Psychoanalytic origins

The early supportive treatments were felt to be largely unscientific, relying somewhat on suggestion and varying degrees of showmanship. The majority of psychoanalysts attempted to distance themselves by emphasising the differences between supportive psychotherapy and psychoanalysis. Hence in the 1920s, supportive psychotherapy lacked a positive definition, being described in terms of what it was not (relative to psychoanalysis), rather than what it was. However, as psychoanalysis began to be used with more damaged patients, such as those with borderline personality disorder, the limitations of the ‘classical’ model became increasingly apparent and some analysts began to acknowledge that certain patients required supportive techniques alongside exploratory ones (Reference HolmesHolmes 1995).

Nevertheless, the place of supportive interventions in psychodynamic/psychoanalytic therapy remains contentious. Reference LuborskyLuborsky (1984), for example, views supportive and exploratory techniques as lying on a continuum, both being used in a psychoanalytic ‘supportive expressive’ therapy as appropriate to the patient's need. Others hold the dichotomous view that therapy is either supportive or exploratory. Indeed, some see support as anathema to psychoanalysis, where the exploration of unconscious emotion is of necessity initially anxiety-provoking (Reference CrownCrown 1988).

Supportive psychotherapy within a psychodynamic framework

Several authors have conceptualised models in which supportive interventions lie firmly within a psychodynamic framework. In Reference RocklandRockland's (1987) psychodynamically oriented supportive psychotherapy, practised in the USA, patients with borderline personality disorder are seen once or twice weekly for 50 minutes. Reference de Jonghe, Rijnierse and Janssesde Jonghe et al (1994) describe psychoanalytic supportive psychotherapy, and argue that it is a therapeutic modality in its own right. Another example is supportive analytical therapy, described by Reference HolmesHolmes (1988) as lying somewhere between a formal analytical/psychodynamic psychotherapy and ordinary good psychiatric practice.

Supportive psychotherapy as an integrative model

The concept of supportive psychotherapy in more recent literature has broadened. It is now viewed by many as an integrative therapy which has no single theoretical background, but draws from many approaches, including psychoanalysis, Rogerian counselling, cognitive, behavioural, systemic, interpersonal and ego psychology and attachment theory. The practitioner will choose from the available techniques on the basis of the patient's need and, probably, their own training background.

Some view supportive psychotherapy as a ‘common factors approach’ (Reference Trijsburg, Colijn, Holmes and GabbardTrijsburg 2007). Common factors are the elements found in all psychotherapies, regardless of model, and it has been suggested that it is these commonalities that are the effective ingredients of psychotherapy (Reference Frank and FrankFrank 1991). Supportive psychotherapy contains many of these common factors. Reference PinskerPinsker (1994) conceptualises supportive psychotherapy as a body of techniques, or a ‘shell’, which can function comfortably with many various theoretical orientations. However, it is noted by Reference DouglasDouglas (2008) that despite these moves towards an integrative model, psychodynamic language and theory continue to be present in much of the literature, making it difficult to practise supportive psychotherapy without some degree of psychodynamic understanding.

Models of practice

The traditional view of supportive psychotherapy in National Health Service work in the UK is that of a long-term therapy, held less frequently than weekly (fortnightly, monthly or even two-monthly), lasting from 10 to 60 minutes and usually continuing over 2 years (Reference Van Marle, Homes, Holmes and BatemanVan Marle 2002). The patient group at which this long-term work is aimed is often described as being chronically psychologically weakened and unsuitable for more exploratory work. In practice, this group of patients usually have severe and chronic psychotic, mood, personality or anxiety disorders. Reference Hartland and HolmesHartland (1991) defines this type of supportive psychotherapy as ‘a long-term psychotherapy aimed at maximising the patient's strengths, restoring his equilibrium and acknowledging, but attempting to minimise, his dependence on the therapist.’

This view of supportive psychotherapy as long-term work for patients with chronic disorders has moved on. Short-term supportive psychotherapy is now well described for a wide range of psychiatric disorders, including depression, anxiety, adjustment disorders or other acute crisis or loss events. It is most suitable for patients who have current acute difficulties, perhaps associated with self-blame or internal conflict, but who had good premorbid functioning. Other patient characteristics which suggest suitability for short-term work include psychological mindedness, motivation for treatment, good impulse control, good reality testing, and mature coping and defence mechanisms (Reference Novalis, Rojcewicz and PeeleNovalis 1993).

Some authors view supportive psychotherapy as being a component of ordinary good psychiatric practice. For example, Reference PinskerPinsker (1997) makes a convincing argument when he writes: ‘Many psychiatrists see patients briefly for management of psychopharmacologic treatment. Remarkably, often patients are efficient about the medication issues and quickly attempt to involve the “medicating” psychiatrist in conversation about his or her life, so supportive therapy is part of the package whether intended or not’.

