S E C O N D E D I T I O N

Learning Supportive Psychotherapy: An Illustrated Guide provides a

EDITION
SECOND
time-tested text accompanied by carefully scripted case vignette videos de-
signed to help beginning therapists learn how to build a relationship and es-
tablish rapport with psychotherapy patients. The authors, whose experience
conducting and teaching psychotherapy encompasses decades, provide clear
guidelines for practicing supportive psychotherapy, including how to establish
and maintain a positive therapeutic alliance, how to understand and formulate
patients’ problems, how to set realistic treatment goals, and how to effectively
use supportive psychotherapy interventions. This new second edition has been
thoroughly updated to offer clear and complete coverage of the concept and
LEARNING

Glen O. Gabbard, M.D., Series Editor

LEARNING SUPPORTIVE PSYCHOTHERAPY
principles of supportive psychotherapy, with emphasis on the therapeutic al-
liance, which is the best predictor of patient outcome. The authors have also
included a chapter of self-study questions to allow the reader to check compre-
hension and recall. SUPPORTIVE

AN ILLUSTRATED GUIDE
Learning Supportive Psychotherapy: An Illustrated Guide provides be-
ginning therapists, social workers, psychiatric nurses, and others with the prac-
tical instruction and real-world models they need to forge positive relationships
with a broad range of patients and deliver effective psychiatric interventions.
PSYCHOTHERAPY
Arnold Winston, M.D., is Chairman Emeritus, Department of Psychia- AN ILLUSTRATED GUIDE
try and Behavioral Sciences, Mount Sinai Beth Israel, New York, New York;
Professor Emeritus, Department of Psychiatry and Behavioral Sciences, Icahn
School of Medicine at Mount Sinai, New York, New York; and Professor 32 ISO 80

and Associate Chairman, Department of Psychiatry, St. George’s Univer- Video

sity School of Medicine, St. George’s, Grenada Illustrated
32 32B

Richard N. Rosenthal, M.D., M.A., is Director of Addiction Psychi-

atry, Department of Psychiatry and Behavioral Health, Stony Brook
Medicine, Stony Brook, New York; Professor of Psychiatry, Department
of Psychiatry and Behavioral Health, Renaissance School of Medicine at

WINSTON • ROSENTHAL • ROBERTS

Stony Brook University, Stony Brook, New York; and Adjunct Professor of
Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York

Laura Weiss Roberts, M.D., M.A., is Chairman and Katharine Dexter

McCormick and Stanley McCormick Memorial Professor, Department of
Psychiatry and Behavioral Sciences, Stanford University School of Medi-
cine, Stanford, California

ARNOLD WINSTON, M.D.

Cover design: Rick A. Prather
RICHARD N. ROSENTHAL, M.D., M.A.
Cover Image: © Elena Ray
Used under license from Shutterstock LAURA WEISS ROBERTS, M.D., M.A.
Learning Supportive
Psychotherapy
An Illustrated Guide

Second Edition
Learning Supportive
Psychotherapy
An Illustrated Guide

Second Edition

Arnold Winston, M.D.

Chairman Emeritus, Department of Psychiatry and Behavioral
Sciences, Mount Sinai Beth Israel, New York, New York; Professor
Emeritus, Department of Psychiatry and Behavioral Sciences,
Icahn School of Medicine at Mount Sinai, New York, New York;
Professor and Associate Chairman, Department of Psychiatry, St.
George’s University School of Medicine, St. George’s, Grenada

Richard N. Rosenthal, M.D., M.A.

Director of Addiction Psychiatry, Department of Psychiatry and
Behavioral Health, Stony Brook Medicine, Stony Brook, New York;
Professor of Psychiatry, Department of Psychiatry and Behavioral
Health, Renaissance School of Medicine at Stony Brook University,
Stony Brook, New York; Adjunct Professor of Psychiatry, Icahn
School of Medicine at Mount Sinai, New York, New York

Laura Weiss Roberts, M.D., M.A.

Chairman and Katharine Dexter McCormick and Stanley
McCormick Memorial Professor, Department of Psychiatry and
Behavioral Sciences, Stanford University School of Medicine,
Stanford, California
Note: The authors have worked to ensure that all information in this book is accurate at the
time of publication and consistent with general psychiatric and medical standards, and that
information concerning drug dosages, schedules, and routes of administration is accurate at
the time of publication and consistent with standards set by the U.S. Food and Drug Admin­
istration and the general medical community. As medical research and practice continue to
advance, however, therapeutic standards may change. Moreover, specific situations may re­
quire a specific therapeutic response not included in this book. For these reasons and because
human and mechanical errors sometimes occur, we recommend that readers follow the ad­
vice of physicians directly involved in their care or the care of a member of their family.
Books published by American Psychiatric Association Publishing represent the findings,
conclusions, and views of the individual authors and do not necessarily represent the poli­
cies and opinions of American Psychiatric Association Publishing or the American Psychi­
atric Association.
Disclosures of interests: The authors have no competing interests or conflicts to declare.
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Library of Congress Cataloging-in-Publication Data
Names: Winston, Arnold, 1935– author. | Rosenthal, Richard N., author. | Roberts, Laura
Weiss, 1960– author. | American Psychiatric Association Publishing, issuing body.
Title: Learning supportive psychotherapy : an illustrated guide / by Arnold Winston, Richard
N. Rosenthal, Laura Weiss Roberts.
Other titles: Core competencies in psychotherapy.
Description: Second edition. | Washington, D.C. : American Psychiatric Association Pub­
lishing, [2020] | Series: Core competencies in psychotherapy | Includes bibliographical
references and index. |
Identifiers: LCCN 2019037391 (print) | LCCN 2019037392 (ebook) | ISBN
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A CIP record is available from the British Library.
 To my wife, Dr. Beverly Winston,

for her steadfast love, help, and support.

—Arnold Winston, M.D.

To my late father, Harold M. Rosenthal,

whose conversations with me about psychoanalysis

inspired my lifelong interest in the life of the mind.

—Richard N. Rosenthal, M.D., M.A.

For Gabrielle.

—Laura Weiss Roberts, M.D., M.A.

Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Video Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

1 Evolution of the Concept of Supportive Psychotherapy . . . . . 1

2 Principles and Mode of Action . . . . . . . . . . . . . . . . . . . . . . . . 13

3 Assessment, Case Formulation, and Goal Setting . . . . . . . . . 33

4 Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

5 General Framework of Supportive Psychotherapy . . . . . . . . 89

6 The Therapeutic Relationship . . . . . . . . . . . . . . . . . . . . . . . . 105

7 Crisis Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

8 Applicability to Special Populations . . . . . . . . . . . . . . . . . . . 141

9 Evaluating Competence and Outcome Research. . . . . . . . . 163

10 Questions for Self-Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

Introduction

We are pleased to present a revised edition of our book, Learning Support­

ive Psychotherapy, first published in 2004 as Introduction to Supportive Psy­
chotherapy and revised in 2012. One of our authors, Dr. Henry Pinsker, has
retired, but we have been fortunate to find an outstanding new coauthor,
Dr. Laura Roberts, who brings a wealth of experience and expertise to
this new edition.
This book is written for beginning therapists who need to learn the
fundamentals of psychotherapy and in particular need to learn how to
talk with psychotherapy patients. All practitioners search for effective
ways to treat patients. We believe that the beginning resident attempting
to practice supportive psychotherapy needs clear guidelines for the con­
duct and progression of psychotherapy from beginning to end. Accord­
ingly, we have attempted to present straightforward guidelines to help the
beginner in four major areas:

• Forming and maintaining a positive therapeutic alliance

• Understanding and formulating patients’ problems
• Setting realistic treatment goals
• Knowing what to say to patients (technique)

After introducing the concept of supportive psychotherapy, we pres­

ent the basic principles of this treatment approach and the position of
supportive psychotherapy on a continuum from supportive to expressive
psychotherapy on the basis of the extent and level of a patient’s psycho­

ix
x Learning Supportive Psychotherapy

pathology. We describe supportive psychotherapy interventions available

to the therapist, the process of performing a thorough patient evaluation
and case formulation, and the process of setting realistic goals with the
patient. The general framework of supportive psychotherapy—including
indications, phases of treatment, initiation and termination of sessions,
and professional boundaries—is outlined. We include therapeutic rela­
tionship issues (transference, countertransference, therapeutic alliance)
and self-disclosure guidelines.
We then discuss crisis intervention, which uses many supportive psy­
chotherapy approaches, and the applicability of supportive psychother­
apy to special populations, including patients with chronic mental illness,
substance use disorders, and co-occurring conditions. We conclude the
book with a discussion of how to determine whether a psychiatry resident
has achieved competence in supportive psychotherapy and with a pre­
sentation of the evidence for the efficacy of supportive psychotherapy, in­
cluding a number of outcome trials. The final chapter includes a number
of questions for self-study.

Arnold Winston, M.D.

Richard N. Rosenthal, M.D., M.A.

Laura Weiss Roberts, M.D., M.A.

Acknowledgments

Residents at Beth Israel Medical Center and St. Luke’s-Roosevelt Hospi­

tal Center were recruited as patients and therapists for the psychotherapy
videos. We are grateful for their efforts in production of these videos.
The following residents participated from Beth Israel Medical Center:
Caroline Blackman, M.D., Nivea Calico, M.D., David Edgcomb, M.D.,
and Glenn Occhiogrosso, M.D. The following residents participated
from St. Luke’s-Roosevelt Hospital Center: Justin Capote, M.D., Nonso
Ekene Enekwechi, M.D., Adrienne Mishkin, M.D., and Vinod Pachagiri
Suresh, M.D.
We wish to acknowledge the importance of the Beth Israel Brief Psycho­
therapy Research Program in providing the milieu for the writing of this
book and our appreciation of our colleagues from this program, especially
John Christopher Muran, Jeremy Safran, and Lisa Wallner Samstag. Finally,
we are grateful to the Supportive Psychotherapy Study Group, including
Victor Goldin, Esther Goldman, David Hellerstein, David Janeway, Steve
Klee, Lee Shomstein, Fran Silverman, Jeffrey Solgan, Adam Wilensky,
and Philip Yanowitch, for help in developing many of the ideas contained
in this book.
We also wish to express our appreciation to Gabrielle Termuehlen,
Tenzin Tsungmey, and Ann Tennier for their excellent work in editing,
engaging with the authors, and performing literature reviews in the de­
velopment of this most recent edition.

xi
Video Guide

The videos in this book provide detailed examples of supportive psycho­

therapy. Each video includes text boxes at the bottom of the screen high­
lighting the therapist’s interventions. The videos can be viewed online by
navigating to www.appi.org/Winston and using the embedded video
player. The videos are optimized for most current operating systems, in­
cluding mobile operating systems.

Video cues provided in the text identify the

vignette by title and approximate run time.

Case Vignettes
Chapter 3. Assessment, Case Formulation, and
Goal Setting
Vignette 1: Assessment (9:54)
This vignette illustrates how to perform a thorough assessment of a new
patient while developing and maintaining a therapeutic alliance.

xiii
xiv Learning Supportive Psychotherapy

Chapter 4. Techniques
Vignette 2: Severe, Persistent Mental Illness in an Uncooperative
Patient (13:42)
This vignette illustrates a highly supportive approach with an uncooper­
ative patient who has a great deal of psychopathology.

Vignette 3: Supportive-Expressive Treatment (30:49)

This vignette is of a reasonably well integrated young woman who is
treated with supportive-expressive psychotherapy.

Chapter 5. General Framework of Supportive

Psychotherapy
Vignette 4: Addressing a Misalliance (6:22)
In this vignette, the therapist addresses a misalliance within the patient­
therapist relationship and “owns up” to making a mistake, which helps to
alleviate the misalliance.

Chapter 7. Crisis Intervention

Vignette 5: Crisis Intervention (18:00)
This vignette illustrates a number of different techniques that can be used
for a patient with posttraumatic stress disorder.
Session 1 (0:00–7:13)
Session 2 (7:14–12:47)
Session 4 (12:48–15:03)
Session 5 (15:04–18:00)

Chapter 8. Applicability to Special Populations

Vignette 6: Substance Use Disorder (7:00)
This vignette illustrates the use of psychoeducation in a patient with sub­
stance use disorder in order to address the patient’s use of denial and the
moral model of addiction.
Evolution of the
Concept of
1
Supportive
Psychotherapy

Origins
Supportive psychotherapy is a treatment approach focused on patients’
overall health and well-being and their abilities to adapt constructively to
their life circumstances. The domain of supportive psychotherapy has be­
come larger in recent years, reflecting changes in the definition, and even
more so in the practice, of psychotherapy. Today, supportive psychother­
apy has a robust evidence base and plays an important role in the care of
individuals living with diverse mental and physical disorders and in the
care of individuals facing difficult life events or experiences, such as the
transition to college, the birth of a child, changes in employment, divorce,
and bereavement.
Supportive psychotherapy was developed in the early twentieth cen­
tury as a treatment approach with more limited objectives than psycho­
analysis, which had previously been the only psychological treatment in
medicine. Psychoanalysis and psychotherapy were originally developed as
treatments for neurosis, which was the principal concern of office-based
(i.e., nonhospital) psychiatrists. Neurosis was conceptualized as an un­

1
2 Learning Supportive Psychotherapy

conscious attempt to solve a psychological conflict. As psychotherapy be­

came more widely accepted, therapists applied psychotherapeutic
techniques to a broad range of problems that were outside the scope of
the earliest psychotherapy and not adequately explained by the theories
associated with it. Because of practical considerations, including afford­
ability, a course of treatment often consisted of a small number of visits,
and the objective was limited to relief of the presenting problem. Thera­
pists found it necessary to be more interactive and responsive with pa­
tients. Flexible response to clinical reality called for more general use of
supportive approaches. Although some therapists feared that they were
diluting “real” psychotherapy by not adhering to its rules, therapists were,
in fact, applying a different psychotherapy.
Psychoanalytic thinkers who formulated theories about the causes of
symptoms and personality problems created a general theory of mental
organization and behavior referred to as psychodynamic theory. Many con­
cepts of psychodynamic theory have become so widely disseminated that
they are now accepted as established truths about mental life by much of
the educated public in the Western world. Therapy that was not psycho­
analysis but that instead was based on theories developed by psychoana­
lysts became known as psychodynamic psychotherapy. This therapy has
been called psychoanalytically oriented psychotherapy, intensive psycho­
therapy, uncovering psychotherapy, change-oriented psychotherapy, in­
sight-directed psychotherapy, or—the term we employ—expressive
psychotherapy (not to be confused with dance therapy, art therapy, and so
forth, which have also been designated as “expressive”).
Between 1950 and 1970, psychodynamic psychotherapy became the
most widely practiced psychological treatment approach in the United
States. It was taught as the embodiment of theories of personality devel­
opment, with the objectives of reversing the primary disease process or
restructuring the personality (Ursano and Silberman 1999).
Although personality change is invariably assumed to be the objective
in the psychotherapy literature, for many patients, the objective is stabil­
ity and adaptation, not fundamental change. The objectives of supportive
treatment, as initially defined, were not to change a patient’s personality
but rather to help a patient cope with symptoms, to prevent relapse of a
serious mental illness, or to help a relatively healthy person deal with a
transient problem. Supportive psychotherapy differed from traditional
psychoanalytic treatment in that the therapist played an active and direct
role in the therapeutic relationship.
Authors continue to propose different definitions of supportive psy­
chotherapy (Douglas 2008; Winston et al. 1986) and continue to hold
different opinions about whether or not supportive psychotherapy is a
Evolution of the Concept of Supportive Psychotherapy 3

psychodynamic therapy or a distinctive form of therapy. The problem of

definition is compounded by the coexistence of two incompatible defini­
tions of psychodynamic therapy. Some writers use the term psychody­
namic psychotherapy broadly to describe any therapy in which the
therapist’s understanding of mental life is based on theories developed by
psychoanalytic writers; other authors use the term narrowly to describe
only therapies that employ the essential techniques of expressive therapy.
Definitions of supportive psychotherapy have been organized around
four themes:

1. What the therapist hopes to achieve (objectives)—for example, to

maintain or improve the patient’s self-esteem, to minimize or prevent
recurrence of symptoms, and to maximize the patient’s adaptive ca­
pacities (Pinsker et al. 1991)
2. What the patient wants to achieve (goals)—for example, to maintain
or reestablish the patient’s best possible level of functioning given the
limitations of his or her personality, inherent ability, and life circum­
stances (Ursano and Silberman 1999)
3. What the therapist does (technique)—for example, encouragement,
reassurance, education, and advice
4. What it is not—that is, an exposition of elements that have been sub­
tracted from expressive therapy (Dewald 1964, 1971)

In addressing the question of where supportive psychotherapy fits

among the many models of psychotherapy, Rockland (1989) proposed
the acronym POST to signify psychodynamically oriented supportive ther­
apy, explaining that all psychotherapies involve both supportive and ex­
ploratory interventions and that therapy should be “based on as complete
an understanding as possible of the patient’s core conflicts, characteristic
defensive maneuvers, ego functions, superego organization, and object re­
lations” (p. 7). Although Rockland’s acronym has not caught on, his
thinking reflects the views of most people who have written about sup­
portive psychotherapy in the past 25 years.
A therapist who accepts the following tenets of modern psychody­
namic therapy is a psychodynamically oriented therapist (Fonagy and
Target 2009):

• Assumption of psychological causation

• Assumption of limitations of consciousness and the influence of uncon­
scious mental states
• Assumption of internal representations of interpersonal relationships
• Assumption of ubiquity of psychological conflict
4 Learning Supportive Psychotherapy

• Assumption of psychic defenses

• Assumption of complex meaning
• Assumption of emphasis on the therapeutic relationship
• Assumption of the validity of a developmental perspective

According to Gabbard (2017, pp. 4–18), three elements of psychody­

namic psychotherapy pertain to the therapist’s understanding of the patient:

• Much of mental life is unconscious.

• Childhood experiences in concert with genetic factors shape the adult.
• Symptoms and behaviors serve multiple functions and are determined
by complex and often unconscious forces.

Three elements of psychodynamic psychotherapy pertain to the thera­

pist’s actions, or to the conduct of the treatment:

• The patient’s transference to the therapist is a primary source of under­

standing.
• The therapist’s countertransference provides valuable understanding
about what the patient induces in others.
• The patient’s resistance to the therapeutic process is a major focus of
the therapy.

A final element of psychodynamic psychotherapy describes the objective,

or what the therapist hopes to accomplish:

• The goal is to assist the patient in achieving a sense of authenticity and

uniqueness.

The psychodynamically oriented therapist practicing supportive psy­

chotherapy understands the patient in terms of the first three of Gabbard’s
(2017) points but does not conduct treatment in the manner described in
the next three points. Transference is used only to the extent necessary.
Resistance might be used without implications about unconscious process
to describe the patient’s clinging to familiar patterns. Although the ther­
apist would be pleased to achieve the outcome described in the last point,
the formal objectives of supportive psychotherapy are limited to symp­
tom relief and better adaptation in promoting overall health and personal
well-being.
The early characterization of supportive psychotherapy as a limited
approach was based on its deviation from classical theory. Although the
rationale and techniques of today’s supportive psychotherapy can be ex­
Evolution of the Concept of Supportive Psychotherapy 5

plained in terms of theory, the techniques were developed from practical

work with patients. Novalis et al. (1993, p. 5) observed, “Virtually all of
the several hundred psychotherapies are based upon a concept or theory
of mind. Supportive psychotherapy...is not dependent upon any specific
overriding concept or theory, but utilizes the rich work done by many
theorists in understanding how people change as this work is confirmed
empirically.”

Psychodynamic Therapy and the Supportive-

Expressive Continuum
In his textbook Psychotherapy: A Dynamic Approach, Dewald (1971) ex­
plained the contrast between supportive psychotherapy and insight-directed
therapy (i.e., expressive therapy, in our terminology), observing that a pa­
tient’s treatment usually falls somewhere in between the two (Figure 1–1).
As Dewald (1964) noted, “The ends of the continuum can be clearly dis­
tinguished from each other in regards to the theory of psychotherapy, and to
the technique which evolves logically from this theory. In the center of the
continuum these differences are less discrete and less clearly demarcated.
The treatment of most patients involves both supportive and expressive el­
ements, which must be used in a coherent, integrated fashion” (p. 97).
Dewald described supportive psychotherapy as generally aimed at symp­
tom relief and overt behavior change, without emphasis on modifying per­
sonality or resolving unconscious conflict. He wrote, “The majority of people
with psychiatric illness..., character problems, acute or chronic psychosis,
etc., are not suitable candidates for a formal attempt at insight-directed psy­
chotherapy. Instead they are more suitably and expeditiously treated by a dy­
namically oriented supportive approach” (Dewald 1971, p. 114).
Expressive therapy is a collective term for a variety of approaches that
seek personality change through analysis of the relationship between the
therapist and patient and through the acquisition of insight about previ­
ously unrecognized feelings, thoughts, needs, and conflicts, which the pa­
tient must attempt to consciously resolve and better integrate. We prefer
using the term expressive therapy in order to avoid using the word psy­
chodynamic with two different meanings.
To emphasize that the treatment of each patient involves both support­
ive and expressive elements, a linear representation of this continuum has
been presented by a number of authors (see Figure 1–1). At one end, the
frequency of supportive interventions is high and the frequency of explor­
atory intervention is low. At the other end, the frequency of supportive in­
terventions is low. The supportive and expressive stances, or points of view,
are very different. The most supportive stance involves guidance, whereas
 6

Supportive Counseling Supportive Supportive-expressive Expressive­ Psychoanalysis

relationship psychotherapy psychotherapy supportive
psychotherapy

Figure 1–1. Supportive-expressive continuum.

Learning Supportive Psychotherapy
Evolution of the Concept of Supportive Psychotherapy 7

the most expressive stance involves discovery. Luborsky and Mark (1991,
p. 110) described expressive therapies as “techniques aimed at facilitating
the patient’s expressions about problems and conflicts and their understand­
ing.” The supportive position may encourage use of a defense; the expressive
position may seek to discover the roots of the defense with the hope that its
use will end. Even though treatment invariably entails both supportive and
expressive elements, the therapist’s basic stance, at a single point in treat­
ment of a patient, must be primarily one or the other. When the stance is ex­
pressive, the therapist follows the dictum “be as expressive as you can be,
and as supportive as you have to be” (Wallerstein 1986, p. 688). When the
stance is supportive, the therapist follows Wachtel’s (1993) advice: “Be as
supportive as you can be so that you can be as expressive as you will need to
be” (p. 155). This distinction is critical.
If asked what they are doing, most practitioners will respond “psycho­
therapy” or “supportive psychotherapy” or “psychoanalytically oriented
psychotherapy” or “psychodynamic psychotherapy.” It is important to note
that the world of psychotherapy has changed greatly, and psychotherapy is
no longer limited to approaches based on psychodynamic formulations.
Supportive interventions may be used productively in the conduct of cogni­
tive-behavioral therapy, for example, without raising significant theoretical
or practical problems. The graphic representation in Figure 1–1 is not an in­
dication that the patient population is distributed on a bell-shaped curve.
Essentially, when we describe the conceptual basis of therapy, supportive­
expressive psychotherapy and expressive-supportive psychotherapy meet
at the center of the visual representation. When we describe practical work
with patients, we believe that supportive-expressive psychotherapy is what
most practitioners are doing most of the time with most of their patients.
If the treatment of each patient involves both supportive and expres­
sive elements, why are the elements taught separately? As Rockland
(1989) pointed out, “supportive and exploratory psychotherapies...[are]
sufficiently discrepant in major ways to deserve clear differentiation and
separation” (p. 20). Supportive psychotherapy, expressive therapy, cogni­
tive-behavioral therapy, family therapy, and group therapy, among others,
are all taught by different specialists because there is a lot to know about
each of them. As in all areas of education, it is the task of the student to
integrate all that he or she has learned.
We appreciate that many, many approaches to therapy have been
named that emphasize an element of treatment, personality develop­
ment, or symptom formation that is thought to be novel or especially sig­
nificant. Although, as Winston and Winston (2002) said, theories “are de­
scribed separately to maintain clarity, these various models come together
to inform the psychotherapy approach for a given patient” (p. 13).
8 Learning Supportive Psychotherapy

“Therapists...should be able to transition from one approach to another.

Such transitioning involves combining various interventions from differ­
ent psychotherapy traditions into a cohesive therapy” (p. 264).

Definition of Supportive Psychotherapy

The term supportive therapy is frequently used in nonpsychiatric studies
to denote an approach that involves expression of interest, attention to
concrete services, encouragement, and optimism. This is a supportive re­
lationship or supportive contact but not supportive psychotherapy. Sup­
portive relationships with family, friends, coworkers, clergy, and others
may indeed be useful and sustaining, but in our opinion they should not
be called “therapy.” We note, too, that the boundary between counseling
and psychotherapy is not clear. Supportive psychotherapy is based on di­
agnostic evaluation; the therapist’s actions are deliberate and designed to
achieve specified objectives. The professional relationship is unique and
exists solely to meet the needs of the patient. The therapist’s gratification
must come from doing the job well, rather than from the patient’s ex­
pressions of gratitude or from using the patient as an audience. In every­
day life, there are many motivations for being supportive. In the
professional supportive relationship, the motivation must be to meet the
patient’s needs—to help the patient adapt and cope in order to live his or
her best life.
In psychiatric literature, the terms supportive therapy and supportive
psychotherapy have been used interchangeably. This is unfortunate be­
cause the nonspecific support provided to patients who have medical or
surgical problems is also characterized as supportive therapy, in this case
referring to efforts that make the patient more comfortable. We will al­
ways use the long form—supportive psychotherapy—to emphasize that
we are writing about a professional service that is provided in a mental
health context by a person trained in mental health theory and practices.
We define supportive psychotherapy as a dyadic treatment that uses di­
rect techniques to 1) ameliorate symptoms and 2) maintain, restore, or
improve self-esteem, ego function, and adaptive skills (see below) with a
focus on the patient’s overall health and well-being. Treatment may ex­
amine real or transferential relationships and past and current patterns of
emotional response or behavior in order to accomplish these objectives.

