patient, particularly relatives
7. Permission for Catharsis
The therapeutic relationship permits the patient to share with a sense of relief pent-up
feelings like fear, grief, sorrow, concern, frustration and envy.

CONCLUSION
Supportive psychotherapy relies on direct measures to support the patients defenses, to allay
anxiety, and to enhance the patients adaptive skills. The relationship between patient and therapist
the therapeutic alliance is recognized as a highly potent element of the treatment, but the
alliance becomes a subject for discussion only when problems in the relationship threaten to disrupt
treatment.