Taking this flexible framework further, it has been suggested that supportive psychotherapy can take place in the context of just one or two meetings (Reference RocklandRockland 1989) or in regular annual sessions (Reference CrownCrown 1988). Within this broad view, it could be said that supportive psychotherapeutic work is carried out by many different healthcare professionals and in a wide variety of settings, both within and outside psychiatry. As Tyrer states: ‘Literally thousands of therapists are providing something akin to supportive psychotherapy every working day throughout the land’ (Reference Robertson and TyrerRobertson 1995).

Summarising from all of this, the current position of supportive psychotherapy is perhaps most accurately described by Van Marle & Holmes (2002) as ‘a flexible, non-manualized form of therapy which is practiced in different ways and at different levels by a variety of professionals’.

Aims and techniques

There is general agreement in the literature on the aims and techniques of supportive psychotherapy. Some of the specific aims are listed in Box 1. Broadly speaking, the aim is to bolster and to improve the patient's psychological functions (or ‘ego functions’), which are for some reason deficient. Reference Applebaum and RocklandApplebaum (1989) draws parallels between supportive psychotherapy and a good early child–parent relationship: just as the parent fosters development in the child, so a therapist aims to foster psychological and emotional maturation in the patient.

Much can be written about the strategies and techniques of supportive psychotherapy. Here, we offer a brief overview, but highly recommend some of the available literature (marked in the reference list by an asterisk) for a more detailed account, including disorder-specific techniques. The key techniques are listed in Box 2.

The supportive relationship

The most important component of supportive psychotherapy is the supportive relationship (also sometimes termed the therapeutic alliance). This relationship can be therapeutic in its own right, but also acts as the matrix within which other more specific techniques can be implemented (Reference Novalis, Rojcewicz and PeeleNovalis 1993). Many of the techniques are aimed at building this supportive relationship, within which the patient trusts the therapist and feels safe. Important in the therapist is a genuine, warm, respectful and non-judgemental attitude. The therapist works to be a ‘real figure’ and this may be facilitated by judicious self-disclosure or use of humour. Ruptures in the therapeutic alliance are noted and repaired as quickly as possible.

Communication style

Conversation is two-way and responsive, with no anxiety-provoking long silences. The therapist encourages the patient to talk, and listens actively, attempting to understand their story and to hear also what is not being said. Some interruption and persistence is appropriate if important issues are being avoided. Ventilation of feelings and expression of affect can bring relief, but should be encouraged only to the degree that the patient is able to manage. The therapist does not aim to uncover deeply repressed material. Accurate empathic responses show that the patient is being understood and encourage further communication.

Transference and countertransference

Being a ‘real figure’ helps the therapist to prevent a strong positive or negative transference developing, an approach some describe as ‘managing the transference’. A mild degree of positive transference may help the therapeutic alliance and can be left intact. However, if negative transference is developing, the therapist may need to act to restore the patient's sense of reality. The therapist should be aware of the countertransference, particularly as the active-therapist stance necessarily involves making judgements. Again, ruptures in the therapeutic alliance are noted and repaired as quickly as possible.

A secure base and containment

The reliable and consistent clinician will come to form a secure base for the patient and some degree of necessary dependency may occur while the patient works towards greater long-term independence. The therapist acts to contain the patient's emotions, touched by them, but able to think about and manage them and to respond therapeutically.

Focus on current problems

The focus of the work is largely the present, helping the patient to examine and manage current difficulties. Goals are agreed collaboratively. Self-esteem and sense of mastery may be improved by encouragement and praise. The therapist may teach problem-solving skills and support the patient in using their own resources to solve problems. If this is not successful, then more direct suggestion or advice may be necessary. Reassurance is appropriate if the patient has unrealistic fears, but should be offered only once these have been adequately explored.

Behaviour

The therapist helps the patient to increase functional and reduce dysfunctional behaviours, although in the spirit of working with a patient's strengths, minor problematic behaviours could be selectively ignored. Functional behaviours can be encouraged through praise. An uncritical but questioning attitude towards dysfunctional behaviours may lessen these. If behaviour is unacceptable, non-negotiable limit-setting is sometimes required. These limits may serve to contain the patient and shape harmful behaviours into more appropriate ones. Patients who have difficulty in managing affect and controlling impulses may be assisted in recognising these patterns and trying alternative strategies.

The therapist can model behaviour such as being on time and maintaining boundaries. The self-critical patient can learn from the compassionate therapist how they might be kinder to themselves.Footnote ^†

Reality testing

The patient is assisted in reality testing. Psychoeducation can help greatly in correcting inaccurate views of the illness. Basic cognitive and behavioural techniques can be used to help the patient to identify and challenge distorted thinking, and to experiment with changing behaviours.