• Self-esteem involves the patient’s sense of efficacy, confidence, hope,

and self-regard.
• Ego functions include relation to reality, thinking, defense formation,
regulation of affect, synthetic function, and others, as enumerated by
Evolution of the Concept of Supportive Psychotherapy 9

Beres (1956, pp. 164–235), Bellak (1958, pp. 1–40), and other au­
thors. Ego functions could alternatively be called psychological functions
because they are addressed by behavior therapists and cognitive ther­
apists whose formulations do not include the ego as a component of a
mental apparatus. Ego functions are often categorized as psychic struc­
ture. As cognitive functions are increasingly understood in physical and
physiological terms, psychological terminology may be eclipsed, but it
still appears to be useful in the clinical setting at present.
• Adaptive skills are actions associated with effective functioning. Social
skills are one example of an adaptive skill for individuals living with a
chronic psychotic disorder or personality disorder. The boundary be­
tween ego functions and adaptive skills is not sharply defined. The pa­
tient’s assessment of events is an ego function; the action taken in
response to the assessment is an adaptive skill.

We have explained that supportive and expressive therapies are different

and that the treatment of an individual patient is likely to involve elements
of both. In practice, supportive psychotherapy, as we have defined it, describes
what is identified as supportive-expressive psychotherapy on the contin­
uum. When we teach or prescribe psychodynamic therapy, we are usually
referring to what is identified on the continuum as expressive-supportive
psychotherapy. Most psychotherapists in the United States are guided by
psychodynamic principles, but it is possible to address self-esteem issues,
ego-function problems, and adaptive skills without accepting psychody­
namic principles.
In the following three examples, the therapists’ approaches represent
different points along the supportive-expressive continuum.

Case Illustration 1
Juan is a 55-year-old man who attended school for 6 years in his native
country in Latin America. In the United States, he has held various un­
skilled jobs. He was married for several years, but his wife divorced him
when he became involved with illicit substances. He has been drug-free
since serving a 2-year prison sentence 20 years ago, but he has had in­
creased difficulty obtaining work. He now has several medical problems,
and he keeps his clinic appointments and follows prescribed treatment. A
resident has monitored his antidepressant medication in the psychiatric
clinic once a month for more than a year. Juan attends a day program for
medical patients, but he has been threatened with expulsion because he is
quick to show anger and lash out if he feels that someone is pushing him
aside at lunchtime or taking the seat he wished to occupy. The day pro­
gram and his clinic visits are his only structured activity. The treating res­
ident discusses the recommendations of the other physicians with Juan
and talks about the effects of his medications, encouraging Juan to tell the
10 Learning Supportive Psychotherapy

other physicians if he has any problems. The resident responds empathi­

cally to Juan’s descriptions of loneliness and praises Juan for his success at
maintaining sobriety. The resident is satisfied that Juan’s angry responses
are not associated with delusional thinking, but she has been unable to in­
volve Juan in scrutinizing the reason for his angry responses or offering
anything but the most superficial justifications for his actions. Juan does
accept the suggestion that he should always seek help from a staff member
if he is angered by other participants in the day program. (This is an en­
tirely supportive approach, involving encouragement, praise, and ad­
vice about adaptive skills. Success will be measured by the patient’s con­
tinued acceptance of medical treatment and antidepressant medication
and ability to control his temper.)

Case Illustration 2
Richard has the same problems as Juan, but he has a greater ability to think
about his internal life. He says that if someone gets ahead of him, he feels
that the person is putting him down and mocking him. Richard says he was
brought up this way. When he did not stand up for himself, his father
would become very angry and punish him, and no one in his family or
neighborhood would have considered his father to be wrong. The therapist
explains that people with such experiences in the past may be quick to de­
fend themselves from what appears to be an affront, and Richard agrees
that this makes sense. (The therapy in this case is supportive-expressive
because it involves assumptions about mental life. The therapist seeks to
help the patient begin to understand problem-causing behavior in terms of
attitudes about which he had been unaware.)

Case Illustration 3
George is aware of having an “anger problem” and becomes very irritable
when his therapist asks, as he had done in previous sessions, whether
George has been involved in any conflicts since the last visit. George re­
sponds sullenly and tells the therapist that the medication he had been
taking for several months was causing too many side effects and wasn’t
helping at all. The therapist suggests that perhaps being asked about pos­
sible failures of self-control reminds George of his childhood experience
of being scolded by his father. George says he hadn’t thought of that, but
it might be true. (Suspecting that the patient’s anger might be of trans­
ferential origin, the therapist suggests a link between past and present re­
lationships—an expressive element. This therapy may be described as
located at the midpoint of the supportive-expressive continuum.)

Teaching Supportive Psychotherapy

Although supportive psychotherapy is the most widely practiced form of
psychodynamically oriented psychotherapy, teaching supportive psycho­
therapy poses challenges. Supportive psychotherapy is not based on rig­
orous and internally consistent or appealing theory, and it does not offer
Evolution of the Concept of Supportive Psychotherapy 11

solutions to intractable clinical problems. The field has no conferences,

no stars, and relatively few books.
Education of psychotherapists throughout much of the twentieth cen­
tury was based primarily on principles developed by psychoanalysts. In a
short text for beginners, Balsam and Balsam (1984) wrote, “The psycho­
therapist’s central task is learning to understand...the emotional experi­
ence of the patient” (p. 1). Treatment techniques that had specific
rationales in psychoanalysis were presented as universal techniques re­
quired for all psychotherapy. If the patient stopped talking, the therapist
was advised to wait for him or her to continue or to ask what he or she was
thinking. The therapist was advised to avoid direct answers to questions
(Colby 1951, pp. 55–56). In short, the treatment that was taught was in­
tended “to relieve the patient of distressing neurotic symptoms or discor­
dant personality characteristics” (Colby 1951, p. 3).
This model provided no guidance about how to work with patients
who were inarticulate or poorly educated, patients who had intractable
social problems or severe behavioral problems, or patients who were ex­
pected to drop out after a few monthly or bimonthly visits. Psychother­
apists who failed to discover how to conduct supportive psychotherapy
provided their patients an irrational, unintegrated mixture of expressive
assumptions and supportive tactics.
In a recent review, Brenner (2012) advocated for a much more sophis­
ticated approach to teaching supportive psychotherapy in the twenty-first
century. He suggested that the mandate for competence in supportive psy­
chotherapy, the strong evidence base for supportive psychotherapy, and the
growing prominence of the recovery movement in psychiatry all served to
demonstrate the importance of greater curricular attention to supportive
psychotherapy in psychiatric residency programs. Brenner articulated three
important factors in teaching supportive psychotherapy: its relevance for
common factors underlying all forms of psychotherapy; its role on a spec­
trum of psychodynamically informed psychotherapies; and its value as a
modality that includes specifically definable techniques and aims. Brenner
highlighted several examples of the importance of supportive psycho­
therapy, including helping patients with emotional regulation, grief, im­
pulsivity, reality-testing, self-esteem, responsibility-taking, and healthy
self-identification. Moreover, Brenner recommended teaching supportive
psychotherapy in diverse clinical rotations, including inpatient and consul­
tation-liaison services as well as ambulatory settings.
In time, residents who have received training in supportive psychother­
apy will observe that patients with the greatest psychological strengths are
suitable for treatment that is primarily expressive. Nevertheless, the fact
that a patient has the resources and psychological characteristics needed to
12 Learning Supportive Psychotherapy

undergo expressive therapy does not mean that expressive therapy is indi­
cated. Providing more support than needed may be effective but may de­
prive the patient of an opportunity to make more impressive changes in his
or her life. As Hellerstein et al. (1994) pointed out, a strong case can be
made for employing the supportive (i.e., supportive-expressive) model
for most patients, shifting to more time-intensive expressive measures
only to the extent required. In all cases, treatment planning must involve
consideration of what the patient wants to accomplish.
Supervisors working with residents may note that the fundamental ob­
jectives of supportive psychotherapy can be achieved by early career cli­
nicians who may not have much exposure to psychodynamic principles.
Beginners who cannot yet attempt expressive psychotherapy may be
competent at providing good supportive-expressive treatment. With
practice, therapists become aware of how a patient is responding to them
and then of how they are responding to the patient. Viederman (2008)
described a very active approach in which the clinician asks the patient
for memories about earlier times in life that are related to the clinician’s
observations and interpretations and then communicates to the patient
an understanding of the patient’s predicament. He wrote, “The consul­
tant enters the patient’s world, develops a picture of him, of his experi­
ence with people in his life, and communicates this in a language which is
familiar to him. This results in a climate that is the essence of a supportive
relationship” (p. 352). One of the many satisfactions of being a psycho­
therapist is that the clinician improves and continues to improve as the
decades pass. Supervisors working with residents who are learning sup­
portive psychotherapy approaches may help establish the groundwork
for such professional growth.

Conclusion
Supportive psychotherapy and the expressive psychotherapies have dif­
ferent objectives and employ different techniques. The treatment of an
individual patient whose treatment plan calls for psychodynamically ori­
ented supportive psychotherapy involves both supportive and expressive
elements. The clinician must understand and must be able to integrate
both approaches. Psychiatric residency programs must ensure that their
graduates are competent in psychotherapeutic approaches, including
supportive psychotherapy. Learning supportive psychotherapy can help
reinforce the common factors underlying all forms of psychotherapy, as­
pects of psychodynamically informed psychotherapy, and specifically de­
finable techniques and aims of psychotherapy.
Principles and
Mode of Action
2
Underlying Assumptions
Supportive psychotherapy relies on direct measures. The therapist is active
and addresses conscious problems or conflicts rather than underlying un­
conscious conflicts or personality distortions (Dewald 1994). A major
tenet of Freud’s early psychoanalytic work was that symptoms are caused by
unconscious conflict; through psychoanalysis, the conflict becomes con­
scious and is worked through, and then the symptoms disappear because
they are no longer psychologically necessary. In supportive psychotherapy, it
is not assumed that improvement will develop as a by-product of insight.
Greater self-awareness or insight about the origin of problems is not essential.
In supportive therapy, the relationship between patient and therapist is a
relationship between two adults with a common purpose. As in all profes­
sional relationships, one person provides a service that the other requires.
The professional person, the therapist, owes the patient respect, full atten­
tion, honesty, and vigorous effort to accomplish the stated purpose by using
the knowledge and skills of the profession. Adhering to these obligations is
known as staying within boundaries. Because the therapist is understood to
be a whole person, with professional training and life experience, and is not
required to be minimally communicative or to be a “blank slate” in the ther­
apeutic relationship, there is greater symmetry between the patient and
therapist than in other therapeutic relationships.

13
14 Learning Supportive Psychotherapy

This said, the relationship in supportive psychotherapy is wholly focused

on fostering the overall health and well-being of the patient, on reducing
symptoms and sources of distress, and on bolstering his or her adaptive
strengths. The interaction may be friendly, but the two individuals do not
become friends. The therapist does not advise the patient on how to vote,
whom to marry, or how to decorate the home. The therapist does not seek
assistance from the patient. If the therapist talks at length, describing his or
her own experiences, thoughts, or feelings, the therapist must consider
whether it is really for the patient’s benefit or whether it is because the ther­
apist enjoys talking. Using the patient in this manner is exploitation.
When the stance is expressive, the therapist tries to remain neutral and
cautious when responding so that the patient’s perception of thoughts and
feelings about the therapist can be analyzed as projections of feelings asso­
ciated with important figures in past or present life. This projection is
termed transference. The expressive stance avoids responses that might en­
courage the patient to perceive the therapist as a person with opinions,
tastes, family, or even personality. It is this technical maneuver that has pro­
duced the image of the psychotherapist as an individual who parries all
questions with evasive answers or reflects all questions back to the patient.
The degree to which the therapist and patient discuss transference de­
pends on the type of therapy. In expressive therapies, analysis of transfer­
ence is a key element in the process of understanding the patient’s inner
life. Although transference occurs in supportive psychotherapy, as it does
in all relationships, it is typically discussed only when manifestations of
transference threaten the continuation of therapy. Because most psycho­
therapy is supportive-expressive in practice, transference is not a taboo
subject. In relational therapies, which have been increasingly popular
since the 1980s (Fonagy and Target 2009; Greenberg 2001; Mitchell
1988), intense and ongoing examination of the patient-therapist interac­
tion is a major focus of the therapeutic process, and the therapist may dis­
close much more than would be done in classical treatment. This is not an
approach to be undertaken by the novice therapist. Even at the support­
ive end of the spectrum, it is often useful for the therapist to try to make
the patient aware of problems in their real-time interaction.

THERAPIST 1: You haven’t said you disagree with me, but you have found
something of concern with every observation I have made today (a
clarification that might encourage the patient to be more frank,
without examining underlying issues).
THERAPIST 2: Are you aware that when I have tried to focus on steps you
might take to manage better in daily life, you go back to talking
about what your wife did wrong? (an observation in the course of
supportive-expressive therapy)
Principles and Mode of Action 15

THERAPIST 3: Are you aware that when I ask you about your father, you
talk about problems at work or the world situation? (confrontation
in the course of expressive-supportive therapy)

As stated earlier in this chapter, the supportive psychotherapy relation­

ship is a relationship between two adults with a common purpose. The
therapist encourages the development of positive feelings; if the patient
brings up the presence of these positive feelings, the therapist accepts them
without attempting to have the patient understand them. The patient’s
positive feelings about the therapist, even if moderately unrealistic, are use­
ful for maintaining the therapeutic alliance and potentially useful for iden­
tification with the therapist. (For further discussion of the patient-therapist
relationship, see Chapter 6, “The Therapeutic Relationship.”)

PATIENT 1: You always have such a clear way of thinking about things. I’m
all over the place. You always know what the problem is and what
to do about it.
THERAPIST 1: Thanks. It’s easier when you hear a description of a complex
issue than when you’re in the midst of it.

If negative feelings about the therapist or the therapy are evident, or even
suspected, they must be discussed because negative feelings may threaten
or lead to disruption of treatment.

PATIENT 2: Getting here seems to be more difficult. Things always come

up at the last minute. I apologize for being late.
THERAPIST 2: We could try to change your appointment time if that
would help, but I wonder if you’re finding it more difficult now be­
cause you’re having some doubts about continuing.

In expressive psychotherapy, the patient’s reaction to events in his or

her current life may be discussed as possible (unconscious) expressions of
the patient’s feelings about the therapist.

PATIENT: I was on the phone with customer service for half an hour. This
really drives me up the wall. It was worse than ever. Those people
are incompetent. I keep losing my temper.
THERAPIST: Last week you were complaining because I hadn’t come up with
a quick answer for all your problems. Maybe you were especially angry
with customer service and saw them as incompetent because you were
thinking I was incompetent and you were angry with me.

In supportive psychotherapy, however, events in the therapy may be of­

fered as illustrations or models for everyday life.

PATIENT: This really drives me up the wall. It was worse than ever. Those
people are incompetent. I keep losing my temper.
16 Learning Supportive Psychotherapy

THERAPIST: Last week you were complaining because I hadn’t come up

with a quick answer for all your problems. You were polite and
thoughtful, and we were able to discuss it, and you didn’t seem to
be “up the wall.” Maybe you could be as reasonable and controlled
when you talk to customer service as you are here with me.

In the course of supportive psychotherapy and supportive-expressive

therapy, the therapist gives simple, direct answers to personal questions,
within the bounds of information that he or she is willing to share with an
acquaintance. The disclosure of information that is ordinarily kept private
is often associated with a violation of the boundary that must separate the
personal from the professional. These are nuanced judgments in the
course of supportive psychotherapy— for example, a patient who re­
cently moved from another state may inquire about the therapist’s past
moves after graduating from residency and moving to a new community.
The therapist must decide whether responding with personal information
will serve the therapeutic alliance and the goals of the therapeutic work or
whether it will introduce complex transferential issues that are counter to
the goals of treatment. When the stance is primarily expressive, the ther­
apeutic strategy is based on the assumption that the patient’s thoughts
about the therapist will reveal evidence of transference. In supportive
psychotherapy, the transferential aspect may be more or less relevant in
relation to the goals of treatment.

Conversational Style
Supportive psychotherapy is conducted in a conversational style. Because
conversation is the principal form of interaction among adults, readers
might wonder why it is necessary for us to say anything about it in this
book. When we first wrote about supportive psychotherapy, it was im­
portant to convey to the beginner that the therapist’s task is not listening
silently to a patient who has been instructed to “say whatever comes to
mind.” Today, the psychiatry resident who listens silently at length usu­
ally does so because he or she does not know what to say, or expects the
patient to pause at any moment, or hopes that the next sentence will be
important and that the patient will soon get to the point. The beginning
therapist probably knows that by interrupting a silence too quickly, he or
she may never know what is troubling the patient. When the therapeutic
stance is supportive, the therapist will not wait long. Faced with a long
pause, the expressive therapist thinks, “Is there an indication for me to
speak?” In contrast, the supportive therapist thinks, “Is there a reason for
me not to speak?”
The therapeutic interaction is conversational in style, but it is not nor­
mal conversation. In normal conversation, the speakers alternate: your
Principles and Mode of Action 17

turn, my turn. You tell me what happened on your way to work this
morning, and I tell you what happened to me on my way to work; you talk
about your pets, and I talk about my pets. In therapy, the therapist is re­
sponsive, but it is always the patient’s turn.
Physicians who are new to psychotherapy often have had years of prac­
tice polishing a style of communication that is not responsive and not sup­
portive. They have mastered the art of obtaining the history by asking
questions. When every utterance is a question, the process is interroga­
tion. Miller and Rollnick (1991, p. 66), writing about motivational inter­
viewing, advised that one should not ask more than three questions in a row
because doing so implies an interaction between an active expert and a pas­
sive patient. To maintain a supportive conversational style, the therapist
must be responsive. In the act of responding, the therapist is giving some­
thing to the patient. Except for narcissistic individuals who get satisfaction
from having an audience, people want to be given something in return for
what they give, and this giving, by an intelligent, interested person—the
therapist—is gratifying and reassuring.
To maintain a conversational style, the therapist responds both to what
the patient volunteers and to the patient’s responses to questions. Com­
pare the following two interactions:

PATIENT 1: I slept better most of the time.

THERAPIST 1: OK.
PATIENT 1: But it’s still hard being out of work; I’m just getting by on my
unemployment checks.
THERAPIST 1: OK.
PATIENT 1: I try to keep busy, like you said.
THERAPIST 1: OK.
PATIENT 1: But I still feel bad some of the time.
THERAPIST 1: OK. (This is a dreadful, nongiving style of response, not
unusual in hospitals.)

PATIENT 2: I slept better most of the time.

THERAPIST 2: I’m glad to hear it. And that’s without medication, isn’t it?

PATIENT 2: Yes. But it’s still hard being out of work; I’m just getting by on

my unemployment checks.
THERAPIST 2: When you are used to working, unemployment insurance is
important, but it doesn’t fill your life.
PATIENT 2: I try to keep busy, like you said.
THERAPIST 2: Good. What are you doing?
PATIENT 2: I’ve been cleaning my basement, bit by bit. Not just the floor,
but cleaning the old grit from overhead pipes and things like that.
It’s not really important.
THERAPIST 2: It sounds like a project that isn’t exciting, but you can see
the results of what you have done.
18 Learning Supportive Psychotherapy

PATIENT 2: But I still feel bad some of the time.

THERAPIST 2: I’m sorry to hear it. We have to work on that. (The therapist’s
responses, although not profound, indicate interest and concern.)

The physician who has many patients and little time is tortured by pa­
tients who are diffuse and vague. To manage this problem, physicians de­
velop habits of asking leading questions, asking questions that include
prompted answers (including multiple-choice lists) or questions that in­
vite yes/no answers.

THERAPIST 1: Did you leave school because you had to work to help the
family? (A better approach is “I’d like to know about your decision
to quit school.”)
THERAPIST 2: Did your mother think it was a good idea for you to quit
school, or did she object? (A better question is “What did your
mother say about your decision to quit school?”)
THERAPIST 3: How much do you drink? A little wine with meals? (A bet­
ter question is “What is your usual use of alcohol?”)

The open-ended question has the greatest potential for eliciting infor­
mation. Prompts and suggestions are appropriate when the patient is un­
able to respond to a broad question. Prompts that elicit a “no” answer or
multiple-choice lists that fail to include a correct alternative may cause
the patient to infer that the therapist does not understand.
The beginner therapist who has overcome the habit of asking questions is
at risk of falling into unproductive agreeableness, always responding to the
patient’s most recent words. The therapist asks a question, the patient gives a
partial answer and then moves to another topic, the therapist asks a question
about that, and the process is repeated, with the therapist never having the
opportunity to deal with anything useful. Beginning therapists are often eas­
ily put off because if a patient’s answer is not adequate, they go on to another
question instead of pursuing an answer to the initial question. In short, asking
too many questions is not good form, but if a question is asked, it should not
be abandoned without an attempt to get an answer. The therapist who does
not attempt to understand the whole story sends the message that he or she
does not really care. Compare the following two interactions:

THERAPIST 1: Do you have any thoughts about any issues or events that
may have led up to your depression last year?
PATIENT 1: Nothing. It just happened. It came out of the blue.

THERAPIST 1: Have you ever felt suicidal? (The therapist, if curious about
what led to the depression, should have attempted to persist with
that topic even though suicide is also an important issue.)
Principles and Mode of Action 19

THERAPIST 2: What was happening in your life in the month or so before

the depression began? (persisting with a general question that does
not call on the patient to make cause-and-effect connections)
PATIENT 2: Nothing special. I went to work. I came home. My husband
was working. The kids were in school (uninformative).
THERAPIST 2: Let’s take them one at a time. What about work? What were
you doing? What about coworkers? Any problems? Did anyone you
care about leave? Was your assignment changed? Your supervisor?
Advancement? (By deliberately offering multiple-choice options,
the therapist hints at topics that might be important.)
PATIENT 2: Not really. Everything was routine (uninformative).
THERAPIST 2: OK. Tell me about your husband and children at that time.
What was going on? We are looking for things that might have been
disturbing but that you might have brushed aside at the time with­
out paying much attention. (The prodding question is asked in a
supportive way. Although suggesting answers to questions was de­
scribed earlier as bad form, it may be used as a tactic for educating
the patient about important issues and maintaining focus.)

Seeking more complete information about what the patient is saying is

a demonstration of interest and attention, so it is a supportive act, pro­
vided that the pursuit of additional information does not take on the qual­
ity of an attack. Emotionally attuned listening and clarification seeking
can be very reassuring to a patient, and much more information may
come forward in the interaction between the therapist and patient. The
key to obtaining complete information is often the wonderful phrase
“Give me an example.”

PATIENT 1: If I get mad at work, I just don’t go back.

THERAPIST 1: Give me an example. What was the incident that got to you?
PATIENT 1: It was nothing. I was working a counter. A customer was ar­
guing with me.
THERAPIST 1: So a customer started to argue with you. Let’s try to look at
what happened. What did the customer say, and what did you say?

PATIENT 2: I have to do everything. My husband is helpless in the house.

I come home from work and I have to get dinner, even though he’s
been home.
THERAPIST 2: What do you mean by “helpless?” Does he do any tasks at all?

PATIENT 3: No, I never get angry. I can’t remember ever losing my temper.
THERAPIST 3: Can you describe some instance in which something dis­
pleased you a little?

Maintaining and Improving Self-Esteem

Maintaining or improving self-esteem is a major concern of supportive
psychotherapy. One person helps the self-esteem of another person by
20 Learning Supportive Psychotherapy

conveying acceptance, approval, interest, respect, or admiration. The

person whose daily life and relationships are lacking or deficient in these
qualities may respond to any indication of their presence. The patient
who cannot form relationships with others, who is avoided by others, or
who perceives (perhaps correctly) that people look at him or her disap­
provingly, finds in the therapist a person who is accepting and interested.
The therapist’s acceptance and respect are unspoken. The therapist com­
municates interest in the patient by making it evident that he or she re­
members their conversations; recalls what the patient has said; and is
aware of the patient’s likes, dislikes, and attitudes. Acceptance is commu­
nicated by avoidance of arguing, denigrating, and criticizing—verbal in­
teractions common to many relationships, including, unfortunately,
many contacts between patients and health care providers.
Below are therapist responses that are negatively stated followed by re­
sponses that are more positive, congenial, and encouraging.

THERAPIST 1: It doesn’t make any sense to get an MRI [magnetic reso­

nance imaging] just because you forget people’s names (argument).
THERAPIST 2: Forgetting names is usually the first memory issue that
healthy people experience. If that is the only problem, it’s not
caused by the sort of thing that shows up on an MRI (respectful, re­
assuring).

THERAPIST 1: What are you trying to say? (denigration)

THERAPIST 2: OK, I am not sure I understand. Can you say more? (en­
couraging clarification)

THERAPIST 1: Didn’t they tell you to take your medication every day?
(criticism)
THERAPIST 2: A lot of the effect is lost if you don’t take your medication
every day. If the dosage is too large, we should discuss it. A smaller
dosage might be the answer (informative, nonjudgmental, inviting
response).

In their efforts to boost or avoid lowering the patient’s self-esteem,

therapists need to avoid language that is overpowering (directly or by im­
plication) and behavior that may make the patient feel diminished or
helpless, such as pomposity, overelaborate speech, or ostentatiousness.
The following are some overpowering statements:

THERAPIST 1: I’m trying to get you to understand....

THERAPIST 2: I’m going to medicate you.

THERAPIST 3: It’s your imagination.

Principles and Mode of Action 21

Here are better ways to express the same ideas:

THERAPIST 1: I hope I’m being clear.

THERAPIST 2: Let’s talk about medication.
THERAPIST 3: When you hear something that people around you don’t
hear, it’s not imagination; it’s an event in your brain that’s not trig­
gered by something in the environment.

Questions that begin with the words why or why didn’t you are often
experienced as attacks, and they should be avoided (Pinsker 1997). In the
course of growing up, most people learn that “Why did you do it?” is not
so much a search for information as a rebuke for having committed a cer­
tain act. Similarly, “Why didn’t you do it?” means “You should have done
it.” Attack is inimical to self-esteem. Alternatives to why questions might
include the following:

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?

Attacking questions are accepted as a matter of course in most relation­

ships, and they are certainly customary in conventional medical practice, so
reasonable use of them will not destroy the therapy. The objective is to con­
duct therapy with finesse, thus enhancing the prospects for success. When
possible, it is better to ask a general question than a narrow question. For ex­
ample, “What is your usual use of alcohol?” is a better question than “Do you
drink wine with meals?” It is also better practice, when possible, to ask ques­
tions in a way that elicits a positive response rather than a negative response.
The therapist should not be a person to whom the patient must too often an­
swer “No.” Asking questions that are likely to be answered with a “no” implies
that the therapist does not understand the patient.
The doctor-patient relationship involves a person who has the power
to give help and a person who needs help. The doctor should give help in
a skillful manner that minimizes the inherent inequality of the transaction
and communicates respect for the patient. Respect is good for self-esteem
and good for the therapeutic alliance. Giving the patient vague, dismissive
explanations conveys lack of respect.

PATIENT 1: I think this medication is making me sleepy.

PHYSICIAN 1: It hasn’t been a problem for most people. How’s your ap­
petite? (dismissive)
22 Learning Supportive Psychotherapy

PATIENT 2: I don’t feel any better.

PHYSICIAN 2: Well, you look better. (If coupled with an explanation that
depressed people look better before they feel better, this would be
fine. As an abrupt response, it is dismissive and argumentative.)

Even educated, sophisticated patients tend to tolerate disrespectful at­

titudes and behavior from health care providers because patients are de­
pendent on health care providers and cannot risk animosity. The patient
may employ the defenses of rationalization or denial in order to avoid
awareness of resentment. For many individuals, the reality of needing care
has a negative effect on self-esteem. The health care provider should not
rub salt into the wound.
We recommend that therapists discuss with the patient the reasons for
asking specific questions, explain to the patient the direction being taken,
and ask the patient for agreement on topics to be discussed. We refer to
these tactics as setting the agenda or showing the map. For patients, these
tactics help to prevent both the anxiety that may be associated with going
in unknown directions and the interrogatory atmosphere that reinforces
the idea that the patient is in an inferior position.

Defenses
In the supportive approach, defenses are encouraged (supported) when they
serve their unconscious purpose—protecting the individual from anxiety or
other unpleasant affect. When therapy is primarily expressive, defenses are
identified and examined to discover the underlying conflicts that made the
defenses necessary. In supportive psychotherapy, defenses are questioned
only when they are maladaptive. For example, a patient’s denial as a strategy
for not thinking about the inevitably fatal outcome of his or her own life is
adaptive, whereas a patient’s denial that leads to his or her refusal of poten­
tially safe and beneficial treatment is maladaptive. In expressive psychother­
apy, passive-aggressive behavior might be explored as an indicator of
unconscious hostility and a need to control others; in supportive psychother­
apy, the same behavior might be accepted as adaptive. When dealing with
defenses, the situation is fluid—a therapist may support one defense and
question another. Also, a therapist might recognize and not question a de­
fense early in treatment but question it later in treatment.
In maintaining the supportive stance in the therapist-patient relation­
ship, the therapist should consider it permissible and desirable to explore
the meaning of the patient’s actions and thoughts. Whether the therapist
supports, ignores, or questions a statement that appears to reflect a de­
fensive position depends on the current situation, including the context
of the patient-therapist conversation (e.g., the therapist must consider
Principles and Mode of Action 23

whether to interrupt the patient to raise a question or to go along with the

patient’s flow). The following are examples of different responses:
PATIENT: I hated being in the hospital. Every day someone would be act­
ing up, and they’d jump on him with a needle. I was glad I wasn’t
that bad off.
THERAPIST 1: Yeah (accepts the defense without comment).
THERAPIST 2: Maybe you were afraid on some level that it could happen
to you. A lot of people equate mental illness with being out of con­
trol, so if they find themselves in a hospital because they have a
mental illness, they are afraid they may be in danger of being out of
control (proposes an explanation for the defense, using the tech­
nique of normalization to lessen the impact).
THERAPIST 3: Yes. Your condition was quite different. Severe depression is
one thing; a psychotic episode is another. That wouldn’t happen to
you (encourages the defense).

When does the therapist need to be expressive? Expressive techniques

can be used without altering the supportive stance whenever the basic
supportive techniques do not appear to be enough to accomplish the pa­
tient’s goals and it appears that the patient’s life can be improved by use
of expressive techniques. As stated in Chapter 1, “Evolution of the Con­
cept of Supportive Psychotherapy,” the therapist must know whether his
or her basic stance with a patient is supportive or expressive—the thera­
pist cannot maintain both transference-encouraging neutrality and a real
relationship at the same time.

Psychodynamic Assumptions
Many physicians begin psychiatric training without having had exposure to
psychodynamics or any form of psychotherapy. Some trainees are from
countries where psychodynamic thinking has not been widely dissemi­
nated. Trainees may not know what to talk about with a patient after com­
pleting the history, hoping that improvement will occur, in some way, if
the patient talks about his or her past and feelings. For the absolute begin­
ner (and no one else), we offer the following words about psychodynamics.
Psychodynamics is the interaction between conscious and unconscious
elements of mental life. It is an explanation of the meaning of behavior.
One of the tasks of psychotherapy is to create order out of symptoms and
dysfunctions. To accomplish this task, the patient and therapist join in de­
veloping a history or narrative in which these symptoms and dysfunctions
make sense. Cause-and-effect connections are established. Different
schools of psychodynamic thinking may derive different explanations at
times. The process of making a comprehensible story may be what mat­
ters most.
24 Learning Supportive Psychotherapy

The following are a few examples of psychodynamic formulations.

Case Illustration 1
David, a man who is ordinarily self-sufficient and cheerful, becomes de­
manding and uncooperative when hospitalized following a heart attack,
although he has been reassured that his prognosis is very good. A psycho­
dynamic hypothesis might be that the passive, somewhat helpless role of
hospital patient is anxiety provoking, and David is attempting to compen­
sate by assuming an overbearing attitude. Because he is unaware that the
enforced passivity is behind his unusual behavior, his behavior is consid­
ered to be unconscious.

Case Illustration 2
After being criticized by his parents for watching television all night,
Mark, a patient with schizophrenia, becomes angry with his parents and
stops taking his antipsychotic medication. According to his chart, he has
been educated about taking the medication and has verbalized under­
standing. He is not aware that “forgetting” to take his medication may be
psychologically motivated defiance.

Case Illustration 3
After returning home for Thanksgiving during his first year of college,
Zach, a healthy teenager, provokes a big argument the day before he
leaves, with the consequence that he is angry when he leaves. He is not
aware that part (not all) of him would like to stay home and be depen­
dent. By going away angry, he is protected from the sadness that is part of
his departure.

Case Illustration 4
Susan comes irregularly for clinic visits, each time giving a detailed ac­
count of how other people mistreat her. After many attempts to get Susan
to examine her role in causing or maintaining at least some of her troubles,
the therapist raises the question of why Susan has sought psychotherapy
and whether it should be discontinued. A psychodynamic hypothesis
might be that because repeating familiar patterns is an anxiety-reducing
element of human behavior, Susan may be setting up a situation in which
she will be rejected, thus confirming her expectations about relationships
with people.

Unrecognized Emotions
An assumption of psychodynamically oriented therapies is that unrecog­
nized emotions are often responsible for current unpleasant feelings or mal­
adaptive behavior. At times, simply becoming aware of the emotions may
provide relief. More often, the discovery of the feeling must be followed by
conscious decisions about more effective methods of coping—this is the
adaptive skills focus of supportive psychotherapy. In the past, many pa­
Principles and Mode of Action 25

tients’ symptoms were related to what they perceived as unacceptable sex­

ual feelings—a problem that is less common today. Unrecognized anger is a
frequently seen problem (“getting the anger out” was once proposed as a
simple, curative tactic but is now recognized as counterproductive). Other
often-hidden feelings might be grief that was not experienced at the time of
an important loss, guilt or hopelessness, or a wish to be admired or to be
obeyed. Some individuals are scarcely aware of any feelings at all; the term
alexithymia has been used to describe these patients. For patients with alex­
ithymia, an important objective is to recognize, acknowledge, identify, and
label emotions (Misch 2000). The general task is to incorporate awareness
of feelings into the fabric of memories and current life.
The beginner therapist often asks, “How did it feel?” or “How does it
feel?” in response to almost anything the patient says, with no intent or
plan about what to do with the answer. If the therapist and patient are
working on the problem of unrecognized feelings, the patient’s feelings
connected to events in the past should be explored. Feelings should be ex­
plored if the therapist and patient are examining coping strategies or if the
therapist is seeking opportunities to expand his or her empathic under­
standing. Often, with respect to a current feeling, the question to discuss
must be “What is going to be done about it?” The question “What did you
think?” is as useful as “What did you feel?” because it pertains to thought
process, reality testing, or adaptive skills.
In short, a person who knows thoughts but does not know feelings needs
to feel more, whereas a person who feels too much needs to think and eval­
uate more. Therapeutic dialogue often involves both feelings and thoughts;
jumping to adaptive solutions without understanding the patient’s emo­
tional response is just as wrong as ignoring adaptive solutions altogether.
However, supportive psychotherapy often focuses on thoughts, especially
for more impaired patients who have problems with feelings and require a
more cognitive focus.
The question “How did you feel?” is pertinent when it initiates discus­
sion of how the patient dealt with the feeling or, if there was no feeling,
discussion of the possibility that this lack of feeling is of itself an import­
ant finding.

PATIENT: I asked the guy next door to go to the mall with me, but he said
he didn’t have time. He doesn’t have any more to do than I do.
THERAPIST: How did you feel about that?
PATIENT: It’s all right. He doesn’t have to. (evasive, denying emotional re­
sponse)
THERAPIST: You’re right. He doesn’t have to. That’s a correct analysis
(praise). But you’re offering an analysis when I asked about your
feelings (confrontation; implied question).
26 Learning Supportive Psychotherapy

PATIENT: I didn’t feel anything.

THERAPIST: You describe a situation in which most people would feel dis­
appointment or anger. That reaction won’t control the other per­
son, but it’s important to know what your feelings are because
when you don’t, you can’t make good decisions about things that
affect you (teaching, normalizing).

Maladaptive Behaviors
Another tenet of psychodynamically oriented therapy is that people often
follow patterns of behavior that were appropriate when established but
now have become maladaptive. For example, during adolescence, when
it is important to reduce emotional dependency on parents, many people
assume a belligerent or defiant style. This attitude may be appropriate at
age 16 but may become a continual source of trouble if it persists at age 26,
46, or 66. Some people, once they see that they are clinging to a pattern
of behavior that is familiar and understandable but no longer useful, are
able, with determined effort, to change their habitual responses. Cogni­
tive-behavioral therapy focuses on the assumptions associated with pat­
terns of thought and provides tactics for overcoming these assumptions.
Although cognitive and psychodynamic approaches are usually taught sep­
arately, tactics of both approaches are integrated in everyday treatment.
The search for patterns that may explain symptoms or maladaptive be­
havior is the expressive component of supportive-expressive psychother­
apy. Once the therapist has elicited the history, he or she is concerned first
about feelings and assumptions that are present but unexpressed, then
about feelings and assumptions that are lightly concealed, and later about
feelings and assumptions that have been truly hidden. A long-familiar
analogy is that psychotherapy is like peeling an onion.

Psychogenetics and Early Life Experiences

Psychodynamic explanations tell about the interplay of factors in current
life; they do not explain the origins of the forces, emotions, or assumptions
that affect behavior. Psychogenetics is the search for these origins. When a
therapist says that a man who seeks to have as many sexual relationships as
possible is hypersexual, the therapist is offering a diagnostic impression
(not a DSM diagnosis). When the therapist says that the patient acts this
way to compensate for insecurity about his masculinity, the therapist is
making a psychodynamic hypothesis. When the therapist says that the pa­
tient is insecure because he was afraid of his overbearing father, the thera­
pist is proposing a genetic hypothesis. If the patient is readily able to form
relationships but always ends them by discovering faults in his partner and
Principles and Mode of Action 27

shifting from loving behavior to quarreling, a psychodynamic possibility is

that he is unconsciously fearful of closeness or intimacy.
The interpersonal and emotional experiences of early life are import­
ant in the development of the individual and his or her problems. Creat­
ing a meaningful autobiography is in itself useful because during the
process, what may have appeared to be random events become connected
into a meaningful story.
The problem for the beginning therapist is that some patients talk end­
lessly about their terrible childhoods, emphasizing how they suffered var­
ious forms of maltreatment. The inexperienced therapist may feel
hopeful that some good will come from allowing ongoing talk by a patient
who is avoiding any discussion about changing his or her patterns or man­
ner of relating to people. Venting can be a legitimate supportive tactic
that is useful when the patient has been unable to put painful experiences
into words, perhaps because he or she has been afraid to do so or because
no one has been available to listen and understand. Recounting the same
story also may be adaptive when the patient’s goal is limited to relapse
prevention and the therapist’s objective is to preserve the status quo;
however, such retelling is maladaptive when the goal is to improve the pa­
tient’s life. Retelling can be especially maladaptive in individuals with a
significant trauma history for whom the retelling is accompanied by tre­
mendous distress.

Mode of Action
Attempts to achieve the supportive psychotherapy objectives of improved
ego function and adaptive skills involve teaching, encouragement, exhor­
tation, modeling, and anticipatory guidance. People in general, not only pa­
tients, respond to teaching and instruction if they want to learn, if they
want to improve their lot, and if they trust the teacher. People may coop­
erate with the teacher to please him or her. Such cooperation has been de­
scribed in psychoanalytic writing as a transference cure. The Menninger
psychotherapy research project found that changes that appeared to come
about for this reason proved stable and durable (Wallerstein 1989). Some­
times, advice or instruction from another person, especially an authority
figure, is a catalyst, allowing the patient to accomplish change that he or
she had already formulated.
The many approaches to psychotherapy have produced competing
claims. Extensive research has aimed to discover the active ingredient in
psychotherapy. Because all therapies have been found to be effective, an
important research question emerged: “What do all therapies have in
common?” A number of common factors have been found, of which the
28 Learning Supportive Psychotherapy

therapeutic relationship or therapeutic alliance is perhaps the most im­

portant (de Jonghe et al. 1992; Frank and Frank 1991; Rosenzweig 1936;
Westerman et al. 1995). If there is a good alliance between patient and
therapist, therapy is helpful. If there is not a good alliance, little is accom­
plished. Therefore, the therapist must make deliberate efforts to encour­
age a good relationship and avoid actions that are inimical to a good
relationship (for further discussion, see Chapter 6). The patient’s experi­
ence of “an atmosphere of warmth, hope, caring, and authenticity” is im­
portant in the therapeutic interaction (Brenner 2012, p. 262).
The patient’s transference may cause him or her to unconsciously per­
ceive the therapist as having attributes associated with unpleasant inter­
actions in the past. The therapist, however, does not respond as the figure
from the past did, and in time, the old feelings become muted, and the pa­
tient no longer needs to replay new relationships according to the old
emotional script. According to theory, this result is accomplished without
explicit analysis. Alexander and French (1946) introduced the term cor­
rective emotional experience to describe this process. Corrective emotional
experiences may occur at any point on the spectrum of psychopathology
and the spectrum of psychotherapies. Gabbard (2017) summarized cur­
rent thinking: “Now most clinicians and researchers feel that insight
through interpretation has historically been idealized and that change
also occurs through the experience of a new kind of relationship in psy­
chotherapy” (p. 94).
Education and instruction are potent agents for bringing about change
in people’s lives. Advice and instruction are most likely to be followed
when given by a person whom the individual trusts and respects. The
skillful therapist or teacher gives instruction that is needed at the time
when it can be absorbed and used. The patient’s mother may have said,
“Clean your room.” The psychotherapist teaches, “It’s not good for your
self-esteem for you to be surrounded by evidence that you can’t keep
some order in your life.” Sometimes, this approach is all that is required to
bring about change.
In the 1960s, learning theory, which previously had been of more in­
terest to science-minded psychologists than to clinical psychiatrists, was
presented as the theoretical basis of behavior therapy (an approach that
had been demonstrated to be effective for many disorders), contrary to
predictions based on theories underlying psychoanalytic therapy. Change,
initiated by a therapy based on an educational approach, was found to oc­
cur even if neither patient nor therapist understood the historical origins
of the problem. Education and instruction have been accepted through­
out history as strategies for changing behavior and thought, although such
changes cannot be guaranteed or predicted—when a patient mentions a
Principles and Mode of Action 29

former therapist, it is remarkable how often the patient tells us what that
therapist told him or her to do. Research on the process of learning, al­
though focused on formal education, has led to observations that new in­
formation is linked to what is already known, that retrieving information
repeatedly enhances subsequent recall, and that elaborating on the mate­
rial contributes to learning (deWinstanley and Bjork 2002). Although the
field of learning theory has contributed potentially useful ways of ex­
plaining the process of education and change, such as critical reflection
(Mezirow 1998), these ideas have not percolated through psychotherapy
education.
The techniques of cognitive and behavior therapies are used somewhat
informally in supportive psychotherapy, usually without the emphasis on
homework. Faulty cognition and the persistence of automatic thoughts
are recognized as processes that often contribute to symptom formation
and to maladaptive behavior. In supportive psychotherapy, the therapist
may address faulty cognition when the patient is able to accept the self­
scrutiny entailed. Desensitization, a central theme of behavior therapy,
may contribute to the beneficial effect of history-oriented psychotherapy
in that it involves repeated safe exposure to once painful memories
(Goldberg and Green 1986).
Patients at the most supportive end of the supportive-expressive con­
tinuum find that simply being able to talk to a person who is interested
and accepting minimizes the loneliness in their lives. Being able to talk
about experiences and worries brings relief, even when the patients re­
ceive no reassuring or normalizing response. Identification with the ther­
apist as a reasonable, stable individual may promote stability and better
relationships with others. When associated with events that have been
concealed, venting can be curative. Repeating the same story month after
month may be comforting for the patient, even when he or she makes no
progress. From the medical perspective, maintaining the status quo may
be a reasonable and responsible objective. At the same time, however, the
therapist hopes to find opportunities to help the patient improve his or
her situation.
The concept of change appears throughout the literature on psycho­
therapy. At one end of the spectrum, change means lasting personality
change. At the other end, desirable changes may involve changing specific
behaviors, such as sitting in front of the television all day, skipping med­
ications, spending money foolishly, remaining in a bad environment, or
failing to control children. If simple advice is all that is needed to get the
patient to change habitual behavior, it is not necessary to examine possi­
ble causes of the behavior. Often, however, there are obstacles to bringing
about change that the patient does not verbalize. If the therapist is to give
30 Learning Supportive Psychotherapy

useful advice, he or she must be familiar with the psychological and emo­
tional problems that may be operating.

THERAPIST 1: The last time you were here, we talked about the support
group, and you said you were going to talk to the social worker
about it. I wonder what happened that you didn’t. (“What hap­
pened?” is not as attacking as “Why?”)
PATIENT 1: I don’t know. I had trouble with my car. I had to go to the dentist.
THERAPIST 1: I know a lot of people have trouble doing too many things in
one week. It’s also an easy habit to get into and not a good one (nor­
malizing, exhorting, judgmental).

THERAPIST 2: People who have not been able to do much for a long time—
it can happen with illness—become fearful of doing new things.
They think that they will do something wrong or won’t know how
to fit in. Does that make any sense? (teaching; confronting—i.e.,
bringing to the patient’s attention feelings or thoughts that had
been outside his or her awareness)
PATIENT 2: I get very nervous when I meet new people.
THERAPIST 2: So we need to find a way to deal with the nervousness that
will make it possible for you to have the interview with the social
worker. Then you can determine whether the group might be of use
to you (scolding replaced by acceptance; moving toward construc­
tive efforts).

These dialogues illustrate how even in work with the most impaired
individuals, the therapist must explore feelings and ideas of which the pa­
tient has not been aware. This exploration is an expressive element. If the
therapy is to go beyond the simplest take-it-or-leave-it advice and beyond
criticizing the patient for being noncompliant, the therapy must take into
account psychodynamic considerations.
Films and plays of the 1950s often show a patient in psychotherapy or
psychoanalysis discovering an early traumatic experience, after which re­
covery is immediate. In real life, once such discoveries are made, a patient
typically must work hard to change his or her ways of thinking and re­
sponding. Although the importance of explaining origins is not as great as
once thought, an explanation of origins still has its uses. For the patient to
own a meaningful personal story is to give him or her a feeling of mastery,
and the creation of the story is a shared task for patient and therapist.
From the scientific point of view, the therapist can never be certain
whether the patient’s story agrees with what actually happened—or
whether the apparent cause-and-effect connections are valid. As an ex­
ample of the latter, people who have been emotionally and physically
abused when they were children are more likely to be abusive adults than
are those who never received such treatment—but this result is not inev­
Principles and Mode of Action 31

itable. Therapists, as well as the general public, often blur the distinction
between anecdote and group data. The methods of cognitive-behavioral
therapy, many of which have been incorporated into supportive psycho­
therapy, may be the principal approach once the patient sees that the be­
havior that is causing distress is the outcome of a plausible story. Misch
(2000) advises the supportive therapist to be like a good parent. The sup­
portive therapist is advised to comfort, soothe, encourage, and nurture
the patient; to set limits; and to confront self-destructive behaviors, all
while encouraging the patient’s growth and self-sufficiency.