Defence mechanisms and interpretation

The emphasis of supportive psychotherapy is on respecting defence mechanisms and acknowledging their possible protective functions for the patient. Some healthy defences may be encouraged (for example, the sublimation of rage into exercise). Harmful defence mechanisms may, however, need to be challenged (for example, denial of a medical problem preventing appropriate help-seeking). There may be a place for some forms of interpretation, but the aim is to reduce anxiety and not to uncover deeply unconscious feelings. For example, the supportive therapist may delay the interpretation until after the emotional tension has cooled – an approach described by Reference PinePine (1986) as ‘strike while the iron is cold’. Some use a partial (inexact) interpretation, which offers an account that is only partly accurate, or a benign projection that attributes the problem to something outside the patient's control.

Other techniques

Many authors see prescribing of medication and environmental interventions as techniques of supportive psychotherapy.

Anxiety disorders

Reference Klein, Zitrin and WoernerKlein et al (1983) describe a randomised trial in out-patients comparing the combinations of behaviour therapy and imipramine with supportive psychotherapy and imipramine. Therapy sessions occurred weekly for 26 sessions. Supportive psychotherapy was found, surprisingly, to be as effective as behaviour therapy.

In a randomised trial involving older out-patients with a range of anxiety disorders, Reference Barrowclough, King and ColvilleBarrowclough et al (2001) treated one group with cognitive–behavioural psychotherapy and the other with supportive psychotherapy. Three different anxiety scales were used to measure outcome. At the end of treatment, changes in anxiety symptoms measured by one of the scales demonstrated a significant benefit of cognitive–behavioural psychotherapy over supportive psychotherapy, but changes on the other two scales suggested that the two treatments were broadly equal in effect.

Depression

Short-term psychoanalytic supportive psychotherapy (SPSP), usually offered as 16 sessions over 6 months, was developed as a treatment for depression (Reference de Jonghe, Rijnierse and Janssesde Jonghe 1994). A mega-analysis of three randomised trials examining the efficacy of this approach in the out-patient setting (Reference de Maat, Dekker and Schoeversde Maat 2008) suggested that SPSP and antidepressants were equally efficacious, that combining SPSP and antidepressants was more efficacious than antidepressants alone, but that combining SPSP and antidepressants was not demonstrably better than psychotherapy alone.

A randomised trial in the treatment of depression in HIV-positive out-patients (Reference Markowitz, Kocsis and FishmanMarkowitz 1998) compared four treatment approaches. Interpersonal therapy and the combination of supportive psychotherapy with an antidepressant were most efficacious. Supportive psychotherapy and CBT were less efficacious, but equal to each other in effect.

Personality disorder

Reference Hellerstein, Rosenthal and PinskerHellerstein et al (1998) compared short-term dynamic and brief supportive psychotherapy (about 40 sessions) in high-functioning out-patients with personality disorder, predominantly of the Cluster C (anxious) category. Similar degrees of improvement were found across the two groups.

Reference Vinnars, Barber and NorenVinnars and colleagues (2005) concluded that a manualised supportive-expressive psychotherapy was as effective as psychodynamic therapy in out-patients with mainly cluster C diagnoses who received weekly therapy for a year.

Reference Clarkin, Levy and LenzenwegerClarkin et al (2007) compared transference-focused therapy, supportive psychotherapy and dialectical behaviour therapy in out-patients with borderline personality disorder. Therapy was offered weekly for a year. Although the three approaches had differing effects in some of the specific outcome domains, overall they were equivalent at producing broad positive change.

Psychosis

Reference Stanton, Gunderson and KnappStanton and colleagues (1984) conducted a trial in patients with schizophrenia to compare the effects of exploratory insight-oriented therapy (thrice weekly sessions) with reality-adaptive supportive psychotherapy (once weekly sessions). Patients were in therapy for up to 2 years, beginning in hospital, but continuing after discharge. Supportive therapy was superior on many of the outcome measures.

In a study of psychotherapy in out-patients with non-affective psychosis, outcomes for supportive psychotherapy were intermediate between those for cognitive–behavioural therapy (CBT) and routine care (Reference Tarrier, Yusupoff and KinneyTarrier 1998).

Anorexia nervosa

In out-patients with anorexia nervosa, Reference McIntosh, Jordan and CarterMcIntosh et al (2005) compared three therapies: non-specific supportive clinical management (a combination of supportive psychotherapy and normal clinical management), CBT and interpersonal therapy. Therapy consisted of 20 sessions over at least 20 weeks. The three treatments were found to have broadly similar results.