Conclusion
Supportive psychotherapy is conducted in conversational style, involving
examination of the patient’s current and past experiences, responses, and
feelings. In supportive psychotherapy, the therapist is active and inquires
and responds in ways that seek to bolster the patient’s strengths. Al­
though the initial focus is on self-esteem, ego function, and adaptive
skills, as with other forms of psychotherapy, the therapeutic alliance may
be the most important element. The therapist seeks to expand the pa­
tient’s self-mastery by helping him or her to become aware of thoughts
and feelings that had been outside awareness and to provide specific sug­
gestions for more adaptive living.
Assessment, Case
Formulation, and
3
Goal Setting

Assessment
The process of evaluation and case formulation is essential for all psycho­
therapeutic approaches. The most important objective of the evaluation
process is to establish a positive therapeutic relationship (alliance) with
the patient. The patient is more likely to see himself or herself as a partner
in the diagnostic endeavor when the therapeutic relationship is positive,
which will lead to a more thorough and informative evaluation. A posi­
tive therapeutic relationship can also further the patient’s interest in and
commitment to psychotherapy.
As the patient evaluation unfolds, the evaluator can establish a positive
relationship with the patient by displaying an interest in what the patient
is saying. This is accomplished by listening attentively and providing feed­
back on symptoms, problems, conflicts, and relationships. The evaluator
should respond to the patient with empathy, interest, and responsive and
explanatory comments so that the patient can begin to understand his or
her problems and conflicts.
A central objective of the assessment process is to diagnose the pa­
tient’s illness and describe the patient’s problems so that the individual
can be treated appropriately. A thorough evaluation should help the cli­

33
34 Learning Supportive Psychotherapy

nician select the appropriate treatment approach. The treatment plan

should be individualized to meet the needs and goals of the patient.
The supportive-expressive continuum, introduced in Chapter 1, “Evo­
lution of the Concept of Supportive Psychotherapy,” is a useful way of
thinking about and conceptualizing the evaluation process. In this chapter,
we combine the psychotherapy continuum (lower labels on Figure 3–1)
with an impairment or psychopathology continuum (upper labels on Figure
3–1). Supportive psychotherapy is indicated for patients on the left side
of the continuum (higher levels of psychopathology), whereas expressive
psychotherapy is better suited for patients on the right side of the contin­
uum (healthier patients).
When a therapist meets a patient for the first time, the therapist gen­
erally does not know the extent of the patient’s impairment, psychopa­
thology, or strengths. Therefore, the therapist should begin the initial
interview by attempting to understand why the patient has come for
treatment. The therapist should thoroughly evaluate the current prob­
lems and past history of each patient. The technical approach will vary,
from the use of a more supportive approach for patients with higher lev­
els of psychopathology to a more expressive approach for healthier pa­
tients. If, in the course of working with a patient, the therapist finds that
the patient has more significant psychopathology, the therapist may have
to quickly move into a more supportive mode. The degree of disturbance
encountered during the initial interview will determine how the clinician
proceeds in that interview.
In this conceptualization, supportive psychotherapy is indicated for
patients with high levels of psychopathology, whereas expressive psycho­
therapy is better suited for healthier patients. We have found in our clin­
ical and research work that supportive and expressive psychotherapies
produce similar results in patients across the psychopathology continuum
(see Chapter 9, “Evaluating Competence and Outcome Research”).
Therefore, supportive psychotherapy is indicated for a wide variety of dis­
orders across the psychopathology continuum (for a full discussion of in­
clusion and exclusion criteria for supportive psychotherapy, see Chapter
5, “General Framework of Supportive Psychotherapy”). The efficacy of
supportive psychotherapy in higher-functioning patients is especially en­
hanced when expressive and cognitive-behavioral techniques are inte­
grated into a supportive approach (Winston and Winston 2002).
The patient evaluation should be comprehensive and, if possible,
should be completed during an extended first session of at least 60 min­
utes. At the end of the evaluation, the therapist should understand the pa­
tient’s problems, interpersonal relationships, everyday functioning, and
psychological structure. The evaluation interview should not be a series of
Assessment, Case Formulation, and Goal Setting 35

Level of impairment

Most impaired Moderately impaired Least impaired

Supportive Supportive- Expressive- Expressive

expressive supportive
Psychotherapy

Figure 3–1. Impairment-psychotherapy continuum.

questions and answers. Instead, it should be more of an exploration of the

patient’s life. The interview should be therapeutic, to help motivate the pa­
tient for treatment and promote the therapeutic alliance. In a supportive
approach, a therapist may make an evaluation therapeutic by using appro­
priate interventions, such as empathic clarifications and confrontations.
The evaluation should begin with an exploration of the patient’s pre­
senting problems or areas of disturbance. Presenting problems may in­
clude symptoms, relationship and self difficulties, work or school issues,
medical problems, and substance abuse issues. Generally, symptoms
should be explored first so that the clinician is informed about the extent
of the patient’s psychopathology. Exploring symptoms first is also helpful
to the patient because symptoms are what patients care about. Informa­
tion about symptoms will enable the clinician to adjust the evaluation in­
terview to the patient’s level of psychopathology. With some patients, the
extent of psychopathology will be clear from the start, particularly if the
patient has a loss of reality testing. With other patients, psychopathology
may be less discernible and more time may be required.
After the presenting problems have been clearly delineated, the thera­
pist should explore the patient’s history. We want to emphasize that ther­
apists should not move on to an exploration of the patient’s history until all
of his or her current problems and symptoms have been thoroughly ex­
plored. Patients will often bring up an important experience from their past
while discussing a current problem. When this occurs, the evaluator should
say, “What you are bringing up is important and I want to hear about it, but
let’s first finish exploring the current issues in your life.”
Exploration of the patient’s history can be accomplished in many ways
but should be systematic and should cover relationships with parents,
other caretakers, siblings, grandparents, and other people in the patient’s
life and household. Descriptions of these individuals should also be ob­
tained. Important issues to inquire about include trauma; separation and
36 Learning Supportive Psychotherapy

loss; medical problems, psychiatric illness, and substance abuse (in the pa­
tient and first-degree relatives); geographic moves; family belief systems;
school history; sexual development and experiences; identity issues; and
financial matters. Past psychiatric treatment, including psychotherapy
and pharmacotherapy, should be explored, as should the patient’s re­
sponse to the therapist, because this knowledge can alert the therapist to
potential problems in the therapeutic alliance.
As soon as the therapist determines that the patient should be treated
with supportive or supportive-expressive psychotherapy, the evaluation
interview should promote the objectives of supportive psychotherapy.
These objectives are to ameliorate symptoms and to maintain, restore, or
improve self-esteem, adaptive skills, and ego or psychological functions
(Pinsker et al. 1991).
A useful method of conceptualizing dynamic psychotherapy, which
encompasses both supportive and expressive approaches, involves the tri­
angles of conflict and person. The focus of the triangle of conflict (Freud
1926/1959; Malan 1979) (Figure 3–2) is on wishes, needs, and feelings
that are warded off by defenses and anxiety. In this model, a therapist who
is pursuing a patient’s feeling is at the wish/need/feeling point of the tri­
angle. As is often the case, the patient may respond defensively to the ex­
ploration of feeling (second point of the triangle). The patient also may
respond with anxiety (the third point of the triangle) because of fear of
the conflicted feeling.
In the triangle of person (Malan 1979; Menninger 1958) (Figure 3–3),
the three points all relate to people and include individuals in the pa­
tient’s current life and past life and the therapist or transference figure. In
expressive or exploratory psychotherapy, the therapist tends to work on
conflict situations using the triangles to explore wishes, needs, and feel­
ings that the patient may have in relation to an important person in his or
her life. When defenses interfere with exploration, the therapist addresses
them. Present and past issues are addressed, and the transference relation­
ship and its exploration are emphasized.
In supportive psychotherapy, the triangles of conflict and person are
used differently. In the triangle of conflict, feelings generally are not pur­
sued, anxiety is diminished, and defenses are strengthened. In the triangle
of person, the real relationship with the therapist is emphasized, and the
therapist works primarily on present persons and current issues in the pa­
tient’s life.
The following video vignette, which is presented as an enactment and
is available online at www.appi.org/Winston, illustrates the use of sup­
portive therapy in an initial evaluation (see Video Vignette 1).
Assessment, Case Formulation, and Goal Setting 37

Defense Anxiety

Wish/Need/Feeling

Figure 3–2. Triangle of conflict.

Past figure Current figure

Therapist

Figure 3–3. Triangle of person.

Video Vignette 1: Assessment

Mary, a 42-year-old woman, was referred by her primary care physician

because of depression, beginning at age 24, and a number of other
problems. She recently went through a divorce and is having a great
deal of difficulty finding a job. She has a history of multiple episodes of
depression and was hospitalized once for suicidal depression.

THERAPIST: So as you know, Dr. Perry sent you to see me for an

evaluation. Can you tell me what the problem is?
MARY: I just don’t feel right. I don’t know. I can’t seem to get
anything done (responds in a vague manner that
could be defensive or a sign of disorganization).
THERAPIST: So you don’t feel right and you haven’t been able
to get anything done and you’re at a loss (responds
with a supportive clarification that helps Mary to
focus on the question at hand).
MARY: Yeah, I just sit around. I can’t get started. Everything is
just a mess. I feel so bad [becomes tearful].
38 Learning Supportive Psychotherapy

The therapist recognizes that Mary may be depressed and asks a

series of questions to determine whether this is so and, if so, the ex­
tent of the depression.

• Have you been feeling down? Have you been crying or feeling
tearful?
• What is your energy level like? Have you been tired a lot?
• Are you anxious, fearful, jumpy?
• What about your sleep patterns? Are you having problems falling
asleep or are you sleeping too much?
• How is your appetite? Are you losing or gaining weight?
• Are you maintaining your social relationships? Do you find plea­
sure in your life? Do you go out? Are you working or having dif­
ficulty at work?
• What is your attitude about the future? Do you feel hopeful?
• Have you wished you were dead or wished you could go to sleep
and not wake up? Have you had any thoughts of killing yourself?
• Have you been thinking about how you might do this? Have you
had these thoughts and had some intention of acting on them
(Posner et al. 2009)?
• Are you able to have sexual relations? Is sex pleasurable?

Mary responds that for the past 2 months, she has been consis­
tently downhearted, tearful, fatigued, and pessimistic about the fu­
ture and has had difficulty concentrating. She has trouble falling
asleep, consistently awakens during early morning hours, and is un­
able to get back to sleep. Her appetite is poor, and she has lost ap­
proximately 10 pounds in the past 2 weeks. She is preoccupied with
death and has thoughts of killing herself but has no defined plan.
She rarely goes out, nothing gives her pleasure or satisfaction, and
she has no sexual desire or interest. She stopped working a few
weeks ago. She has never had a manic or hypomanic episode. In the
past, she was treated with antidepressants, and during her last epi­
sode, she was treated with paroxetine. Mary stopped taking her
medication 6 months ago.
The therapist recognizes that Mary is in the midst of a major de­
pressive episode and has some cognitive difficulties. This level of
psychopathology places Mary on the left side of the continuum (see
Figure 3–1), which indicates that the therapist should continue the
evaluation in a supportive mode.

THERAPIST: So it sounds to me as if you’ve been feeling depressed. From

what you’ve told me, it seems you’re depressed now and have
Assessment, Case Formulation, and Goal Setting 39

been depressed several times in the past. These things you’re

describing—tearfulness, fatigue, difficulty concentrating, trou­
ble sleeping, feeling bad, having a hard time getting started—
all these things are symptoms of depression. (Naming the
problem makes it understandable and reassures the pa­
tient that each symptom is not a separate condition.)
MARY: I just feel so hopeless and horrible. I feel like nothing’s ever
going to get better. It’s just that there are so many things...so
many things that are bothering me. (The therapist has be­
gun to educate Mary about her depression. Education is
important in all forms of psychotherapy, especially in
supportive treatment. Education provides the patient
with knowledge about his or her difficulties and also
demonstrates the therapist’s interest and understand­
ing, thereby promoting the therapeutic alliance.)

Next, the therapist explores how the current episode of depression

began.

THERAPIST: We should try to look at this episode of depression. How

long ago did it start? (proposed agenda)
MARY: Um, it got really bad 2 months ago, but I have to tell you
I haven’t been feeling good, probably for the past year. I don’t
feel myself.
THERAPIST: Did anything in particular happen? (continues to focus)
MARY [tearful]: My husband [Edward], who I’ve been married to for
14 years, I just found out that he had an affair with this woman
that he works with, and he had the affair, and he left me. That’s
all I can say (begins to reveal important material that may
have contributed to the onset of her depression).
THERAPIST: I can see that this is really hard for you (empathic support).
MARY: It’s worse. I don’t know what I did wrong. I feel so stupid. I feel
I can’t do anything. I can’t go to work. I can’t face the people.
The people at work will think that I’m pathetic, and I’m too
ashamed to tell anyone. I don’t like to talk about it (indicates
that her husband’s infidelity and his leaving her led to a
series of automatic [negative] thoughts).
THERAPIST: So have you been able to continue at your job? (early focus
on adaptive activity)
MARY: Well, it’s been a struggle. It has been really hard.
THERAPIST: What do you think your coworkers might be thinking about
you? (begins to explore Mary’s automatic thoughts)
MARY: They think I’m pathetic.... I used to call my husband all the
time from work. I felt so lonely and I felt scared that I couldn’t
do things right, and he would get so angry at me and he would
say, “Why are you calling me? Why are you bothering me?
Can’t you do anything for yourself?”
THERAPIST: You’ve been feeling incompetent?

MARY: I feel so incompetent and...

40 Learning Supportive Psychotherapy

THERAPIST: Can you give me a specific example of this? (The thera­

pist asks for a specific example because remaining at an
abstract or general level promotes vagueness and loss
of focus.)
MARY: Oh, God... I mean, I was feeling incompetent. I remember this
one time when I was at work and I fell and hit my head, and my
head was bleeding and I needed stitches, and I called my husband
to come help me and bring me to the doctor to get stitches, and
he got angry at me and told me that he was busy and not to
bother him and that I can’t do anything right. I just felt so useless
after that (provides a clear interpersonal example).
THERAPIST: So you reached out to your husband for help and not only
did he not help you, but he also put you down for it. This con­
tributed to making you feel incompetent? (summarizes pa­
tient’s story)
MARY : Well, yeah. I can’t do anything right. I can’t do anything
right...yeah.
THERAPIST: I think that most people in that situation would ask for
help and reach out to somebody. So I think that maybe you are
making an erroneous judgment about yourself (normalizing
and then clarifying Mary’s automatic thinking).
MARY: You think so?
THERAPIST: Perhaps this is a pattern with you? (The therapist asks if
this might be her habitual manner of behaving.)
MARY: Maybe...I don’t know?

The therapist has elicited a concrete example of an interaction

with Mary’s husband, an interaction that led her to think of herself
as incompetent and helpless. This way of thinking is an example of
automatic thoughts, which are quite common in depression. Mary’s
thought processes would constitute an important area on which to
concentrate in supportive therapy for this type of disorder. In this in­
stance, the therapist has attempted to point out that Mary’s negative
thinking was faulty, but the therapist has done so in a supportive
manner by asking if Mary agreed. In subsequent sessions, the thera­
pist should help Mary test her automatic thoughts herself.
The therapist then goes on to explore Mary’s relationship with
Edward, the history of their marriage, and her past history. Mary is in
the throes of a major depressive disorder and has had four previous
major depressive episodes as well as milder, chronic depression for
most of her life. Serious difficulties in the interpersonal sphere, as
well as personality problems, limit her ability to function. The ther­
apist, a psychiatrist, concluded that Mary would benefit from med­
ication and a supportive psychotherapy approach employing some
cognitive-behavioral techniques. The therapist explained how both
approaches—medication and psychotherapy—would be helpful in
Assessment, Case Formulation, and Goal Setting 41

treating Mary’s depression, anxiety, and problems in day-to-day

functioning. Mary agreed with these immediate treatment goals
and stated that she thinks the medication and psychotherapy are
worth a try. The therapist explained when the medication will begin
to work and have maximum effect and discussed possible side ef­
fects of the medication.

Diagnostic Evaluation

• Major depressive disorder, recurrent, moderate to severe

• Dependent personality disorder

Case Formulation
For each patient, the treatment approach should be based on the central is­
sues emerging from the assessment and case formulation. The case formu­
lation is an explanation of the patient’s symptoms and psychosocial
functioning. The therapist’s formulation governs what interventions will be
used as well as which issues in the patient-therapist dialogue will be se­
lected for attention. Case formulation depends on an accurate and thor­
ough assessment of the patient. Having a sense of the underlying issues at
the start enhances the therapist’s ability to respond empathically. At the
same time, empathy for the patient helps the therapist guide and plan ther­
apy effectively. The initial formulation is tentative and must be modified as
more is learned about the patient during the course of psychotherapy.
Although the DSM-5 (American Psychiatric Association 2013a) diag­
nosis is an important element of the formulation, it is by no means the
whole story. The diagnosis does not illuminate an individual’s adaptive or
maladaptive characteristics such as disappointments, his or her capacity
for relationships, and how the individual thinks about and interprets life’s
events, nor does the diagnosis explain the unique life history of an indi­
vidual. The DSM diagnosis alone does not fully explain the patient or the
problem.
The following case formulation approaches are derived from psycho­
analytic theory, including interpersonal and relational approaches, as well
as cognitive-behavioral approaches. In the following subsections, we dis­
cuss the following case formulation approaches (Table 3–1): structural,
genetic, dynamic, and cognitive-behavioral. Supportive psychotherapy
uses elements of all these therapeutic approaches but differs in how these
elements are used. For example, a patient’s conflict may be clearly under­
stood and formulated by the therapist but never or only partially explored
in psychotherapy. Although these approaches have always been described
42 Learning Supportive Psychotherapy

Table 3–1. Types and foci of case formulations

Type Focus

Structural Concentrates on fixed aspects of an individual’s

personality within a functional context; assesses
strengths and weaknesses and overall level of
psychopathology
Genetic Explores early development and life events that may
explain the patient’s current situation
Dynamic Highlights the content of an individual’s current
conflicts and relates it to a primary lifelong or core
conflict; examines mental and/or emotional tensions
that may be conscious or unconscious
Cognitive-behavioral Attends to the individual’s automatic thoughts (based
on the person’s core beliefs or negative schemas) and
how they can be addressed to change thoughts,
behaviors, and moods

separately, a great deal of overlap exists, so some repetition occurs in the

descriptions.

Structural Approach
A structural case formulation (Table 3–2) attempts to capture the rela­
tively fixed characteristics of an individual’s personality, which is under­
stood within a functional context (in contrast with genetic and dynamic
approaches, which are more content based). Assessment of an individ­
ual’s strengths and weaknesses and overall level of psychopathology helps
determine the clinician’s technical approach. A thorough structural as­
sessment enables the clinician to determine with some degree of accuracy
where to place the patient on the impairment-psychotherapy continuum
(see Figure 3–1).
Structural functions have been grouped together using Freud’s (1923/
1961) structural approach of id, ego, and superego. These agencies refer to
the inner life of the patient. The following description of psychological or
ego functions is based on the work of Beres (1956) and Bellak (1958).
These categories are not mutually exclusive; there is a great deal of overlap.

Relation to Reality
Beres (1956) and Bellak (1958) described reality testing and sense of re­
ality as major components of relation to reality. The term reality testing
describes an individual’s ability to assess reality. Reality testing is im­
Assessment, Case Formulation, and Goal Setting 43

Table 3–2. Components of the structural approach (ego and

superego)
Ego functions
Relation to reality
Object relations
Affects
Impulse control
Defenses
Thought processes
Autonomous functions (perception, intention, intelligence, language, and
motor development)

Synthetic function (ability to form a cohesive whole or gestalt)

Superego functions
Conscience, morals, and ideals

paired in the presence of faulty judgment and is grossly disturbed in the

presence of hallucinations or delusions. Sense of reality relates to a per­
son’s ability to distinguish self from other; presence of this ability indi­
cates a stable and cohesive body image. Examples of disturbances in this
function are depersonalization, derealization, and identity problems.
Disturbances in relation to reality indicate significant structural problems
that place the patient on the left side of the impairment-psychotherapy con­
tinuum (see Figure 3–1). Such disturbances should point the clinician in the
direction of a more supportive approach. Impaired relation to reality is a key
indicator of structural deficits and should always be thoroughly explored.

Object Relations
Object relations refers to a person’s capacity to relate in a meaningful way
to significant individuals in his or her life. The function includes the abil­
ity to form intimate relationships, tolerate separation and loss, and main­
tain independence and autonomy. It also involves the sense of self and the
ability to form a cohesive and stable self-image without diminishing or
overidealizing self or other.
A patient’s relationships with others form the foundation of the psycho­
logical functions constituting the structural approach. In all forms of psy­
chotherapy, evaluation of object relations is central in determining a
patient’s placement on the impairment-psychotherapy continuum. Pa­
tients who are withdrawn and not interested in others or who have narcis­
sistic, highly dependent, or chaotic relationships generally require a more
44 Learning Supportive Psychotherapy

supportive approach and therefore are on the left side of the continuum.
Individuals who have had at least one meaningful give-and-take relation­
ship tend to be on the right side of the continuum.

Affects, Impulse Control, and Defenses

Affects are complex psychophysiological states composed of subjective
feelings and physiological accompaniments such as crying, blushing, sweat­
ing, posture, facial expression, and tone of voice. The range of affects in­
cludes excitement, joy, surprise, fear, anger, rage, irritation, anguish,
shame, humiliation, sadness, and depression. The individual’s ability to ex­
perience a wide range of affects at some depth and to differentiate between
affects (as opposed to lumping them into a single feeling such as primitive
rage) need to be assessed. Does the individual experience a wide variety
and range of affects? Is the individual able to tolerate love, anger, joy, sad­
ness, and humiliation? What are the predominant affects (Friedman and
Lister 1987), and how regularly are they invoked?
The capacity to control impulses and to modulate affect in an adaptive
manner indicates a well-functioning defensive structure. When impulse
control is faulty, the individual may engage in socially unacceptable be­
havior, such as physically or verbally lashing out at others or making in­
appropriate demands. The ability to delay gratification and to tolerate
frustration is another important aspect of impulse control.
Defenses mediate between a person’s wishes, needs, and feelings and
both internal prohibitions and the external world. Individuals tend to use
the same kinds of behavior as patterned responses in reaction to perceived
danger, difficult situations, or painful affects. Defenses are conceptualized
as having both a developmental and a hierarchical organization. Three
levels of defenses have been described: immature, intermediate, and ma­
ture. Examples of immature defenses are projection, hypochondriasis,
acting out, sarcasm, and avoidance. Intermediate defenses include forget­
ting, intellectualization, displacement, and rationalization. Among the
mature defenses are altruism, anticipation, suppression, sublimation, and
humor (Vaillant 1977, ). Primitive defenses, poor impulse control, severe
affective instability, and shallow affect are indicators of structural deficits
that place an individual on the left side of the continuum and suggest the
need for a more supportive approach.

Thought Processes
The ability to think clearly, logically, and abstractly should be assessed.
High levels of primary process or primitive thinking are a good indicator
of severe psychopathology. Significant limitations in the ability to think
Assessment, Case Formulation, and Goal Setting 45

logically suggest the need for a more supportive approach as opposed to

an exploratory one. Dysfunctional and automatic thoughts should be
identified so that cognitive-behavioral approaches can be applied.

Autonomous Functions
Autonomous functions—perception, intention, intelligence, language, and
motor development—are believed to develop in a relatively conflict-free
manner (Hartmann 1939/1958). Although these functions generally are
not impaired in patients on the right side of the impairment-psychotherapy
continuum, they can be affected in patients with significant psychopa­
thology.

Synthetic Function
Synthetic function (Nunberg 1931) is the individual’s ability to organize
himself or herself and the world in a productive manner so that the indi­
vidual can function in a harmonious and integrated way. Synthetic func­
tion is the psychological ability to form a cohesive whole, or gestalt, by
putting together and organizing the other functions. For example, a
young man meets several men and women for the first time at a dinner
party. He engages each individual in a friendly and open manner with an
appropriate affect. He is thoughtful, coherent, and humorous. In this ex­
ample, the young man synthesizes the ego functions of object relations
(friendly and open), appropriate affect, thoughtfulness and coherence,
and a high-level defense or coping style of humor.

Conscience, Morals, and Ideals

Conscience, morals, and ideals derive from the internalization of aspects
of parental figures and social mores. Freud (1926/1959) conceptualized
these elements as aspects of the superego. Severe impairments in these
functions can interfere with the patient-therapist relationship. For in­
stance, if a patient is not truthful with the therapist, achieving success in
psychotherapy may be difficult.
The following case provides the basis for a structural case formulation.

Case Illustration: Structural Case Formulation

Bert, a 24-year-old man with panic disorder, has developed the belief that
his coworkers are saying derogatory things about him and want to hurt
him physically. His relationships are characterized by an absence of con­
cern for self or others, and this lack of concern often puts him at risk. He
uses women to satisfy his sexual needs, abruptly leaving them and giving
untruthful excuses. At times he becomes enraged with the women he is
46 Learning Supportive Psychotherapy

seeing and is physically abusive. His aggressive and violent behavior

evokes fears of retaliation. He both uses and sells drugs. He has a history of
beginning schools and jobs, quitting when he encounters difficulties, and
blaming others for his failures.
Bert has impaired reality testing, consisting of ideas about others talking
about him and plotting against him. His adaptive skills are poor, as demon­
strated by his inability to work or to complete school. Relationships are con­
ducted on a need-satisfying basis, without concern for others. Bert is often
sadistic but then becomes self-defeating and self-punishing. He exhibits im­
paired frustration tolerance and poorly controlled impulses, and his displays
of rage may indicate a limited repertoire of affective responses. He uses im­
mature defenses, such as projection, acting out, and denial.

Genetic Approach
The genetic approach to case formulation involves exploration of early
development and life events that may help to explain an individual’s cur­
rent situation. The genetic approach follows the development of the child
from birth to late adolescence or early adulthood. Life presents many
challenges, conflicts, and crises. These events can be traumatic, depend­
ing on the severity of the event, the developmental stage of the child ex­
periencing the event, and the quality of the child’s support system at the
time of the event. Events or conditions important in a child’s develop­
ment include the loss of a significant person, separation, abuse, the birth
of a sibling, birth defects and developmental deficits, learning problems,
illness, surgery, and substance abuse. Although a single event can have a
traumatic effect on an individual, it is often negative experiences in day­
to-day life that lead to significant conflict, psychopathology, and charac­
terological problems. Examples of negative day-to-day events include
constant criticism, devaluing and abusive behavior of parents, parental
conflict, and significant parental psychiatric problems.
An example of a persistent difficulty or traumatic situation is the ex­
perience of a young boy growing up with a violent alcoholic father who is
demeaning and at times physically abusive. Persistent trauma such as that
caused by unresponsiveness of a parent may be more subtle and difficult
to evaluate. For instance, a narcissistic mother may use her daughter for
her own self-enhancement. She may ignore her child’s real qualities, de­
manding behavior that the child is unable to deliver or can deliver only at
considerable cost to herself.

Dynamic Approach
The dynamic approach is useful with mental and/or emotional tensions
that may be conscious or unconscious. The therapist using this approach
Assessment, Case Formulation, and Goal Setting 47

focuses on conflicting wishes, needs, or feelings and their meanings. In a

conflict situation, an individual wards off or defends against wishes,
needs, or feelings. The dynamic approach highlights the content of an in­
dividual’s current conflicts and relates them to a primary lifelong or core
conflict (Perry et al. 1987).
In contrast to structural case formulation, which is based on an indi­
vidual’s relatively fixed characteristics and functioning, dynamic case for­
mulation is concerned with meaning and content. The dynamic approach
focuses on current conflicts, whereas the genetic approach focuses on a
person’s developmental history, including childhood and adolescent trau­
mas and conflicts and their possible meanings. Childhood conflicts tend
to be revived and relived in adult life.
A useful approach to understanding the dynamics of an individual,
particularly the core conflict, involves mapping central relationship pat­
terns. Understanding central relationship patterns requires exploration of
three aspects of interpersonal interactions: 1) what the person wants from
others, 2) how others react to the person, and 3) how the person responds
to others’ reactions. These categories form the basis of the core conflictual
relationship theme (CCRT) method, an approach that relies on “narra­
tives, called relationship episodes, that patients typically tell and some­
times even enact during their psychotherapy session” (Luborsky and
Crits-Christoph 1990, p. 15). The CCRT is composed of the patient’s
wishes or needs from others, how others respond (their actual responses
as well as their responses from the patient’s perspective), and how the pa­
tient responds to others. Understanding and using the CCRT method pro­
vides the clinician with a central organizing focus. The CCRT method can
be used differentially with patients according to their position on the con­
tinuum.
The following case illustrates a dynamic conflict as well as its genetic or
historical basis.

Case Illustration: Dynamic Case Formulation

Tim is a passive 48-year-old man whose father has become increasingly de­
bilitated and demanding, a state made worse by early signs of dementia. His
father often telephones with complaints and demands, even though Tim
has been consistently helpful. After these calls, Tim finds himself wishing
that his father appreciated him. He becomes ridden with anxiety and often
expresses anger toward his wife and friends, later feeling guilty about this
behavior. At work, he has become increasingly anxious and perfectionistic,
and he worries that his boss dislikes him and will criticize him.
The dynamic explanation is that Tim has ambivalent feelings toward
his father, consisting of anger and possibly a wish for his father to die, com­
bined with positive feelings based on earlier experiences. He becomes
48 Learning Supportive Psychotherapy

anxious and defends against these feelings or wishes by displacing the an­
ger he feels toward his father onto his wife and friends. The anxiety serves
as a signal of unacceptable feelings. His boss is viewed as an authority fig­
ure and has become linked with his father, who is both loved and hated. In
general, Tim is passive and avoids confrontation. He fears making a mis­
take and being humiliated. Tim’s wish to be appreciated by his father can
be identified using the CCRT method. The response of the other, his fa­
ther, is lack of appreciation combined with hostility. The response of the
self is displacement of anger onto Tim’s wife and friends and a feeling of
being unappreciated. The genetic basis of Tim’s current conflict is related
to his childhood experience of his father being both highly critical and
concerned and loving. This early experience has resulted in mixed feelings
toward his father, consisting of love and rage with accompanying anxiety,
guilt, and lack of assertiveness.

Cognitive-Behavioral Approach
Although case formulation has not been widely used in cognitive-behavioral
therapy, models have been developed that are helpful in assessing an individ­
ual’s problems in cognition (Persons 1989, 1993). Cognitive-behavioral
therapy is initially directed at automatic thoughts, which are based on core
beliefs or negative schemas. Overt and underlying beliefs are closely linked
and are expressed as thoughts, behaviors, and moods. Core beliefs are ad­
dressed later in the course of therapy. The cognitive-behavioral case formu­
lation model, as adapted from Tompkins (1996), has the following
components:

1. Problem list (including automatic thoughts)

2. Core beliefs
3. Origins
4. Precipitants and activating situations
5. Predicted obstacles to treatment
6. Treatment plan

The description of Tim (see “Case Illustration: Dynamic Case Formula­

tion” in the previous subsection) will be used to illustrate these six compo­
nents of cognitive-behavioral case formulations. The problem list is a
complete list of the patient’s difficulties and presenting complaints. It in­
cludes the dysfunctional thinking responsible for maladaptive behavior and
disturbed mood. Tim’s mood problems are anxiety, anger, and feelings of
guilt. His problematic behavior is his inappropriate anger toward his wife
and friends. His automatic thoughts (“I am flawed” and “I will make mis­
takes and be humiliated”) lead to passivity and lack of assertiveness.
Core beliefs are hypotheses about the patient’s self-schemas and views
of others and the world. Tim’s core belief is a pervasive sense that he can­
Assessment, Case Formulation, and Goal Setting 49

not do anything right. This belief makes him especially vulnerable to the
opinions of others. The origins of core beliefs are early experiences, gen­
erally involving parents or parental figures. Tim’s core belief appears to
have derived from his relationship with his overly critical father. Core be­
liefs are generally activated by situations or events that are stressful or prob­
lematic for the patient. The deteriorating health of his father precipitated
Tim’s current difficulty and brought him into treatment.
Obstacles to treatment should be anticipated if possible. Obstacles in
Tim’s case might be reflected in the patient-therapist relationship. Fear of
criticism can emerge in relation to the therapist and lead to increased pa­
tient passivity in the treatment situation. Tim may be reluctant to com­
plete homework assignments because he may fear that the therapist will
be critical. A well-conceived and comprehensive treatment plan should
emerge from the case formulation. This plan should include goals and the
types of interventions to be used. For Tim, the goals should include de­
creasing his anxiety, reducing or eliminating his anger toward his wife and
friends, and decreasing his difficulties at work. The interventions should
consist of cognitive restructuring of Tim’s thinking about his father and
relaxation therapy (including meditation) to reduce anxiety.

The Four Approaches Compared and Applied

A number of similarities exist among the structural, genetic, dynamic,
and cognitive-behavioral approaches as used in dynamic (supportive and
expressive) and cognitive-behavioral therapies. The concept of core be­
liefs and their origins is similar to the idea of the genetic case formulation,
which provides the origins of structural and dynamic factors. The notion
of activating events in cognitive-behavioral therapy is analogous to the
precipitation of genetic and dynamic conflicts. Obstacles to treatment of­
ten relate to the therapeutic relationship, and thus the concept of obsta­
cles is similar in genetic and dynamic approaches. Cognitive-behavioral
therapy adds a different dimension to case formulation and the treatment
approach, particularly when thinking problems are present. Dynamic and
genetic approaches do not involve a major focus on thinking, but the
structural approach does include evaluation of an individual’s thought
processes.
The following subsections provide case formulations and diagnostic as­
sessments of Mary, the patient evaluated in Video Vignette 1 in the “As­
sessment” section earlier in this chapter.
50 Learning Supportive Psychotherapy

Structural Approach
Mary is an intelligent woman with limited insight and judgment. Although
her reality testing is intact, her adaptive skills are impaired. She has diffi­
culty functioning, caring for herself, and working. Her object relations are
on a dependent need-satisfying level. Mary has low self-esteem, a result of
early experiences with her mother and sisters and more recent experi­
ences with her husband. Her depression has intensified her feelings of in­
adequacy. The defenses Mary uses are at the immature level and consist
of avoidance, denial, and projection. Predominant affects are sadness and
anger. Mary has many negative thoughts about herself and is somewhat
impulsive.

Genetic Approach
Mary is the youngest of three girls born to older parents. Her parents did not
expect a third child, and her mother considered aborting the pregnancy.
Mary grew up with a sense of not being wanted by her mother. Mary felt she
was the least favored child compared with her sisters, who were admired by
their mother for their intelligence and beauty. Her mother’s attitude toward
Mary interfered with her development of a positive self-image, resulting in
faltering self-esteem. When Mary was 14 years old, her father—with whom
she had a predominantly positive relationship—suddenly died. At that time,
her mother became less available and more critical of Mary. The death of
her father, who had been a source of comfort during her adolescence, may
have added to Mary’s impaired self-esteem and neediness.

Dynamic Approach
Mary is a needy, dependent woman who wishes to be cared for. The pa­
tient’s core conflict revolves around her wish to be wanted and cared for
by others (mother and husband). When the response of others is to aban­
don her (father’s death), criticize her, or favor others (mother favors her
sisters; husband favors his lover), she becomes depressed and withdrawn,
with diminished self-esteem. Her wish to be cared for is an expression of
her need to feel she has a right to exist.

Cognitive-Behavioral Approach
Mary’s problems include depression, interpersonal difficulties with her
husband and coworkers, and an inability to maintain day-to-day function­
ing. Her automatic thoughts—“I can’t do anything right” and “I need
someone to care for me”—are based on Mary’s core beliefs that she is
worthless, a failure, and in need of constant support, without which she
Assessment, Case Formulation, and Goal Setting 51

cannot function. The origins of her core beliefs are her mother’s and sis­
ters’ view that she was weak, sickly, and not as capable as her sisters.
Precipitants of and activating situations for Mary’s difficulties are her
separation from her husband and the discontinuation of her medication
for previous depression. The obstacles to treatment are Mary’s severe
neediness and her fear that the therapist will view her as inadequate.

Goal Setting
For patients requiring supportive psychotherapy, organizing goals should
be as follows:

1. Amelioration of symptoms
2. Improvement of adaptation
3. Enhancement of self-esteem
4. Improvement of overall functioning

Setting goals in psychotherapy is important in guiding the treatment.

Both therapist and patient must agree on the treatment objectives. The
goals set within the first few sessions should be viewed as preliminary and
open to change. Both immediate objectives for each session and ultimate
goals (Parloff 1967) for treatment should be considered. For example, an
immediate in-session objective for Mary might be to develop a mutually
agreed-on plan for helping her return to work within a short time period.
An ultimate goal for Mary would be to promote job stability and improve
relationships with coworkers.
Clearly outlined goals help motivate patients and promote the thera­
peutic alliance as patient and therapist work toward a common end. The
goals of treatment should be derived from the patient’s problem areas in
order to enhance motivation to change and to promote therapeutic clar­
ity. The goals of supportive psychotherapy are different from the goals of
expressive psychotherapy, which are symptom and personality change
through analysis of the patient-therapist relationship and through devel­
opment of insight into previously unrecognized feelings, thoughts, needs,
and conflicts.
In the past, it was assumed that long-term changes in conflicts and per­
sonality could not occur in supportive psychotherapy. Results of studies by
Rosenthal et al. (1999) and Winston et al. (2001) have suggested, how­
ever, that supportive psychotherapy can produce personality changes in pa­
tients on the healthier side of the impairment-psychotherapy continuum.
The goals of therapy should generally be the patient’s. In the event of
disagreement regarding goals, the therapist enters into an exploration of
the problem. In the case of Mary, one of the mutually agreed-on goals was
52 Learning Supportive Psychotherapy

to resolve her depression and to prevent future episodes of depression.

During Mary’s previous episodes of depression, she stopped taking her
medication when she was no longer depressed. Therefore, an important
goal for Mary is to continue taking her medication to help prevent future
depressive episodes. After the therapist explored the reasons Mary
stopped taking her medication and educated her about the risks of dis­
continuing, she agreed with this treatment goal.
Setting realistic goals is important, especially with patients who have
severe psychopathology. Some patients may have grandiose fantasies or
magical wishes that need to be modified. Mary had the unrealistic expec­
tation that her husband would return to her, which she thought would
solve her problems. Treatment goals should never be regarded as fixed
and unchangeable. For example, once Mary’s depression is resolved, she
may want help with expanding her social network and improving her in­
terpersonal relationships.

Conclusion
Assessment of the patient’s problems, symptoms, and character structure
is critical for arriving at a complete diagnosis, case formulation, and treat­
ment plan. Case formulation should be comprehensive—encompassing
structural, genetic, dynamic, and cognitive-behavioral approaches. We
have illustrated this process by presenting a case example from an initial
assessment and case formulation of a patient, as well as describing the set­
ting of treatment goals for this patient.
Techniques 4
In Chapter 2, “Principles and Mode of Action,” we described the following
principles of supportive psychotherapy: 1) the interaction between patient
and therapist is conversational; 2) the transferential aspects of the relation­
ship are subordinate to the reality aspects of the relationship; and 3) the
therapist relates to the developmental needs of the patient. Rosenthal
(2009) characterized these principles, as well as the need to take direct ac­
tion to maintain the frame of treatment, as contextual techniques because
they underlie all supportive psychotherapy and are deemed necessary for
its conduct. In this chapter, we describe specific techniques (Table 4–1)
that are interventions (a term often used to describe the actions of a thera­
pist). These techniques are employed to maintain the therapeutic alli­
ance—without which nothing can be accomplished—and to achieve the
objectives of supportive psychotherapy (described in Chapter 1, “Evolu­
tion of the Concept of Supportive Psychotherapy”): maintaining or im­
proving self-esteem, ego function, and adaptive skills.

Alliance Building
The term therapeutic alliance implies that the work of forming and main­
taining bonds is intrinsically therapeutic (Kozart 2002). The therapeutic
alliance has been demonstrated to be one of the most critical predictors of
the outcome of any form of psychotherapy (Horvath and Symonds 1991;

53
54 Learning Supportive Psychotherapy

Table 4–1. Supportive psychotherapy techniques

Alliance building
Expressions of interest
Expressions of empathy
Expressions of understanding
Sustaining comments
Self-disclosure
Repairing a misalliance
Esteem building
Praise

Reassurance

Normalizing

Universalizing

Encouragement

Exhortation

Skills building—adaptive behavior

Advice
Teaching
Modeling adaptive behavior
Anticipatory guidance
Promoting autonomy
Enhancing ego functioning
Reducing and preventing anxiety
Conversational style
Sharing the agenda
Verbal “padding”
Naming the problem
Normalizing
Rationalizing
Reframing
Minimization
Modulating affect
Supporting defenses
Limit-setting
Expanding awareness
Clarification

Confrontation

Interpretation

Source. Adapted from Rosenthal 2009.

Techniques 55

Westerman et al. 1995). Thus, the therapist using supportive psychother­

apy works purposefully to build and maintain the therapeutic alliance.
The therapist sustains the conversation, expressing interest, empathy,
and understanding, in order to support the connection between patient
and therapist. When the therapist suspects that the patient holds unreal­
istic positive feelings about him or her, perhaps because of transference, it
is typically not discussed. Threats to the alliance are always a concern,
whether caused by the patient’s life circumstances, the therapist’s actual
behavior, misinformation, or transference. The therapeutic alliance, mis­
alliance, and the repair of ruptures in the relationship are discussed more
fully in Chapter 6, “The Therapeutic Relationship.”
The beginning therapist may not know where to start with a new pa­
tient. It is a good idea to begin by discussing whatever it is that the patient
wants to talk about. The therapist must then decide whether to dwell on
that topic or to move on to other topics that are more fruitful or import­
ant in the therapist’s experience. For example, when the patient has re­
cently been hospitalized, medications are a priority topic. The first
questions to ask are 1) whether the patient is taking medications regularly
and 2) whether he or she is experiencing any unwanted or uncomfortable
effects. When a patient does not take medication as prescribed, the phy­
sician often accuses the patient of being noncompliant. Focusing instead
on unexpected or unwanted effects of the medication helps to transform
the conversation from adversarial to collaborative. Later, the therapist can
broach psychological issues that might affect willingness to take medica­
tion. Possible issues include not wanting to feel overpowered by medica­
tion and not wanting to accept the existence of illness.
The therapist should discuss details of daily life with a nonfunctioning
individual and should seek opportunities to discuss the individual’s adap­
tive skills. A person with a chronic disabling condition ought to have the
opportunity to talk about it. The therapist should make an effort to know
how the patient understands his or her condition and what feelings are re­
lated to it. The patient may have fears about the future that are not ex­
pressed. Depression accompanies many conditions and may be a patient’s
response to discovering that he or she faces a life of disability or a response
to looking back over lost years and family tension.
The therapist should know about the people in the patient’s life.
Higher-functioning patients are likely to have important relationships, to
think about their interactions with others, and to bring up their relation­
ships for discussion. Lower-functioning patients (and some elderly pa­
tients) may lead lives almost devoid of relationships and may talk at
length about their symptoms or abstractly about their mental problems.
The therapist should make an effort to know about family, friends, ac­
56 Learning Supportive Psychotherapy

quaintances, and coworkers and, in the case of an isolated patient, persons

with whom the patient has even brief contact, such as caseworkers, pro­
bation officers, receptionists, guards, and meal servers.

THERAPIST 1: Did you have contact with anyone in the last few days?

PATIENT 1: My sister-in-law called.

THERAPIST 1: Tell me about her.

PATIENT 1: She’s gross.

THERAPIST 1: Can you describe her? (This is a broader and less demanding

question than “Why don’t you like her?”)

THERAPIST 2: Who are the people in your life now?

PATIENT 2: No one. The only people I know use drugs.

THERAPIST 2: Is there someone you talk to most days?

THERAPIST 3: You say your son will come if you call him. Does that mean
he doesn’t come if you don’t call?
PATIENT 3: He’ll drop what he’s doing if we need him, but to come on a
Sunday afternoon? Forget it.

THERAPIST 4: Tell me about the people who live in the residence.

THERAPIST 5: Girlfriend? Is this someone you’ve known for some time?

Some well-spoken or well-educated patients ruminate endlessly and un­

productively about their introspections and their speculations about the
childhood origins of their trouble, without ever saying a word about their
current activity or the people in their lives.

Esteem Building
The supportive techniques of praise, reassurance, and encouragement are
directed primarily to self-esteem concerns. Through his or her attitude,
the therapist conveys acceptance, respect, and interest in the patient.

Praise
A good supportive technique is to express praise when the patient has ac­
complished something. Praise can be interspersed throughout a conver­
sation, sprinkled in like salt from a saltshaker. Praise may reinforce the
patient’s accomplishments or improvement in adaptive efforts, provided
that the patient is likely to agree that the praise is deserved.

THERAPIST 1: Telling your mother that you knew you had been rude was
a good step. Do you agree?
THERAPIST 2: You’re able to make this very clear.
Techniques 57

THERAPIST 3: It’s good that you can be so considerate of other people.

(Note, however, that in some contexts, being too considerate may
be seen as a symptom, and a statement that the patient is consid­
erate might be presented as a confrontation.)

False praise or praise that is meaningless to the patient is worse than

saying nothing. Falsity and deception are incompatible with any good re­
lationship.

PATIENT: I was always afraid of my mother.

THERAPIST: What were you afraid of?

PATIENT: She came in this morning and said, “Why are you still in bed?”

She doesn’t respect me. They argue a lot. I was 15 before I realized
that she was crazy.
THERAPIST 1: You explained that well. (This is a supportive comment
but, in this instance, false praise. Patient has mixed past and pres­
ent and his mother’s attitude toward him and her relationship with
her husband. Thought-disordered responses can be “decoded,” but
the patient cannot be said to have explained the situation well.)
THERAPIST 2: It’s hard for you to describe these things. You’re making a
big effort (accurate and useful).

When the therapist expresses praise for something that the patient can­
not feel good about, the praise will be ineffective and may even have a
negative impact.

PATIENT: I really have been feeling bad. I don’t do anything. I manage to

eat, but most of the time I’m a blob.
THERAPIST 1: Did you do anything last week besides sit around at home?
(Not content with global self-description, the therapist seeks spe­
cifics.)
PATIENT: Well, I went to a movie....

THERAPIST 1: That’s great!

PATIENT: Yeah. (The therapist does not appreciate that being able to do

nothing but go to one movie represents failure to this once high­

achieving patient.)

An important strategy for preventing communication failure is to seek

feedback.

PATIENT: Well, I went to a movie....

THERAPIST 2: That was good! Were you pleased with yourself? What do
you think?
PATIENT: Not really. It’s nothing. I used to be active all day and all night. If
the most I can do is go to a stupid movie, I’m in bad shape.
THERAPIST 2: I think it’s good that you got out. It’s diversion. It’s a good step.
(Instead of arguing and making the situation worse, the therapist
should have engaged the patient by returning to his bad feelings.)
58 Learning Supportive Psychotherapy

THERAPIST 3: So even though you got out and went to a movie, you don’t
count it as “doing anything?” (The therapist makes an effort to un­
derstand the patient before expressing an opinion. None of the ther­
apists in this illustration were in empathic contact with the patient.)

Therapists need to find opportunities to respond with honest praise.

Too much praise may seem contrived or insincere. The healthier the pa­
tient (the closer to the expressive end of the impairment-psychotherapy
continuum; see Figure 3–1 in Chapter 3, “Assessment, Case Formulation,
and Goal Setting”), the less praise is called for. With patients who are the
least impaired, the therapist should express praise only when it is the so­
cially expected response (e.g., congratulations for an accomplishment).
Complimenting a patient for persisting with a difficult area in therapy
may be useful. Praise coming from the therapist’s approval of what the
patient is doing is actually opinion or judgment. The best praise reinforces
the patient’s steps toward achieving previously stated goals.

PATIENT: I took my lithium every day last week.

THERAPIST 1: Good (judgmental, but appropriately so).
THERAPIST 2: Good. That improves your chances for avoiding another ep­
isode (reinforces desirable behavior but is still authoritarian).
THERAPIST 3: Good. You said you were going to do this—not skip a single
dose—and you did it. What do you think? (The therapist reinforces
self-control and discipline and seeks feedback and further engage­
ment.)

Reassurance
Reassurance is a familiar tactic in general medicine. Like praise, reassur­
ance must be honest. The patient must believe that the reassurance is
based on an understanding of his or her unique situation. Reassurance
that is given before the patient has detailed his or her concerns is likely to
be doubted. When the topic pertains to the therapist’s domain as an ex­
pert, the therapist must limit reassurance to areas in which he or she has
expert knowledge. Therapists can reassure patients about effects and side
effects of certain medications, but they cannot reassure patients about
long-term effects of a medication that has just come on the market. Ther­
apists can say, when true, that no side effects have been reported. It is cor­
rect to say that most people recover from an acute episode of psychosis
within a few weeks or that most people recover from bereavement within
a year or so, but it is never correct to say that a treatment is certain to be
successful. A therapist can tell a person with schizophrenia that the dis­
ease often stops getting worse after some years and that later, the patient
may begin to improve. A physician can reassure a chronic patient that he
or she will continue to provide care to the patient because this may be
Techniques 59

more important than a cure. It is never acceptable to offer reassurance

that is simply what the patient (or family) wants to hear. If the patient de­
mands reassurance and this reassurance is outside the therapist’s exper­
tise, the basis for the reassurance should be made explicit.

PATIENT: All day long when my son is in school, I’m sure something bad is
going to happen.
THERAPIST: You see terrible things on the news, but you know the odds
are that nothing bad happens to most people most of the time.
(This is not expert knowledge; it is based on knowledge that comes
from general education and popular information.)

PATIENT: I’m having a hard time finding food that isn’t genetically modi­
fied. It’s dangerous. The people in stores don’t know, and I get the
runaround when I call the 800 numbers.
THERAPIST: I know a lot of people are worried about this, but from what
I read in the paper, there have been no reports of anything actually
happening to anyone. (The therapist knows only what he reads in
the papers.) It’s important to try to keep up with scientific studies
about this and to keep in mind that in your total diet, the quantity
of foods that you worry about may be relatively small.

The therapist’s role is to teach strategies for dealing with fearfulness

about the unknown, not to reassure fearfulness away. Normalizing and
universalizing, for most people, are palatable forms of reassurance.

PATIENT 1: When my grandmother died, I didn’t really feel bad. My

mother was so upset, but I wasn’t. It made me feel guilty.
THERAPIST 1: That’s not unusual. Unless there’s a very close relationship,
children often accept the death of a grandparent as a matter of
course (normalizing and possibly absolving).

PATIENT 2: When I came out to my parents, my mother wanted to know

what she had done wrong, and my father acted like I was a criminal.
I still hate them.
THERAPIST 2: We know that this happens a lot of the time. When your
parents were young and forming their knowledge of the world, the
experts said that homosexuality was caused by the parents doing
something wrong. In those days, homosexuality was classified as a
subtype of psychopathic personality. Haven’t you come across
other gay men who have had similar experiences with their parents
and who feel the same way about them now? (The therapist nor­
malizes the patient’s feelings and encourages understanding
rather than expression of feeling.)

PATIENT 3: I know I shouldn’t be in this program. I’ll never understand Lacan.

THERAPIST 3: Neither will I. (Using oneself as a standard is risky, but
here, the therapist assumes she will be seen as a representative ed­
ucated person and the patient’s peer.)
60 Learning Supportive Psychotherapy

Adages and maxims are a form of normalizing.

THERAPIST 1: You can’t make your [adult] children like each other (reas­
surance given as an authority).
THERAPIST 2: I don’t know of studies, but we know from newspapers, lit­
erature, and the Bible that siblings often don’t get along (normalizing
reassurance given as an educated person).
THERAPIST 3: There’s a saying: “You can’t make your child eat, sleep, or be
happy.” I guess we could add “or get along with a sibling” (normal­
izing using a maxim).
THERAPIST 4: I have never liked my brother either (inappropriate self­
disclosure that serves no useful purpose and crosses the boundaries
of the professional relationship).

Reassuring and normalizing must not extend to pathological and non­

adaptive behavior or to opportunistic, hostile interactions with others.
The objectives of supportive psychotherapy are most effectively ad­
vanced when reassurance is coupled with enunciation of a principle or a
rule (i.e., teaching).

PATIENT: Whenever I go anywhere, I have this fear that I’m going to lose
control.
Therapist 1: You won’t lose control. (Reassurance as an authority is use­
ful but not as potent as reassurance that reinforces the patient’s
strengths or adaptive skills.)
THERAPIST 2: I don’t think you will lose control because you have had this
fear for a long time and you have always been able to maintain good
self-control (reassurance based on patient’s history and reinforce­
ment of adaptive behavior).
THERAPIST 3: People with social phobia always fear losing control, but ac­
tually losing control is not part of the condition (reassurance based
on a principle).

Encouragement
Encouragement also has a major role in general medicine and rehabilitation.
Patients with chronic schizophrenia, depression, or a passive-dependent
style are often inactive, mentally and physically. The therapist might en­
courage patients to maintain hygiene, to get exercise, to interact with
other people, to be more independent, or to accept the care and concern
of others. Rehabilitation requires small steps. Many people discount small
steps, seeing each one as being of no great importance. Therapy with pa­
tients who have disabilities calls for ingenuity in identifying tasks and ac­
tivities that can be conceptualized as acceptable small steps.

PATIENT 1: I don’t see why I should waste time in occupational therapy.

I’m not going to get a job painting flowerpots.
Techniques 61

THERAPIST 1: Occupational therapy isn’t intended to be job training for

flowerpot painting. The idea is to allow people to have the experi­
ence of staying in one place and completing a task; it’s about being
able to cope with detail, with structure. It’s also, for some people, an
opportunity to stop thinking about their psyches or their problems.
(Therapist addresses both the “small steps” element and the diver­
sionary element.)

PATIENT 2: I’m tired of not getting anywhere. My father is willing to pay

and I’m going to start college in the fall.
THERAPIST 2: Before you take such a big step, I’d suggest taking an adult
education course at the high school or community college. It
wouldn’t be all that you want, but it’s a low-risk way to see if you
can handle regular attendance, pay attention, complete assign­
ments, and feel comfortable with other people. (Enrolling in a de­
gree program and failing is not effective rehabilitation; it is bad for
self-esteem. This intervention might also be categorized as advice.)

Encouragement is powerful because people want to believe that their

efforts will lead to something. Encouragement invokes the world of child­
hood; much like a parent, the therapist can offer specific encouragement
that provides the patient with care, compassion, and comfort. Exhortation
is a more insistent form of encouragement.

PATIENT: I’m eating OK, I sleep well, but I can’t get going. My apartment’s
a mess. And they want me to take one of those “welfare” jobs.
THERAPIST: A demoralized person is convinced his efforts will come to
nothing, so he doesn’t try. The only way out of it, once you are eat­
ing and sleeping normally, is to begin doing things. Any kind of
work, even beneath your level, can help you to change your per­
ception and begin to see yourself as a person who can function.
Then you can move to something meaningful.