Effectiveness

From these studies we can perhaps reasonably conclude that elements of what these authors are calling ‘supportive psychotherapy’ are for some patients as effective, or more effective, than other forms of psychotherapy or medication. What the specific ingredients of effect might be, and which patients respond best, is an area that requires more study. Despite the increasing body of literature in the area, supportive psychotherapy requires more specific research before it can be considered evidence-based (Reference Hellerstein and MarkowitzHellerstein 2008).

The trainee

Trainees should be ready to take a case in the second or third year of specialty training (CT2 or CT3). A short case (12–16 sessions) may be more practicable than a long case. Necessary preparation will be some basic theoretical teaching in the psychotherapies which is usually provided through the local MRCPsych/masters teaching. This should include some teaching in supportive psychotherapy. At least a basic knowledge of psychodynamic concepts and of cognitive and behavioural interventions would be expected. Trainees may also attend a psychotherapy case discussion group.

Supervision and assessment of trainees

The consultant may be able to offer this supervision as part of the trainee's existing clinical supervision. Alternatively, specific supportive psychotherapy supervision for a group of trainees may enable shared learning. Regarding frequency, a guideline may be that supervision occurs at least every second session. Styles of supervision will vary; some supervisors prefer detailed written process notes of the session, some prefer a brief overview. Audio- or videotapes can be useful. For in-patients, some direct observation of doctor–patient interaction may be possible during the ward round.

The current competency-based curriculum in psychiatry does not specifically delineate psychotherapy competencies. However, we have extracted some of the competencies that may be relevant to clinical work in supportive psychotherapy (Box 4). These may be helpful in setting learning objectives and assessing progress. A potential tension may lie in reconciling this flexible and integrated approach with the need for a robust and evidenced training experience. Trainees should keep a record of patient contacts. The trainee logbook is likely to require a completed SAPE: Assessment of Psychotherapy Expertise (Royal College of Psychiatrists 2008b). A case report may be helpful.

For many consultants, the supervision of a trainee undertaking supportive psychotherapy will be a new experience. Some guidance comes from Reference PinskerPinsker (1994) and Reference DouglasDouglas (2008). It may be helpful to offer the trainee some direct ‘coaching’ in communication skills and to model the interpersonal style the therapist should aim for. The supervisor may help the therapist to identify and repair alliance ruptures, to understand their responses to the patient, and to think psychoanalytically while behaving supportively. Also important is helping the therapist to do ‘just enough’: to set modest goals, to use supportive techniques judiciously and to value small improvements (Reference DouglasDouglas 2008). Supervisors may find it helpful to meet together, where possible with facilitation by a consultant psychotherapist.

Patient selection

Patients suitable for short-term work are likely to be found among those who are referred from primary into secondary care for out-patient treatment. For many of these patients, this work may be sufficient to resolve the crisis. For others, it may be a holding or preparatory intervention before another psychotherapy (most commonly a psychodynamic therapy or CBT) is accessed. The setting for this work is likely to be the existing out-patient clinic, and in reality the work may differ from the current work of a trainee only in that it is more intensive, more planned out and more closely supervised. In-patients may benefit from short-term work during the admission and immediate post-discharge period. The necessarily high frequency of contact with in-patients may help the trainee to reach the requisite number of sessions. Supportive psychotherapy for the carers of patients with dementia has also been described (Reference Junaid and HegdeJunaid 2007).

Those with severe and chronic illness are most suited to long-term work, and Reference Meaden and van MarleMeaden & Van Marle (2008) describe such work in the assertive outreach setting. This lengthy timescale may not be feasible for a trainee, but these patients may benefit from additional short-term work by a trainee during admission or other acute crisis.

Supportive psychotherapy should not be used with people who would clearly gain more benefit from another form of psychotherapy. Other exclusion criteria include those who have failed to benefit from or have worsened in previous supportive psychotherapy (Reference Novalis, Rojcewicz and PeeleNovalis 1993).

Starting therapy

The assessment for a training case in supportive psychotherapy is most likely to occur in the context of the wider psychiatric assessment. Assessment should include a clear diagnosis, formulation and some defined goals of the work. Given the time constraints, it may be useful to identify a potential patient before the trainee comes into post.

Before commencing therapy, we recommend an explicit discussion and collaborative agreement between therapist and patient over the rationale, goals and duration of the work, for example ‘We agree to meet for half an hour every 2 weeks, for ten sessions, to help you to start an antidepressant and to look together at how you can feel better’.

Reflecting the flexible and practical approach described by many authors, it is suggested that sessions may vary in length between 20 and 50 minutes, and in frequency from as much as several times a week (perhaps for in-patients) to once a month. Session length and frequency can be titrated according to patient need.