The discussion of encouragement thus far has dealt with only one of
the two meanings of the word encourage—that is, “to stimulate, to spur.”
The other meaning is “to give hope.” Therapists also use encouragement
to give patients hope.

PATIENT: All I was able to do last week was go to a movie. I must be in bad
shape.
THERAPIST: One of the worst things about depression is that it makes you
unable to even imagine things being better. If you think of some­
thing that was good in the past, it’s evidence that supports how bad
you are now. That’s the illness. It may be hard to believe, but these
medications usually make a difference and help the depression to
lift. For now, do what you can. Does this make any sense?
62 Learning Supportive Psychotherapy

Skills Building: Adaptive Behavior

Guiding the patient to better adaptive behavior by employing the tech­
niques of advice, teaching, and anticipatory guidance is a major element
of the supportive approach. As stated in Chapter 2, direct measures are
used. When the patient is significantly impaired, the therapist addresses
evidences of impaired ego function. With most patients, the major focus
of skills building is interpersonal transactions. Video Vignettes 2 and 3, fea­
tured at the end of this chapter and available at www.appi.org/Winston, il­
lustrate this element of therapy.

Advice and Teaching

Advice and teaching are appropriate in areas where the therapist is pro­
fessionally expert, such as adjustment, mental illness, normal human be­
havior, interpersonal transactions, reasonable living in society, and
possibly participation in hierarchical organizations. It is important for the
therapist to be familiar with the standards and customs of the patient’s
world. The challenge for the therapist is knowing when to transition from
giving advice to helping the patient find his or her own sources of advice
and information. Offering advice to a dependent patient can be gratifying
but may deprive the patient of the opportunity to grow.
Ideally, giving advice should involve teaching about general principles
or methods of problem solving. If the patient senses that the therapist is
proposing advice that is clearly not in response to his or her needs and in­
stead reflects the prejudices or convictions of the therapist, the patient­
therapist alliance will be damaged.

THERAPIST: You should do regular exercise.

PATIENT: What for?

THERAPIST 1: Everyone should. Obesity is a major problem in this country

(possibly true but presented as a general truth; the patient must in­
fer its relevance).
THERAPIST 2: A number of studies have shown that exercise reduces
symptoms of depression. It can reduce the amount of medication
needed (includes advice relevant to the patient’s condition).

Advice is meaningful to a patient when it is pertinent to his or her

needs. Good advice that is not in step with the patient’s perceived needs
is like a commercial or a sermon: possibly true but not personal, which
may damage the patient-therapist bond. In terms of transference, a pa­
tient may experience boilerplate advice or false praise as a replaying of a
past relationship in which someone on whom the patient was dependent
failed to meet the patient’s needs. Every therapist should know which of
his or her ideas are based on personal convictions or idiosyncrasy.
Techniques 63

Advice about activities of daily living is appropriate for the seriously

impaired. Advice about daily living should not be given to those who are
not impaired, even though it might make their lives better.

THERAPIST 1: When15 you get up in the morning, you should get dressed
and make your bed. It’s important to have a structure and a routine.
THERAPIST 2: Taking an entry-level job would be a big comedown, but
when a person hasn’t worked for a long time and doesn’t have con­
nections, it’s often the only way to get back into the work world. If
you later attempt to get back to your old level, it provides evidence
to a prospective employer that you are able to do a day’s work.
THERAPIST 3: People who are interested in what you do usually don’t want
all the details. They may be interested to know that you enjoyed a
movie, but they may not want to hear the whole story. Try stopping
and noticing whether the other person asks a question indicating
that he or she wants to know more.
THERAPIST 1: They offer you free credit, but you’re better off not getting
into debt (mature wisdom).
THERAPIST 2: Let’s see if we can work out a strategy about what you
should do when you are upset so you don’t have to come to the
emergency room and say you are suicidal (adaptive skills).
THERAPIST 3: I think you should make a plan to begin cleaning up your
apartment because it’s bad for your self-esteem to be surrounded by
evidence of your inability to function (rationale explained).
THERAPIST 4: If you don’t do something about your apartment, it’s possi­
ble that someone will make a complaint to the health department
(anticipatory guidance that borders on criticism).

The therapist should not give advice on issues about which the patient
can make his or her own decisions. Abstaining from offering such “advice”
is one of the distinctions between psychotherapy and social conversation.

PATIENT: You know I worry about everything. Do you think it’s safe to use
my credit card on the Internet? I read that they can steal your identity.
THERAPIST: Yes. I’ve read about that. I think the psychotherapy question
is not whether I think it’s a good idea but how you come to a deci­
sion when there are different opinions or when you have competing
pressures.

The therapist can generally provide advice based on what the patient
has reported. Providing advice based on surmise, even when the patient
seeks the advice, is unprofessional.

P ATIENT : My boyfriend humiliated me in public again yesterday.

I screamed at him when we got home, and he said I was too sensi­
tive. I can’t take it anymore.
64 Learning Supportive Psychotherapy

THERAPIST 1: Tell him that if he does this again, you’re leaving. (Unless
the therapist is totally aware of the unconscious forces that have
kept them together, such advice should be left for family or friends
to give. If the patient leaves and is then unhappy, she may blame
the therapist for giving bad advice.)
THERAPIST 2: Are you able to talk with him about what bothers you at a
time when neither of you is angry? (implicit advice)

Teaching is more important than advice. Teaching involves principles,

which may be based on technical knowledge or on the therapist’s knowl­
edge as a rational, informed person who is familiar with the unwritten
rule book of life. The therapist’s behavior teaches the patient by example.
The term lending ego was once used as a metaphorical statement that the
therapist’s model of reasonableness, self-control, and organization was
beneficial to the patient.

THERAPIST 1: You tend to put up with things until you become furious;
then, for example, you scream at people. Dealing with a problem
before it becomes extreme is usually a better approach.
THERAPIST 2: Even if you are right, people do not like to be told what to do.

Anticipatory Guidance
Anticipatory guidance, or rehearsal, is a technique that is as useful in sup­
portive psychotherapy as it is in cognitive-behavioral therapy. The objec­
tive is to anticipate potential obstacles to a proposed course of action and
then prepare strategies for dealing with them. For patients who are more
impaired, guidance must be more concrete.

THERAPIST: What’s your plan?

PATIENT: I’m going to begin reintegrating into society (nonspecific).

THERAPIST: What will be your first step? (aware that a nonspecific, vague

response is not a plan)

PATIENT: Well, maybe I’ll go to the senior center. My son’s wife said she’d
drive me and bring me home.
THERAPIST: Can you think of any problems that could come up?
PATIENT: She might have to stay late at work.
THERAPIST: What could you do if that happened?
PATIENT: It’s near the library. I could wait there, I suppose.
THERAPIST: Good idea. What else? How do you think you will react to being
there?
PATIENT: I wouldn’t know anyone.
THERAPIST: That’s hard for almost anyone. What will you do?
PATIENT: I suppose I could introduce myself to someone who doesn’t look
too senile.
THERAPIST: Yes. And maybe you could ask the director or someone in
charge to introduce you to a few people. People running these pro­
Techniques 65

grams appreciate that it’s hard for a newcomer. What if you give it
a few days and still don’t feel good about it?

Anticipatory guidance is especially important with patients who have

chronic schizophrenia because they are especially likely to be apprehen­
sive in new situations, unsure of their ability to grasp social cues, unsure of
appropriate responses, fearful of rejection, and unable to maintain pro­
longed effort. This technique is also important for patients with substance
abuse, who often fear rejection and may unwittingly invite it.
Anticipatory guidance may be helpful and supportive in contexts
other than rehabilitation.

PATIENT: I’m seeing my internist next week about this indigestion and
weakness.
THERAPIST: I hope that you start with the most distressing symptom
rather than with the first things that you noticed, like feeling tired.
Are you willing to rehearse what you will say to explain your prob­
lem to the doctor? And if anyone asks “Do you understand?” and
you are not completely sure, say, “Would you go over it again?”

Prevention of relapse is an important supportive psychotherapy objective.

The substance abuse literature includes practical lists of topics to discuss with
patients to prevent relapse (e.g., Marlatt and Gordon 1985, pp. 71–104):

• Identifying high-risk situations and using anticipatory guidance for

dealing with them
• Coping with negative emotional states
• Coping with interpersonal conflict
• Coping with social pressure
• Identifying relapse and using anticipatory guidance to deal with it

Little modification is needed to apply these lists to the needs of nonad­

dicted patients with mental illness.

Reducing and Preventing Anxiety

The supportive psychotherapist intends not only to deal with the patient’s
overt anxiety (a symptom), but also to prevent the emergence of anxiety,
which can exacerbate impairments in ego functioning. The techniques in­
tended to accomplish these objectives include reassurance and encourage­
ment, which were discussed earlier in the section “Esteem Building,” because
anxiety invariably has an adverse effect on esteem. Supporting or strength­
ening of defenses has been discussed not as a technique but as a principle or
strategy (see Chapter 2). In this section we identify a few of the more com­
66 Learning Supportive Psychotherapy

mon techniques to support defenses. The structured setting of therapy, the

holding environment (Winnicott 1965), has an anxiety-reducing effect that
contributes to the efficacy of all forms of therapy. The therapist models adap­
tive, reasonable, and organized behavior and thinking in countless ways; this
modeling is educational and at the same time reassuring and calming.
The therapist should make every effort to avoid the interrogatory style,
which involves asking continuous questions and giving little—the style of
medical history taking or the style of a trial attorney cross-examining a
witness. To minimize anxiety, the therapist shares his or her agenda with
the patient, making clear the reason for questions or topics.

THERAPIST 1: I want to ask questions that will test your memory and con­
centration.
THERAPIST 2: Your relationship with your daughter, you said, was a major
worry. Is there anything new there?
THERAPIST 3: Did you grieve when your father died? Some people have
little response and it’s all right—but some people who don’t have
any response have it bottled up inside, and that can be a problem.

Above, therapist 3 gave a longer explanation. The use of extra words,

even excessive words, can provide padding that reduces the impact of an in­
tervention that the patient may find difficult or uncomfortable. The sup­
portive psychotherapist avoids forcing the patient out on a limb or
requiring the patient to make a stark response. The following two therapists
are trying to obtain the same information, but the second uses more words.

THERAPIST 1: Do you experience sexual stimulation when you see some­

one being hurt by another person? (Very blunt)
THERAPIST 2: This may seem like an odd question, but it’s relevant when
someone has a history that involves as much physical conflict as you
have had: Do you sometimes experience sexual stimulation in con­
nection with pictures of torture? This could include paintings of
martyrs in museums. It’s not rare. All those great paintings show
that a lot of people have found excuses to portray and look at tor­
ture. On the other hand, a person can be involved in a lot of vio­
lence and not have this response. (If the patient says no, he is not in
conflict with the therapist because he has been given permission to
say no. If he says yes, he is in good company.)

One of the highly regarded interventions enunciated by Pine (1984) is to

tell the patient in advance that something might be anxiety producing. This
tactic is effective for minimizing the occurrence of anxiety in treatment.

THERAPIST: I want to return to a topic that we had to leave once because

it upset you. I’d like to know more about what happened when your
mother remarried and her husband’s children moved in.
Techniques 67

The therapist can be even more protective by asking the patient to give
permission to go on with an anxiety-provoking topic.

THERAPIST [continuing]: Do you think you can handle talking more about
this matter?

Naming the Problem

The patient’s sense of control may be enhanced, and thus anxiety mini­
mized, by naming problems. The need for control is one reason why people
classify and count things.

PATIENT: I’m so stupid. I had all those people for dinner, and I didn’t allow
enough time for the rice to cook, and I thought I was smart to make
salad early, but then there wasn’t enough room in the refrigerator,
and I didn’t think to ask everyone if they eat meat. What kind of ex­
ample am I for my daughter?
THERAPIST: Sounds like this is just evidence of your organization problem.
We have talked about it, and you have made progress. Let’s talk about
some specific things you might have done differently. (The objective of
decatastrophizing is approached by reducing what appears to be a
multitude of problems to a single problem with a name.)

Naming the problem can also be used to meet the familiar medical re­
sponsibility of explaining the diagnosis, prognosis, and proposed treatment.

PATIENT: My mother says I shouldn’t lie down so much, but it feels better
when I do. I read the ads every week, but the jobs don’t pay enough
and there’s no future. I don’t have much money left. It would be
great if I won the lottery. There was one job that might have had
something, but I would have to commute, and I hate that.
THERAPIST: This has been going on for a long time. You no longer have signs
or symptoms of depression, so the current medication seems right. I
think your problem is demoralization. That’s a condition in which a
person is convinced that her efforts will not succeed, so she does
nothing. The only way out is to begin doing things, anything. Small
steps can lead to small successes. It’s a rehabilitation approach. It af­
fects self-esteem and confidence. (The therapist names, explains,
and gives advice—techniques of supportive psychotherapy).

Rationalizing and Reframing

Reframing or paraphrasing looks at something in a different light or from
a different perspective.

PATIENT: Everything was going well and then I realized I was talking and
talking and talking. I’ve done this so many times. It’s as if I have no
control.
68 Learning Supportive Psychotherapy

THERAPIST: But in the past, you didn’t know you were doing it and didn’t
figure out what had gone wrong until some time later. Now you see
it when it happens. That’s an advance (reframing—the events are
unchanged but given a different emphasis).

PATIENT: I was so stupid. I got a parking ticket and I could have been back
before the meter ran out. I wasn’t paying attention.
THERAPIST: Yeah. That’s a tough one. If you figure it’s bound to happen
occasionally, you can think of a couple of parking tickets a year as a
routine cost of having a car (rationalization—patient benefits from
discovering that therapist, who represents the adult world, does
not think she is stupid).

Rationalization is a powerful tactic for avoiding unpleasant thoughts or

feelings.

PATIENT: My son doesn’t come very often.

THERAPIST: Yes. A lot of young people are completely caught up in work and
home. And you manage to get things done without his help (rational­
ization and encouragement).

Rationalization is also useful in more expressive psychotherapy.

PATIENT: My son doesn’t come very often.

THERAPIST: It sounds like you are disappointed, possibly angry (hoping to
explore feelings of which the patient appears to be unaware).

The therapist should challenge a patient’s defense of rationalization when

it is pathological.

PATIENT: Yes, I bring things home all the time. My husband says it’s junk,
but I’m saving a lot of money by not buying new things all the time.
THERAPIST: But you told me last time you were here that your husband
threatened to leave. Maybe the problem is that you can’t control
your obsessive-compulsive symptoms (challenging patient’s ratio­
nalization that she is saving money).

The challenge in use of these techniques is to avoid sounding fatuous

and to avoid argument or contradiction.

PATIENT: I feel as bad as ever. I don’t think the medication is any good.
THERAPIST 1: You look a lot better to me (contradiction—not uncommon
in physician-patient discourse).
THERAPIST 2: People who are recovering from depression usually look
better and eat better as the medication begins to work, and this hap­
pens before they feel better (disagreement, but the therapist is con­
veying expert information that may be useful to the patient).
Techniques 69

THERAPIST 3: You have to get up and do things. You can’t stay in bed all
day waiting to feel better (argumentative and not true in every clin­
ical situation).
THERAPIST 4: If you had continued taking the medication as you were
supposed to, you wouldn’t be in this position (pedantic).

Often, therapists negate what the patient says, thinking that this tactic
is useful education. It doesn’t help.

PATIENT: I was feeling bad. I was thinking about how I used to get up and
go to work every day, and I got good pay. I was a somebody.
THERAPIST: Well, you have social security now (unempathic reassurance
or reframing that misses the point of the patient’s situation may
have a negative impact on the therapeutic relationship).

Expanding Awareness
Clarification, confrontation, and interpretation are useful techniques to
make the patient aware of thoughts or feelings of which he or she had not
previously been aware.

Clarification
Clarification involves summarizing, paraphrasing, or organizing what the
patient has said. Often, clarification simply demonstrates that the thera­
pist is attentive and is processing what he or she hears. Clarification is an
awareness-expanding intervention. Both in and outside of psychother­
apy, people say things without appreciating the significance of what they
have said.

PATIENT: I can’t get things done. I have to sell the house, but first I have to
get some things fixed, and I don’t do them. My ex-wife keeps ha­
rassing me with court papers about unpaid child support. I think
the medication is working, but it takes the edge off my creativity.
She’s relentless. I’m bipolar. Don’t they have to take that into ac­
count? My car broke down again, too.
THERAPIST: It sounds like you’re saying that you’re overwhelmed.

Confrontation
As a technical term, confrontation does not imply hostility or aggression.
Instead, it means bringing to the patient’s attention ideas, feelings, or a
pattern of behavior that he or she has not recognized or has avoided or de­
fended against. In the following dialogue, which is a continuation of the
comments presented in the preceding section, “Clarification,” the thera­
pist uses confrontation.
70 Learning Supportive Psychotherapy

PATIENT: I’m living alone in that big house. If I sell it, I can get a smaller
place and have money left over, but I just don’t do anything. I’m so
depressed.
THERAPIST: It sounds like you are avoiding doing the one thing that would
provide you enough money to pay your bills and give your ex-wife
what she wants. (The therapist knows that depression is a univer­
sally used word and that the patient who says “I’m depressed”
does not necessarily meet the criteria for a depressive disorder.)

Human beings are frequently unaware of significant feelings. For example,

in the past, when psychotherapy practice first originated, a patient would of­
ten be unaware of what was then perceived as unacceptable sexual feelings.
Anger can also be outside of the patient’s awareness. Hidden anger may be di­
rected toward authority figures, people who are more successful, those who
are manipulative, or those who are dependent and passive. Anger may be the
emotional response to paranoid ideation. The discovery of anger does not al­
ways lead to reduction of symptoms or impaired function.
Resentment (e.g., of parents, children, partners, coworkers) is related to
anger and is often accompanied by guilt or shame. It is often perceived as a
negative emotion. For example, being excessively dependent on another
person is often associated with resentment. Grief may be a hidden emotion,
especially for individuals who do not grieve the death of someone close.
Delayed grief may also be present in individuals with schizophrenia whose
lives have long been disrupted. After reaching stabilization with antipsy­
chotics, these individuals may finally be able to grieve for the years they
have lost or for any suffering they may have caused others. Some individ­
uals are so scared of vulnerability that feelings of intimacy and caring are
kept out of awareness. The list of avoided feelings can go on and on.
To simply name the feeling and move on is a supportive technique.
When exploring a patient’s hitherto unexamined feelings and assump­
tions, the therapist should seek to learn about other instances of whatever
has been discovered. The therapist should talk about the implications of
the discovery with the patient, seek to understand the basis for it, and ul­
timately determine what is to be done about it.

Interpretation
There is no agreed on definition of interpretation. Many authors use the
term to characterize any proffered explanation of “the meaning of the pa­
tient’s thoughts or the intent of his behavior” (Othmer and Othmer
1994, p. 87). Others limit the term to a linking of current feelings,
thoughts, or behaviors with events of the past or with the relationship
with the therapist. Linking these elements is important for achieving the
objectives of expressive psychotherapy. In supportive psychotherapy,
Techniques 71

links between patient and therapist are generally made only when neces­
sary in order to avoid disruption of treatment.

THERAPIST: You haven’t said you disagree with me, but you have found
something wrong with every suggestion I have made. From what
you have said about your problems at work, it’s possible that you do
the same thing with other people (a link between the therapist and
current behavior; in supportive therapies, such a link may help
with efforts to improve adaptive skills).

Insight about historical cause-and-effect relationships is not an objective

of the most supportive approaches. Creation of a patient’s biography or nar­
rative that makes sense of symptoms and dysfunctions is, however, a useful
shared task and often a tactic for reducing anxiety, as stated in Chapter 2.

Conclusion
Supportive techniques can be enumerated and mastered. With practice,
the therapist can apply these techniques in many situations. More lengthy
elaboration of techniques can be found in a handful of books. Especially
useful are works by Novalis et al. (2020), Pinsker (1997), Rockland
(1989), Wachtel (1993), and Winston and Winston (2002). Guidance
about understanding patients can be found in the thousands of books on
psychodynamics and psychotherapy written in the last 80 years and in the
literature.

Video Vignettes 2 and 3

Video Vignettes 2 and 3 (available at www.appi.org/Winston) are enact­
ments illustrating the spectrum of psychopathology and the associated spec­
trum of treatment (see Figure 3–1 in Chapter 3, “Assessment, Case
Formulation, and Goal Setting”). Video Vignette 2 illustrates the difficult
treatment of an uncooperative patient who has severe, persistent mental ill­
ness. Therapy is entirely at the supportive end of the supportive-expressive
continuum. Video Vignette 3 illustrates supportive-expressive treatment to
right of the midpoint of the continuum.

Video Vignette 2: Severe, Persistent Mental

Illness in an Uncooperative Patient

Jerry is a 21-year-old man who was diagnosed with schizoaffective

disorder when discharged from the hospital 4 weeks ago. He had
been admitted because of self-injury following an argument with his
72 Learning Supportive Psychotherapy

mother. He was referred to the clinic for continuing care. Since com­
pleting high school 3 years ago, he has spent most of his time watch­
ing TV, playing computer games, or surfing the Internet. He has
never had a close relationship.

This is Jerry’s third visit to the clinic. The therapist has observed that
he is grandiose, that his thought processes are characterized by idio­
syncratic connections and assumptions, and that he is negativistic. An
important supportive measure is honest praise for the patient’s ef­
forts. When Jerry is negativistic and rejecting, he may perceive a ther­
apist who praises him as an ally of hostile forces. The therapist’s
immediate objective is that Jerry continue in treatment and take the
prescribed medication, so her main concern is establishing a thera­
peutic relationship; she tries to avoid anything that might be taken as
criticism and is cautious about praise. She offers advice carefully, with
explanations. As often happens in an interview with a new patient
who has a significant thought process disorder, the therapist at times
does not know what Jerry is talking about. She does not want to
agree with anything unrealistic but at the same time does not want to
challenge him or ask too many questions.

THERAPIST: So, what’s been happening?

JERRY: Not much (uncommunicative). Actually, I just started working.
It’s a few blocks from where I live.
THERAPIST: Tell me a little about that (asking for elaboration in
general terms; doesn’t want to appear demanding).
JERRY: It’s mostly fixing computers. I started yesterday. It’s a friend of
my mother’s.
THERAPIST: How does it seem after 1 day?
JERRY: It doesn’t make any difference (negativistic and pessimistic).
It’s just like staying at home watching TV. It’s really no different.
THERAPIST: What about the fact that you can earn some money? (trying
to identify an asset)
JERRY: I don’t care about making money.
THERAPIST: How many days a week will you work? (trying to maintain
conversation without seeming confrontational)
JERRY: Well, there’s a movie rental business. I’ll look after that and fix
computers. Maybe 3 days a week?
THERAPIST: OK, so it keeps you busy? (neutral facilitator)
JERRY: It’s nothing.
THERAPIST: I’d say it’s too early to know if it will work out, but it’s my im­
pression that you don’t want to commit yourself (clarification
without contradicting).
JERRY: [no response]
THERAPIST: Is there anything about the job that you might find diffi­
cult? (looking for opportunity to attempt anticipatory
guidance)
Techniques 73

JERRY: I can fix most any computer. It’s usually just that someone’s
screwed them up (a positive statement at last).
THERAPIST: Right, well I heard that the first thing they told every new
computer user was that you can’t break a computer (still trying
to establish dialogue).
JERRY: They’re stupid.
THERAPIST: So you have a job; it seems like you’re quite good at this job
(praise)—but it doesn’t give you any pleasure. Do I understand
that correctly? (clarification and asking for feedback)
JERRY: Yeah. It’s just like staying at home, watching TV (agrees with
therapist’s perception).
THERAPIST: I could go on to another topic, if you’d like. (The therapist
introduces a new topic, “showing the map”—sharing the
agenda, asking permission—so that patient will not per­
ceive the questioning to be interrogation.)
JERRY: [grunts assent]
THERAPIST: Let me ask you this: How are things with you and your
mother and your brother?
JERRY: My brother is home from school this week, and my mother has
been really getting on my nerves. She actually lost her job. It
puts a lot of pressure on me.
THERAPIST: What happened? (conversational response; avoiding
narrowing focus)
JERRY: I don’t know. She may have a new job. She might start today or
tomorrow. Some guy has to call her. (The patient talks about
his mother, not about his long-standing conflicts with
her.)
THERAPIST: Do you think that she understands how depressed you
were when you were in the hospital? (The therapist tries to
maintain focus on the patient’s relationship with his
mother.)
JERRY: I don’t know. Maybe.
Therapist: Tell me a little bit about the pressure she puts on you
(maintaining focus and seeking specifics).
JERRY: Well, I feel like I have to make money.
THERAPIST: So—you kind of think she doesn’t get it. Kind of like she
really doesn’t understand. (The statement is an implied
question—a tactic for avoiding direct questions that
might be experienced as interrogation.) And you know,
it’s funny—some people, they don’t really understand mental
illness. They think that you can just sort of snap out of it—like
it’s in your control how you feel (an empathic comment and
at the same time another implied question).
JERRY: I don’t try to explain. Some people, when I talk, they listen.
Other people, no. I don’t bother with them. (The patient is
referring to his self-image as an unappreciated teacher.)
THERAPIST: Well, you can try again; you never know (vaguely positive;
puzzled about patient’s shift of subject from mother to
“people”).
74 Learning Supportive Psychotherapy

Jerry dismissed the therapist’s efforts to reinforce what seemed to

be an adaptive step: getting a job. Because the therapist is hopeful
that this will help to boost Jerry’s self-esteem, she attempts to stay
with that topic and refrains from approaching Jerry’s conflict with
his mother, even though she knows that this is important.
In the next video segment, Jerry makes reference to impairment
of sense of self. The therapist deals with this concretely, not naming
it as a problem. The therapist’s values are in evidence when she sug­
gests that helping people might give Jerry satisfaction at work. She
explores the extent of his conviction that making money is wrong—
that is, his grandiose rejection of most people’s motivation. When
Jerry accuses his mother of being “negative,” the therapist surmises
that this is projection and that he is angry because he wants to main­
tain his dependent relationship with her.

THERAPIST: What would you say about your mood now? (Avoiding
confrontation, the therapist elects to start a new line of
inquiry—without her usual attention to mutuality.)
JERRY: About the same. It’s hard to explain. It’s sort of like a reflection
of where I am. If I’m in a positive place, I can be positive. If I’m
in a negative place, I’m negative. (The patient’s description
suggests a defect in his sense of self, an ego-function
deficit.)
THERAPIST: How’s the work environment? Is that a positive place for
you? (hoping to find a behavior or an attitude that she can
reinforce)
JERRY: Any place you go where the sole purpose is to make money is
negative (usual contrary, negative response).
THERAPIST: Even if you’re helping people? (potentially argumenta­
tive—the therapist hopes to find a way to reinforce the
idea of work as adaptive behavior)
JERRY: I’m not helping anybody.
THERAPIST: What if you worked as a volunteer to help people—you
wouldn’t be making any money. If it wasn’t about money, do
you think that would be a negative environment? (testing in­
ternal consistency of patient’s thinking)
JERRY: It would be negative at home. My mother would be angry
with me because I wasn’t making any money. (The patient
shifts from the therapist’s question about work environ­
ment and returns to criticism of his mother.) When I was
teaching English, I didn’t charge anybody. But my mother, it
would drive her up the wall if she found out that I wasn’t
charging anybody.
THERAPIST: Well, your mother needs money for rent, food for the two
of you and your brother, who’s still in school. Don’t you think
that would be helpful? (The therapist’s argumentative
Techniques 75

question is intended to communicate what she believes

are appropriate values.)
JERRY: It’s not that. The only reason she can’t get a job is because she’s
always so negative about everything. Everyone she talks to
thinks, “I’m not going to hire this person; this person’s going to
be a problem.”
THERAPIST: How do you know this? (checking on reality testing)
JERRY: Her tone, the things she says; it’s hard to explain. Just the way
she talks to people. It gives the impression that she’s a negative
person. Everything’s going to be a problem. That’s why she
can’t get a job. The guy who said he would call her about the
job—she called him, and it sounded like she was the boss. The
way she acts, it causes her problems. It’s not that I’m not help­
ing. It’s hard to help someone who doesn’t help herself. (His
helping his mother and her helping herself are not the
same, but he uses the words as if they are the same con­
cept; the therapist used “help” to mean “beneficial.”)
THERAPIST: When I suggested that you may be interested in trying to
contribute to your family’s support, you shifted to talking
about what’s wrong with your mother (confrontation, intro­
ducing the idea of examining unconscious motivation).
When you talk about your own motivations, things sort of get
fuzzy and inconsistent (identifying a problem).

The therapist wanted to reinforce some aspect of the work situ­

ation, but the patient’s negative attitude prevailed. He said that his
mother was a negative person and because of this had trouble get­
ting a job. Probably, he wants to be supported by her. When the
therapist suggested that it would be helpful if he provided money
for the family, she used the word help to mean “beneficial”; Jerry
construed help to mean improving oneself.
Later, if the therapeutic relationship becomes more solid and
Jerry becomes able to look at what he is doing, the therapist can try
to show him that mixing different meanings of a word (i.e., a
thought process disorder, which is an ego-function problem) inter­
feres with understanding and with communication.

JERRY: What I really like to do is analyze things—analyze my life, the

places I go, what I do (grandiose disdain). The result is al­
ways negative. I don’t see the point of why people do the
things they do. I see things in a different way. I see things cor­
rectly. The way I look at it, nothing I do is really going to
change the way things should be. It’s like people just decided
to live the way they do.
THERAPIST: Tell me, did something happen? (conversational response
to the grandiose statement)
76 Learning Supportive Psychotherapy

JERRY: Everywhere I go, everyone’s trying to make money. Just look at

them. There’s no point to what they do. They go to work, they
come back from work, they go to sleep; the next day they go
back to work (patient’s first elaborated response—about
his grandiose disdain for people). There’s no point. It’s not
like they’re becoming better at anything; it’s not like they’re
evolving.
T HERAPIST: I wonder if you feel that you can evolve when you’re
watching TV (deliberately argumentative as an attempt
to overcome patient’s apparent lack of involvement and
to encourage further conversation).
JERRY [sighs]: I’m one man alone, and I can’t change anything just being
one person. If I try to do something positive with myself, nothing
good is going to come of that because I’m just one person.
THERAPIST: It sounds like you’re really discouraged (empathic clarifi­
cation). If you could do something really positive that you re­
ally wanted to do, what do you think that would be? (hoping
to identify an interest with potential for adaptive action)
JERRY: If I went to college, I would study philosophy—but then where
would I be? It’s not like I can go to an employer and say, “Hire
me; I’m a philosopher.” There’s no place for people who think
about things these days (therapist missed opportunity to
praise his awareness of reality). The patients in the hospi­
tal—they were more willing to listen to me. They realized that
they needed something, and they could get it from me. People
on the outside—they don’t want to absorb anything. They’re
not ready to listen to anything. So it was better in the hospital.
I could talk to people, and I felt that communication had some
purpose.
THERAPIST: It’s hard to change people (tracking, paraphrasing, em­
pathic).
JERRY: It doesn’t change the fact that people need to change.
THERAPIST: Have you ever thought about the way that you react so
perhaps you wouldn’t get so upset? (challenging maladap­
tive aspect of patient’s position)
JERRY: I think it’s appropriate to be upset.
THERAPIST: You’ve given a lot of thought to your situation—perhaps
more than most people—and your conclusion is that maybe
you should do nothing because it all seems hopeless (praise
and clarification, tracking). It doesn’t seem to matter
whether your conclusions are correct or not because the isola­
tion you describe usually leads to depression (avoids abstract
argument; gives advice based on professional mental
health expertise).Everyone needs activities that are good for
them—something for their self-esteem—teaching, making
money, doing something like that, something that they can
feel good about. It doesn’t have to be important in and of it­
self. It could just be something that you like to do. It doesn’t
have to generate a degree or a career or be the basis of an ed­
Techniques 77

ucation (gives advice and explains the rationale). And

when I say “something that’s good for your self-esteem,”
I don’t just mean feeling superior. I mean something that really
makes you feel good. Not feeling superior because you can see
the folly in the human condition and feel better than other
people (advice). What do you think? (solicits feedback)
JERRY: Sounds like a waste of time (still negativistic).
THERAPIST: Well, perhaps you should give it some thought before our
next appointment.

The therapist stated her position about self-esteem, making every

effort to avoid being critical or argumentative. She did not go into
Jerry’s portrayal of himself as the teacher whom all the hospital pa­
tients wanted to listen to. She explained the rationale behind her
advice. Her objective at this point is to establish a relationship based
on honesty and openness. In the same visit, she discussed Jerry’s use
of medications, paying attention to possible uncomfortable effects
and to his apparent lack of confidence that anything will help.

Video Vignette 3: Supportive-Expressive

Treatment

Ann is a 28-year-old woman whose presenting problem is chronic

depression. After high school, Ann worked for several years, saved
some money, and is now enrolled at a community college. She has a
history of relationships that turned sour. Ann described being sensi­
tive to slights and felt she was often treated unfairly, but she did not
seem to have ever been delusional or pathologically suspicious. It
was noted at the time of initial assessment that she often jumped
from one topic to another, and this was thought to be a manifesta­
tion of anxiety, not thought disorder. The diagnosis was personality
disorder not otherwise specified and depression.

Ann has been attending the clinic for 4 months. She is reasonably
well integrated and has the capacity to think about her mental pro­
cesses, interpersonal relationships, and the patient-therapist rela­
tionship. In this video, the therapist responds empathically, praises
Ann’s efforts, explains her reasons for questions, involves Ann in set­
ting the agenda, praises her efforts, answers questions directly,
maintains focus despite Ann’s tendency to jump to other topics, and
offers guidance about alternative ways of thinking about what had
been perceived as criticism.
78 Learning Supportive Psychotherapy

THERAPIST: How have things been going since our last meeting? (the
initial question involves reference to therapeutic rela­
tionship.)
ANN: I wasn’t so down this week. I got to shop a little bit. But some­
times when I’m there and looking through things, I find it hard
to make a decision when there are two or three things I’m
looking at (indecisive). And sometimes I realize, “Wow, here
I am staring at these things, and people are looking at me and
wondering, ‘What is she doing?’” (self-conscious) But I just
kind of push it out of my mind and get over it.
THERAPIST: That’s good. I’m glad you were able to get more done this
week (praise, expressed personally). Let me ask you—when
you had trouble making a decision when you were shopping,
did it lead to any problems? (The therapist elects to focus on
adaptive skills.)
ANN: No. Like I said, I got over it. I was able to sort of move through it.
But I guess, since I brought it up, maybe I didn’t fully get over it
and that’s why I’m talking with you about it (volunteers psy­
chological connection).
THERAPIST: What were you buying? I want to understand how this may
be interfering with your life. (Explains reason for question—
a demonstration of respect for the patient—which is
good for self-esteem)
ANN: I was buying gloves, and I was just trying them on, seeing how
they looked, if they were warm, how they felt. It wasn’t any­
thing as ridiculous as trying to pick out the perfect onion to
bring home for dinner (patient is sardonic—evidence of
observing ego).
THERAPIST: You said you got over it, and then you said you wouldn’t
have brought it up if it wasn’t a big problem, so you seem to be
kind of saying that it is a problem and that it isn’t a problem. So
I’m wondering if you think we should talk about this? (clarifi­
cation, then involvement of patient in setting agenda)
ANN: I think we’ve talked about it enough. I think we can skip it. I will
say that when I got home, I got a call from my mom, and she
can really be a pain sometimes. I didn’t want to talk to her, but
I did for a little bit, and I just told her that I’d been shopping
and that I was OK, and I didn’t want to give her the full report
on my life. I don’t know. I don’t know if she felt like I was
brushing her off. I felt a little bit guilty afterward (sensitive
to potential impact of her behavior).
THERAPIST: How did you handle her call? (Initial focus is on action,
not feelings.)
ANN: I was polite. I told her what I’d been doing, that I was shopping,
and that I felt OK. I didn’t really spend much time with her. I
hope that was OK for her.
THERAPIST: It seems like you felt like you were brushing her off. Were
you rude enough to feel guilty? Or did you feel guilty because
you didn’t do what she wanted you to do? In other words, you
Techniques 79

didn’t want to talk to her (still focused on action, but adds

inquiry about underlying feelings).
ANN: I don’t think I was rude. Probably it’s how I felt. I just didn’t do
what she wanted. I didn’t speak with her longer or spend more
time with her.
THERAPIST: It sounds like you were asserting your will (emphasis on
action).
ANN: Yeah...yeah, I guess I was.
THERAPIST: That can sometimes be very difficult (normalizing, em­
pathic).
ANN: Yeah. My last therapist used to say that it’s all right sometimes
to say what we mean, and we can have these ideas that might
upset us, but as long as we don’t act on them, that it’s OK.
What do you think?
THERAPIST: I think that’s generally true (direct answer to a question).
ANN: Yeah, I guess. I was thinking [when talking to her mother], “I
wish you’d just leave me alone. Maybe all this wouldn’t have
happened—all this trouble that I have in my life—if it wasn’t
for you.” It’s my life after all. She just really screwed me up
when I was a kid.
THERAPIST: You know, you did say that you weren’t rude in that situ­
ation (reinforcing acceptable social behavior). How do
you feel that you handled yourself? (not revisiting child­
hood, staying with action and self-perception)
ANN: I think I was good. I don’t think she really had a clue that I didn’t
want to talk to her.
THERAPIST: It sounds like you were pleased with yourself (reinforcing
good adaptive action).
ANN: Yeah, I was. I used to think a lot that things might happen to
her, and I’d have these thoughts, and I’d get very, very scared.
I would see my mom getting hit by a car, and all these terrible
things happening to her, and I would really think, “Oh, these
are going to happen.” My last therapist told me that it’s really
OK—these are just thoughts—and that my thoughts aren’t go­
ing to make things happen, and that I should just relax a little
bit about that. And really, my mom wasn’t so bad. Maybe I was
just too sensitive as a kid. I don’t have the same fantasies any­
more, but I do get annoyed when she calls. Like I said, I went
shopping, and I was looking for gloves, I got some food, and I
wasn’t really feeling down. That’s good. I don’t know if it’s be­
cause of the medication. I don’t want to believe it’s just all
about the medication. I hope it’s also something within me
and our therapy, but I don’t know. I’m trying to get my act to­
gether and decide what I want to do in my life.
THERAPIST: OK. You know, you just said a lot of different things. (The
therapist is concerned that patient may have an ego­
function problem, i.e., scattered thinking.) And I think
something that’s important is to look at one thing at a time.
Sometimes when you say a lot of things and you’re thinking a
80 Learning Supportive Psychotherapy

lot, it can make you feel more disorganized and more anxious.
So I think one thing that’s very important is that we kind of
take one thing at a time (explains her concern; gives ad­
vice). All the things you said could be very important—you
talked a little bit about medication, your relationship with
your mother, fears when you were a child. There are a lot of
different things, and all of them are important, but perhaps
we should talk about each one separately, one at a time.
ANN: OK. So, all I know is that when I finish school, I don’t want to
live around here anymore (not responding to therapist’s
teaching).
THERAPIST: Do you have any thoughts about what I had said before
about your mixing ideas? (maintaining focus)
ANN: Oh, about that? Yeah—I mean, you’re probably right. Some­
times I know that I’m doing it.
THERAPIST: What about what I said before about jumping around in
your thoughts as making you feel more tense? Do you think
that’s accurate? (reiterating the point and asking for
feedback)
ANN: Yeah, I think it’s possible. And maybe I’ll go to Boston. If it’s not
too big and there’s a lot going on, you know, all those schools.
Or maybe even to the South.
THERAPIST: How do you think you’re going to decide? (focusing on the
process of decision making, not the issues being decided)
ANN: I don’t know. I’ll flip a coin. Of course it depends on whether
I have a boyfriend at the time, I guess.
THERAPIST: It bothers you that you have trouble with decisions, but
from the way you are speaking, it sounds like you are actually
able to make decisions just fine. Do you agree? (Contradicting
the patient is generally not supportive, but patient
agrees.)
ANN: Yeah, I guess so. I don’t really have to make any decisions now
about where I’m going to go after school. I still have time.
THERAPIST: Sometimes when you bring up your uncertainty about the
future, it’s not really a current problem; it’s sort of like you’re
reciting your flaws. Maybe that’s a familiar pattern for you,
and you’re aware of the fact that you are not called on to
make a decision right now (naming the problem, possibly
challenging a defensive pattern).
ANN: I don’t know. Maybe.
THERAPIST: Sometimes, repeating familiar patterns can be a source of
comfort (education about mental process). It’s important
for you that you don’t think you’ve discovered something new
every time you do it (guidance).
ANN: OK.
THERAPIST: Sometimes, when you bring up things that you may feel
are problematic right now, they may not really be what your
main issues are that brought you into treatment. Sometimes,
what the mind does is to focus on these sorts of things, which
Techniques 81

makes it easier to not talk about some of the more vital issues.
I think that it’s sometimes easier to think about these more
neutral types of things. I’m not saying you do this on purpose,
but sometimes the mind has a funny way of doing that. What
do you think of that? (Therapist continues education
about defensive styles, being excessively wordy to
avoid sounding overbearing; then asks for feedback.)
ANN: I can understand that. Maybe. I’ve been described as having a
“grasshopper mind.” (Patient agrees.)
THERAPIST: In some circles, people describe that as charming. And
then oftentimes, some people may say that it’s a little bit an­
noying.

The therapist suggested that Ann could alter her tendency to­
ward scattered thinking simply by becoming aware of it, and she
provided reasons for being concerned about this behavior. In future
sessions, the therapist might, if necessary, look for sources of uncon­
scious anxiety that might play a part in causing this behavior. When­
ever the therapist becomes aware of it, she will point it out to Ann
and then structure the conversation so that topics are finished be­
fore being abandoned. “Say whatever comes to mind” is not the
rule for supportive psychotherapy. The therapist praised evidences
of adaptive behavior, and she praised Ann’s description of her prob­
lem, intending to enhance her self-esteem. The therapist did not be­
come involved with the specifics of choices Ann described, choosing
instead to discuss the decision-making process.
In the next video segment, the therapist continues with the ten­
tative confrontation that Ann’s symptoms served a defensive func­
tion. The therapist also tentatively confronts Ann about the possible
underlying provocative intent behind what Ann describes as a sim­
ple question. In each instance, the therapist is tentative to avoid in­
creasing Ann’s anxiety or appearing overbearing because such
behavior would be inimical to her self-esteem.

T HERAPIST : How are you doing with school? Are you still able to
study? (The therapist returns to current function with a
new topic.)
ANN: Yeah. It’s not bad. I get bored sometimes, but it’s better than it
used to be, definitely. But there is this one instructor in my eco­
nomics class, and I swear he has it in for me. He asks me ques­
tions in class; he’s always looking at me. I asked him a question
once, and he answered it in a way that showed he thought I
was stupid or something. I’m sure it was a put-down.
THERAPIST: That really sounds unpleasant. You thought you were be­
ing put down (empathic). And I think this is an important
82 Learning Supportive Psychotherapy

worry—perhaps we can stay with this? (The therapist wants

to maintain focus and also to involve the patient in set­
ting the agenda.)
ANN: Yeah, OK. Since then, I’ve just kept my mouth shut, and I’ll
probably pass the final. But there’s something else that’s both­
ering me. I’ve been wondering whether it’s the medication. I
wonder if I’m holding back because I am afraid that more is
going to be expected of me, and I’ll begin to be resentful if I
can’t meet that expectation. Then I might drag my feet and
get depressed again. I just don’t want that.
THERAPIST: That’s a very complicated idea, and you’re quite insightful.
You expressed your concerns quite clearly (praise). But some­
thing you have to maybe be careful about is almost overintro­
specting when you’re depressed (education; tentative, to
avoid a challenging approach). It’s almost like having a pim­
ple that you keep picking at. It can serve to distract you from
other issues that are going on and kind of keep you down and
keep you feeling quite bad. What are your thoughts about this?
ANN: It sounds like you’re saying that I’m being too sensitive, and
I should just cheer up and snap out of it. (The therapist’s ed­
ucational effort was not successful.)
THERAPIST: No, I don’t think it’s that way—I think that’s superficial. I
didn’t mean to be sort of superficial like that. (The therapist
attempts to repair the rupture without going into rela­
tional aspects of the miscommunication.)
ANN: OK, so what do you mean? I should just be OK and live in the
present? I don’t understand. (Continuation of therapy is not
threatened, so transference issues are not discussed.)
THERAPIST: That to me sounds a little bit like a slogan. I don’t mean to
be giving you slogans or anything. The point I really want to
get across to you is that you feel very depressed, and you are
very aware of your thoughts—you’re introspective—which can
be good, because you have this awareness. But sometimes
there’s almost too much awareness (exhortation)—and
there’s awareness of negative consequences, and there’s kind
of a fixation on these negative consequences. There’s some­
thing called mindfulness (education). And it seems that you
are being mindful, in that you are considering your inner
world and your thoughts. However, with mindfulness, it’s im­
portant to kind of leave your thoughts as is—they belong to
you—and then sort of let go. And not be too concerned about
all the negative consequences and all the what-ifs. Just to sort
of step back and be aware of your thoughts without feeling
that you have to solve all your problems and act on all your
thoughts and worry so much (expert advice).
ANN: Oh, so sort of like, because they’re just going to come and go—
and I don’t need to be so entwined with them? OK, I under­
stand. And thanks for the explanation. I really didn’t mean to
be disrespectful before.
Techniques 83

THERAPIST: That’s OK. You know, I didn’t really take it as disrespect

(direct response). And if it’s OK, however, I’d like to sort of
switch gears right now and talk a little bit about what hap­
pened in your economics class. (By pointing out that she is
“switching gears,” the therapist avoids authoritarian
style of questioning.) I know that you had asked a question
in class—I was wondering about that (staying with specifics).
ANN: Yeah, so the question I asked was, “Wouldn’t it be more sensi­
ble to teach economics as a psychology course?” Then I would
actually get useful credits for my major. What do you think?
THERAPIST: I read in the newspaper that some important people in eco­
nomics are emphasizing the social and psychological aspects of
it (indicates source of information that is outside profes­
sional knowledge). But the question that I think is important
for us to address is what your intent was when you asked the
question in class. I wonder if on some level you weren’t being a
little provocative with your question? (defines the focus of
therapy, confrontation)
ANN: Well, I don’t think I was trying to be provocative. I thought it
was a good idea. Maybe if economics was in psychology, I
wouldn’t dislike it so much.
THERAPIST: Sometimes people don’t always like to be told that what
they’re doing is wrong (education about universals of be­
havior). And even though you did put it as a question, it
doesn’t mean that you weren’t really making a statement (in­
direct question about adaptive behavior).
ANN: Yeah, but this is college. Aren’t you supposed to be able to say
anything, to express yourself, to try new ideas in college?
THERAPIST: Yes, you’re right—it is college. But also you have to be real­
istic about this. It’s a community college. They’re hard-working
people who are there just like you, just to learn. They’re not
training graduate scholars. I’m not so sure it’s the best place to
bring up a deep debate like the one you had mentioned
(teaches about priorities, reinforces current program).
ANN: Yeah. I mean, maybe so. I guess it was just getting off topic, or
something.
THERAPIST: Can you buy that? (requests feedback)
ANN: Yeah, I do, I understand.
THERAPIST: OK. Well, I do want to stay with this a little longer (per­
sonalizes question). What was your professor’s response to
this, ah, question? (uses extra words to maintain conver­
sational [not interrogatory] style)
ANN: He said something like, “That’s a novel idea; I don’t think they’ll
do this.”
THERAPIST: It seems like you didn’t really like that. And I wonder what
you didn’t like about that answer?
A NN : It was obviously the word novel. You know—“novel”—it
sounded very sardonic and sarcastic to me. I don’t know.
84 Learning Supportive Psychotherapy

THERAPIST: I understand that, but I think it’s also important to be re­

alistic and try to understand where the teacher is coming from,
too. His priority is to get through the class and to make sure
that the material gets taught—not necessarily to engage in a
deeper, more philosophical debate. Does that sound OK? (ed­
ucation about the rules of life)
ANN: Yes, it makes sense.

Because Ann’s level of integration places her slightly to the right

of center on the psychopathology spectrum, the therapist was able
to employ some interventions that are characteristic of expressive­
supportive treatment, although the therapist’s overall stance con­
tinued to be supportive. The therapist addressed mental processes
and unconscious motivation, as well as content. The focus was on
Ann’s verbal coping or adaptive behavior. At times, the therapist
padded her statements with extra words to avoid sounding abrupt
or challenging.
A few weeks later, the therapist addresses Ann’s automatic self­
criticism and raises the possibility that role transition, which is one of
the main foci of interpersonal therapy, is a factor in her discomfort.
The therapist supports adaptive behavior, is empathic and optimis­
tic, and raises the possibility of anticipatory guidance when Ann
speaks of an upcoming date. The therapist supports defensive posi­
tions rather than exploring them.

ANN: Everything is OK, but there is something funny.My English lit

class instructor pulled me aside the other day and said, “You
know, you’re better than your grades. You’re always making
small mistakes—c’mon, get it together.” I understand she was
trying to be helpful, but I went home all sad and down and de­
pressed again, just beating myself up (automatic thoughts)
because I know that I screw up all the time (exaggeration).
Everyone has always told me, “Good job; I’m glad that you’ve
decided to go to college, and you didn’t just stay working
some job.” But I don’t know—I’m thinking I’m in over my head
and that maybe I’m just not going to be able to do it, and I’ll
find some way to ruin it again, especially if I slip back into my
depression (negative thoughts). Sometimes I wonder if my
mom hadn’t been so critical of me, maybe I wouldn’t have all
this insecurity.
THERAPIST: I’m sorry to hear that you had to go through with this, but
perhaps it’s not such a catastrophe (empathic and optimistic
response). We did talk a few weeks ago about how quick you
were to see the negative implications of your teacher’s re­
marks and to start feeling very bad about yourself and very
critical of yourself when you looked at his remarks in a certain
Techniques 85

light (follow-up on earlier topic). And it also seems like in

this situation, perhaps you did something similar. You sort of
exaggerated the significance of what she said, and you took it
very, very personally—and then you started criticizing yourself.
And I’m wondering if you were able to connect the insight
about yourself when you began this round of worry? (estab­
lishing that there is one theme and not a multitude of
problems)
ANN: No. I just thought that she was telling me that I make mistakes
and that I’m over my head, that it’s too much for me.
THERAPIST: (Because the patient doesn’t see the connection, the
therapist decides to move on.)Well, I have a question that
may seem a little bit off topic from what we have been discuss­
ing. What would you say is the biggest difference between
your current life and the way you lived for the past few years?
(gently introduces a new topic—role transition)
ANN: When I was working, I was always doing things. Whatever I did,
I knew immediately what to do—whether it was the right
thing or the wrong thing. I got paid, and I knew what I was
getting paid for. Now that I’m in school, I have no idea. I take a
test, I turn in my exam—I get the grade a week later. Every­
thing is so indefinite. It’s not very comfortable. They told me
not to overdo it and that I should go along with the plan. And
I’ve been doing that, but if I want something more now, then
I feel that I just can’t go asking to bring it back. I don’t want to
look like I’m complaining. I know that school is a good idea. It’s
been what I’ve wanted to do all these years when I was unable
to do it before, and I had to drop out. It’s been my one goal to
get back, and now I’m back. But sometimes I just really think
that I can’t make it. I don’t know. I just think, all this time has
gone by, and I could have been earning my way since that time
that I dropped out.
THERAPIST: I think you put it very well (praise for being articulate).
And I think a lot of people would find it very difficult adjusting
to a new schedule (normalizing, education). A transition is a
hard thing for a lot of people. You were working, and then you
go back to school. And that’s a big transition (offering partial
explanation for patient’s difficulties). Now, a lot of change
has happened, and you discussed a lot of changes. But it’s im­
portant to remember that sometimes it can take months to re­
ally adjust (education). And just because you’re having some
difficulties initially with the adjustment doesn’t mean it’s always
going to be that way. It’s also to be expected (reassurance).
ANN: OK, so what do I do about it?
THERAPIST: Something you can do is that you can remind yourself
when you get discouraged that you’re doing something that’s
very hard for a lot of people to do—you’re changing your life
(advice). And that doesn’t mean that college is too hard for
you or that you’re not up to it—or that perhaps you made the
86 Learning Supportive Psychotherapy

wrong choice. But it’s hard and it’s normal for it to be hard (ex­
hortation). And as far as not making stupid mistakes, do you
have any ideas about what you can do—now that you recog­
nize the problem? (reinforces progress; avoids trap of pro­
posing solution to a competent person)
ANN: I guess I can just try harder.
THERAPIST: Do you think there is anyone you can turn to for help? (a
question intended as advice to help patient find a solu­
tion)
ANN: I know that in the guidance office, I had seen some material be­
fore about how to study more effectively and stuff. It’s funny,
because when I first saw it, I thought, “How stupid is this?” But
maybe I’ll just go back and take a look at that again. I think it
probably would be helpful.
THERAPIST: So if you look into it, it may be quite useful; it may actually
not be a waste of time (cautiously reinforcing the plan).
ANN: Yeah. You know, remember the guy that I told you about be­
fore? Well, he called.
THERAPIST: The one who you met at lunch? (demonstrates that she
remembers the story)
ANN: Yeah, yeah. His name is Michael, and we’re actually going to
get together this Friday.
THERAPIST: So, what do you think? (open-ended facilitator)
ANN: I don’t know; I’d like to meet someone nice, and I hope he is. I
guess I’ll have to tell him that I’m depressed and I take medi­
cations. But I probably don’t have to tell him that right away.
Right?
THERAPIST: That’s a good point. Honesty is important; however, the
fact that you have been depressed doesn’t define you. It’s not
something you should feel you have to tell him on day one
(specific advice).
ANN: Yeah, but if it’s going to be something that turns him off and
makes him not like me, I’d rather know at the beginning than
before I get too involved with him. Then I’ll just be more de­
pressed afterward.
THERAPIST: That makes sense. As you said, you don’t have to tell him
right away (supports adaptive approach). Do you have a
plan for this date? (open-ended question)
ANN: Do you mean are we going to bed together? I don’t know yet.
THERAPIST: Well, I was being more general. I was more referring to
any issues you may have about this meeting that you think per­
haps we should talk about? (exploring possibility that an­
ticipatory guidance might be helpful)
ANN: No.
THERAPIST: Well, during all our meetings, we’ve talked quite a bit about
a lot of things; we’ve talked about depression, school life, your
mother, your past. But there’s really been nothing about the
men in your life and the past relationships you’ve had with men.
And I know that one of the things you had told me in the be­
Techniques 87

ginning is that your depression started at the end of a relation­

ship and that it was quite a nasty breakup (concerned that
patient’s offhand approach might reflect denial).
ANN: Yeah, it was. No, no—there haven’t been any more relation­
ships. Most of the guys in my school are complete idiots. That
being said, I do think I’m ready to move on, and this is only a
date. And I’ll see how it goes.
THERAPIST: Well, that seems reasonable. Moving on is a good way to
put it (responsive praise).
ANN: I know I haven’t spoken about it, but I am worried about my ex.
He has a new girlfriend, and I know that she was in a car acci­
dent. And knowing him, he’s probably all involved fixing the
car, taking care of her. He doesn’t have any money, and I know
he can’t afford this. He just gets way too involved all the time.
THERAPIST: Well, help me understand this a little bit. He dumped you,
right—and now you are worrying about him. How do you ac­
count for that? (considers exploring what may be the de­
fense of reaction formation)
ANN: Yeah, that’s true. I know it doesn’t make sense. I was very upset
at the time obviously, when he dumped me, but I try not to be
mad at people for too long. He hasn’t done anything recently to
make me mad. I don’t know. I just try not to be mad at people.
THERAPIST: So you’re a generous person (compliment). Does your
worrying about him affect your ability to do what you want to
do? Most people, when someone dumps them, feel quite an­
gry and quite hurt. They may even take pleasure in that per­
son’s misfortunes. Do you think it’s possible that your concern
for him is kind of a mask for your continuing anger about the
ending of the relationship? It’s funny—that’s the way the mind
works sometimes. It doesn’t have to be that way, and it may
not be that way, but it is something to think about. (Use of ex­
cess verbiage is padding to avoid seeming challenging
or causing anxiety.)

In this video segment, the therapist was able to praise Ann for her
insightful self-descriptions. She instructed Ann about a frequent
source of distress that is an area of major concern in interpersonal
therapy. The therapist did not elaborate but plans to return to the
topic. She did not offer concrete advice about how Ann might try
harder but rather supported the idea that Ann could develop a solu­
tion on her own. If Ann had said she wanted to talk about the up­
coming date with a new man, the therapist would have attempted
to present several common scenarios to consider how Ann might re­
spond and to explore her fears or likely automatic critical thoughts.
Because Ann did not want to talk about the date, the therapist ac­
cepted her choice. The therapist suspected that Ann’s concern for
the well-being of her ex-boyfriend might be reaction formation to
88 Learning Supportive Psychotherapy

mask underlying anger. Had the therapist attempted to go further

in this direction, the therapy would be categorized as expressive­
supportive; because the therapist did not pursue unconscious feel­
ing, the therapy continued to be supportive-expressive.
General Framework
of Supportive
5
Psychotherapy

Indications and Contraindications

For years, supportive psychotherapy was described as the treatment for indi­
viduals considered unsuitable for expressive therapies—persons who were
difficult to treat or for whom expressive techniques were expected to fail
(Rosenthal et al. 1999; Winston et al. 1986). From this perspective, sup­
portive psychotherapy was said to be indicated for people with 1) a predom­
inance of primitive defenses (e.g., projection and denial); 2) an absence of
capacity for mutuality and reciprocity, exemplifying an impairment in object
relations; 3) an inability to introspect; 4) an inability to recognize others as
separate from oneself; 5) inadequate affect regulation, especially in the form
of aggression; 6) somatoform problems; and 7) overwhelming anxiety related
to issues of separation or individuation (Buckley 1986; Werman 1984).
The findings of the Menninger psychotherapy study, however, indicated
that patients treated with supportive psychotherapy made greater than ex­
pected gains (compared with patients who received psychoanalytic treat­
ments) and may have achieved lasting character change (Wallerstein 1989).
In addition, data support the premise that higher-functioning patients for
whom expressive treatments have traditionally been indicated respond just
as well to supportive treatment. The target complaints and psychiatric
symptoms of higher-functioning patients diminish (Hellerstein et al. 1998),

89
90 Learning Supportive Psychotherapy

and, because of supportive psychotherapy interactions, patients develop a

more differentiated and adaptive self. These changes can be measured as
lasting reductions in intensity of patient-rated interpersonal problems after
termination of treatment (Rosenthal et al.1999).
Studies of individuals with depression suggest that supportive psycho­
therapy is valuable in the context of moderate depression (Driessen et al.
2016), but studies do not consistently demonstrate superiority of support­
ive psychotherapy over cognitive-behavioral or psychopharmacological
treatment (Arnow et al. 2013). That said, a recent study of individuals
with depression revealed a strong preference for supportive psychotherapy
over cognitive-behavioral therapy and psychodynamic psychotherapy
(Yrondi et al. 2015). Taken together, these studies suggest that supportive
psychotherapy may play an important role for some, but not all, individ­
uals with depression. Similarly, studies of individuals with schizophrenia
and other psychotic disorders indicate that supportive psychotherapy
cannot substitute for traditional psychopharmacological treatment but is
a valuable adjuvant treatment strategy for strengthening overall psycho­
social functioning (Harder et al. 2014; Lysaker et al. 2015). Studies sug­
gest that supportive psychotherapy can also play a positive role in the
treatment of individuals with personality disorders, such as borderline
personality disorder (Jørgensen et al. 2013; Vinnars et al. 2005).
Supportive psychotherapy may have an especially important role in the
treatment of co-occurring conditions. An interesting study suggested that
cognitive-behavioral therapy and supportive therapy had value in the care
of individuals with depression following traumatic brain injury (Ashman et
al. 2014). A rigorous meta-analysis found that supportive psychotherapy,
as with other psychotherapies, reduced symptoms of depression and im­
proved coping in individuals with advanced cancer (Okuyama et al. 2017).
Findings suggest that supportive psychotherapy not only is applicable
to patients for whom traditional expressive treatments are not indicated
but can also be used successfully with patients with a wide spectrum of
problems and with higher-functioning patients. Indeed, the most widely
used form of psychotherapy is supportive psychotherapy with some ex­
pressive elements. Luborsky (1984) and others have developed various
forms of supportive-expressive psychotherapy that have produced posi­
tive results in clinical trials. Supportive psychotherapy may be the best
initial approach when psychotherapeutic intervention is being considered
(Hellerstein et al. 1994). The therapist should move away from support­
ive psychotherapy only when there is a positive indication for another
specific treatment. There are several indications for which supportive
psychotherapy has the best contextual fit and specific efficacy (see also
Chapter 8, “Applicability to Special Populations”).
General Framework of Supportive Psychotherapy 91

Indications
Indications for supportive psychotherapy described in the older literature
are essentially a statement of contraindications for expressive treatment.
These indications for supportive psychotherapy conceptually fall into two
groups, which are not really discrete: 1) crisis, which includes acute illnesses
that emerge when the patient’s defenses are overwhelmed in the context of
intense physical or psychological stress, and 2) chronic illness with concom­
itant impairment of adaptive skills and psychological functions.

Crisis
Crisis is an indication for supportive psychotherapy among relatively
well-functioning and well-adapted individuals who have become symp­
tomatic in the context of acute, overwhelming, or unusual stress. Under
other circumstances, persons in this group might be referred for expres­
sive treatment because these individuals have good reality testing, a ca­
pacity to tolerate and contain affects and impulses, good object relations,
an ability to form a working alliance, and some capacity for introspection.
For this group, supportive psychotherapy is usually delivered in an
acute-care or episodes-of-care model. For example, a high-functioning
patient developed a marked depressive reaction to the change in her body
image after a mastectomy. This reaction was accompanied by a loss of
self-esteem, a negative attitude toward her work, and problems with so­
cial relationships. The patient benefited from an empathic therapist’s psy­
chological support, which helped her to begin to grieve the loss of her
breast, her feeling of bodily integrity, and her health. As she worked
through her loss, she began to revise her expectations and plans and grad­
ually returned to the usual routines of her everyday life.
The following subsections detail some of the diagnostic and situational
indications that fall into the category of crisis.
Acute crisis. Acute crisis is not a diagnosis but rather a general descrip­
tion for patients whose customary coping skills and defensive structures
have been overwhelmed by an (often unexpected) event, resulting in in­
tense anxiety and other symptoms (Dewald 1994). Crisis is the state that
individuals experience when they are faced with actual, impending, or
possible loss, such as a life-threatening illness, loss of liberty for a criminal
offense, loss of personal or public safety (e.g., after the terrorist attacks of
September 11, 2001; after devastating hurricanes and flooding), or loss of
a loved one. (For a more complete discussion, see Chapter 7, “Crisis In­
tervention.”) Supportive techniques may even be implemented in the
middle of expressive therapies when there is a crisis for which support is
clinically indicated.
92 Learning Supportive Psychotherapy

Adjustment disorders in relatively well-compensated people. People

in crisis may meet criteria for an adjustment disorder. Adjustment disor­
ders are time limited, lasting no more than 6 months (American Psychi­
atric Association 2013a). Supportive psychotherapy can help a patient to
manage uncomfortable feeling states and improve or develop coping
strategies during the episode. The focus of treatment is 1) to reassure the
patient that symptoms are time limited, 2) to reduce stress by clarifying
and providing information about what the patient is having difficulty ad­
justing to, and 3) to support novel coping and problem-solving methods,
including environmental change (Misch 2000). At its best, supportive
psychotherapy facilitates a more rapid diminution in symptoms and res­
olution of the episode of illness. In addition, the treatment may help pre­
vent the condition from becoming chronic.

Medical illness. For a large number of medical conditions, supportive psy­

chotherapy is the only treatment recommended. An understanding of the in­
dividual’s innate defensive, cognitive, and interpersonal styles (i.e., core char­
acter and personality) enables the therapist to assist the patient in developing
better coping strategies (Bronheim et al. 1998). Supportive or supportive­
expressive psychotherapy has been recommended for or has shown utility in
the following areas: reducing pain intensity and interference with normal
work, sleep, and enjoyment of life in patients with HIV-related neuropathic
pain (Evans et al. 2003); reducing the frequency and impact of stressful
events in patients with primary (Hunter et al. 1996) or metastatic (Classen
et al. 2001) breast cancer; and treating HIV-positive patients with depres­
sion (Markowitz et al. 1995), patients with pancreatic cancer (Alter 1996),
cancer patients with depression (Massie and Holland 1990; Okuyama et al.
2017) or chronic pain (Thomas and Weiss 2000), and hospitalized patients
with somatization disorder (Quality Assurance Project 1985).

Substance use disorders. Early in the treatment of substance depen­

dence, the therapist focuses on development of a therapeutic alliance,
both to assist treatment retention and to create a context within which
the patient can begin cognitive and motivational work to assist recovery
efforts (O’Malley et al. 1992). Kaufman and Reoux (1988) suggested that
for patients with substance dependence, expressive therapies (when ap­
propriate) should not commence until the patient has implemented a
concrete method of maintaining sobriety because expressive therapies
provoke anxiety that may trigger relapse. A broader discussion of sub­
stance use disorders is found in Chapter 8.
Acute bereavement. Acute bereavement is profoundly difficult and can
overwhelm the coping skills and defensive operations of patients with
General Framework of Supportive Psychotherapy 93

poor ego strength. These patients generally experience such symptoms as

self-reproach, social withdrawal, and an inability to maintain job or inter­
personal functioning and anxiety and depressive symptoms such as insom­
nia and anorexia (Horowitz et al. 1984). Supportive psychotherapy
provides the patient with an empathic holding environment in which he or
she can talk and vent about pain and hostility, have his or her self-esteem
directly supported through reassurance and appropriate praise, gain di­
rection for activities of daily living, and reality-test his or her role in the
life and death of the deceased. This process supports the use of healthy
defensive operations, concrete assistance for routine activities the patient
is not able to perform, and appropriate reaching out as a measure against
the tendency to remain socially withdrawn (Novalis et al. 1993).
Alexithymia. Patients who are typically characterized as alexithymic
demonstrate characteristics that make expressive therapy difficult, if not
impossible. These characteristics include severe restriction of affect, a
seeming lack of capacity for introspection, an inability to articulate feel­
ing states, and a diminished or absent fantasy life (Sifneos 1973, 1975).
When these patients become symptomatic because of stressors such as
acute medical illness, they may become somatically preoccupied and
have greater difficulty with coping but remain unable to communicate
the effect of the stress on their affective experience. Supportive psycho­
therapy can specifically address alexithymia by working directly on so­
matic experiences and personal metaphors and helping the patient to
recognize, acknowledge, identify, and label emotions, increasing his or
her sense of mastery and self-esteem (Misch 2000).

Chronic Illness
Compared with individuals in crisis, patients with chronic mental illness are
traditionally treated with supportive psychotherapy and are more likely to
receive longer-term therapy (Drake and Sederer 1986; Kates and Rockland
1994; Werman 1984). Patients with chronic mental illness typically have
lower self-esteem related to deficits in adaptive skills and ego functioning. Pa­
tients with chronic mental illness include not only those with primary mental
disorders with a chronic or intermittent course (formerly Axis I disorders)
but also those who have moderate to severe personality disorders and whose
idiosyncratic interpersonal styles, adaptive skills, and ego deficits are chronic,
pervasive, and maladaptive (Sampson and Weiss 1986). The majority of
psychotherapy patients in outpatient psychiatric clinics have probably been
treated with dynamically informed supportive psychotherapy.
Some chronic conditions not usually associated with severe mental ill­
ness can be damaging to adaptive and psychological functioning and may
94 Learning Supportive Psychotherapy

be helped by supportive psychotherapy. These conditions include later

stages of severe medical illness from which the patient is not expected to
recover. Supportive psychotherapy has been shown to assist in reducing
suffering and in maintaining self-esteem, adaptive skills, and ego func­
tioning for as long as practicable in patients with chronic illness (e.g., can­
cer; Thomas and Weiss 2000).

Contraindications
Because supportive psychotherapy is based on the factors common to all
psychotherapies, it is contraindicated in relatively few circumstances
(Frank 1975; Pinsker et al. 1996). Hellerstein et al. (1994) argued that
supportive psychotherapy is the appropriate default approach to psycho­
therapy and that supportive psychotherapy can be applied over a wide
range of psychopathology and situations.
Supportive psychotherapy is contraindicated when psychotherapy it­
self is contraindicated. This list of contraindications is short. Novalis et al.
(1993) suggested that supportive psychotherapy is unlikely to be effec­
tive in delirium states, other organic mental disorders, drug intoxication,
and later stages of dementia; these are conditions in which any psycho­
therapy would be expected to fail. Individuals who seek help and yet
chronically reject all help that is offered (help-rejecting) do not make good
use of supportive interventions. These individuals may become worse as
they repeatedly confirm that the therapist’s good will and concrete ad­
vice are not useful. Individuals who lie or malinger as a matter of course
do as poorly in this treatment as in other treatments. Psychopathic indi­
viduals who establish a pattern of pseudomutuality in the therapeutic re­
lationship either quickly understand the lack of opportunity for real
gratification and drop out of treatment or become focused on attempting
to use the relationship to inappropriately gratify real or imagined needs.
In the latter case, in order to elicit the therapist’s good will and expected
personal gain, the patient may come across as increasingly needy or may
become coercive.
There are few contraindications for supportive psychotherapy. A more
formal cognitive-behavioral treatment appears to be more effective than
supportive psychotherapy for a number of conditions, including Tourette’s
disorder (Wilhelm et al. 2003); acute adolescent depression (Brent et al.
1997), although cognitive-behavioral therapy does not have a better ef­
fect on the long-term outcome of adolescent depression (Birmaher et al.
2000); major depression (Arnow et al. 2013); panic disorder (Beck et al.
1992); obsessive-compulsive disorder (Foa and Franklin 2002); and buli­
mia nervosa (le Grange et al. 2007; Walsh et al. 1997). The integration of
General Framework of Supportive Psychotherapy 95

supportive psychotherapy and cognitive-behavioral therapy is discussed

at length by Winston and Winston (2002).

Initiation of Treatment
The therapist essentially conducts supportive psychotherapy in the first ses­
sion with a patient, during which the therapist determines whether or not
supportive psychotherapy is the treatment of choice (see Chapter 3, “As­
sessment, Case Formulation, and Goal Setting”). Supportive psychotherapy
is conversational in style and serves as the context for all patient-therapist in­
teractions. History taking, payment negotiations, interchanges on the rules
and conduct of therapy, goal setting, and length-of-treatment discussions
are conducted within a supportive framework in the first session.
The ground rules of supportive psychotherapy should be made ex­
plicit. The therapist should obtain the patient’s agreement about the
ground rules. The therapist may need to temper the message depending
on certain characteristics of the patient, including educational level, ego
strength, reality testing, and the context of treatment. The overall idea in
creating an unambiguous format for the rules of engagement in support­
ive psychotherapy is to reduce anxiety by setting clear limits. For exam­
ple, two clear-cut rules are that 1) no physical aggression and no verbal
abuse can be used during sessions and 2) patients should not come for
treatment in an intoxicated state.

Office Arrangement
Seating
Seating for supportive psychotherapy is best arranged in a manner that is
welcoming, friendly, comfortable, and professional, just like the treat­
ment itself. The therapist should provide adequate lighting that is not
harsh and comfortable chairs that are neither too close nor too far apart so
that participants can sit upright and see and hear each other easily. Under
these arrangements, the therapist can pick up nuances of verbal tone, fa­
cial expression, and body language, which are important because sup­
portive psychotherapy relies on a dynamic understanding of the patient.
The therapist is sensitive to unconscious communication, even if the ther­
apist does not make that awareness explicit to the patient in the form of
confrontation or interpretation.
Physical distance can be varied in response to clinical need. For exam­
ple, respecting the patient’s need for distance, the therapist may sit a little
farther away from a patient who expresses paranoid ideation. The thera­
pist should not be too far away or the patient’s anxiety may increase be­
96 Learning Supportive Psychotherapy

cause talking face to face with someone for an extended length of time
from some distance (e.g., 10 feet) is socially unusual. Sometimes patient
and therapist need to be closer than usual, for example, when the thera­
pist is conducting supportive psychotherapy sitting next to a patient who
is confined to a hospital bed.

Amenities
In the past, the literature about supportive psychotherapy framed the
therapy as a treatment for the most impaired individuals. It was suggested
that—in contrast to the abstaining, nongratifying position of the therapist
in some expressive treatments—the supportive psychotherapist provide
small comforts to the patient in his or her office in the form of a box of tis­
sues on the table or a small plate of cookies or other treats by the door. All
psychotherapy should be provided in a humane and respectful fashion in
a reasonable setting, and we suggest that this aim can generally be
achieved without feeding the patient to enhance his or her positive image
of the therapist. Providing food for a patient is concretely accommodat­
ing, and although it provides a supportive relationship, it is typically re­
served only for the patients with the greatest challenges in functioning.
The therapist’s provision of practical items (e.g., bus tickets) and snacks
for the most impaired patients may help to sustain the therapeutic alli­
ance. Gifts from the therapist to the patient are not expressly prohibited
if a gift is related to the therapy, such as an informational manual, or if an
institutional practice has been developed to supply items of need to the
neediest patients (Novalis et al. 1993; Roberts 2016). In certain cultural
contexts, provision of food and gracious acceptance of small gifts are en­
tirely appropriate (Roberts 2016) and always should be acknowledged
and explored in therapeutic interactions.

Initiation and Termination of Sessions

The therapist is expected to begin and end sessions on time. This tempo­
ral framing is respectful to both the patient and the psychotherapist. In
supportive psychotherapy, the therapist does not focus on occasional
lateness; however, when a patient demonstrates a pattern of lateness, the
pattern can be explored within the supportive framework. In expressive
treatment, the therapist labels the pattern of lateness and adheres to the
assumption that lateness is due to resistance or other unconscious pro­
cesses. The therapist encourages the patient’s verbalization, with the ob­
jective of exploring the resistance and enabling the patient to express his
or her wish or feeling, which is generally related to the therapist or ther­
apy. In supportive psychotherapy, the therapist is free to discuss matters
General Framework of Supportive Psychotherapy 97

of lateness from a practical point of view. Keeping appointments is an

adaptive behavior; arriving late to a meeting that is genuinely in the pa­
tient’s best interests is not. The therapist can attend to such lateness using
a collaborative, problem-solving approach. A pattern of missing sessions
can be addressed in the same way.
The following dialogue illustrates a supportive psychotherapy ap­
proach to lateness.

PATIENT: Sorry, I’m late again. I just don’t know—I was sure I gave myself
enough time [angry]. No matter how I try, I’m always late to every­
thing! I do everything wrong! I should just go home! (overinclusive
negativism, nihilism, defeatism)
THERAPIST: I know it can feel that way because it’s frustrating to have a
habit that gets in the way, but even the hardest habits can be broken
[engaging smile]. Are you sure you do everything wrong? If that were
the case, you wouldn’t have made it here at all today, and you might
have forgotten your socks! (slogans, humor; challenges the negative
self-statements)
PATIENT: OK, OK, maybe not everything [begrudging smile]. I just hate it
when I’m late! It feels like someone’s got a fix against me, no matter
how hard I try (esteem-lowering experience of powerlessness, pro­
jection).
THERAPIST: That can’t make you feel good about yourself. Perhaps we can
look at how you decide what time to leave? Sometimes people leave
themselves some extra wiggle room in case of any unforeseen events
so that they have enough time to get to an appointment. That would
increase your sense of control over things and help you feel better.
Want to give it a shot? (empathy and anticipatory guidance)
PATIENT: Sure.

Similarly, a patient may establish a pattern of continuing beyond when

the session was scheduled to end, which might have different uncon­
scious motivations, all amenable to discussion in the context of support­
ing ego function and adaptive skills. With some patients and in certain
cases, the therapist might determine that extending a session is therapeu­
tically appropriate. For example, when a patient is unavoidably detained
by traffic but is in a crisis, the therapist might choose to give the patient
extra time if the schedule allows or might briefly connect and reschedule
the patient’s next appointment if an earlier date is available. Similarly, the
therapist is clinically compelled to take a few extra minutes to address
“doorknob issues” (Pinsker 1997)—issues brought up as the patient is ex­
iting the session—if they are clinically provocative and raise the thera­
pist’s acute concern. Concerns about not gratifying the patient’s infantile
wishes should be entertained but should take second place to reasonable­
ness, which the therapist should always be modeling.
98 Learning Supportive Psychotherapy

The therapist might decide not to extend a session because doing so

would support maladaptive, regressive behavior without reasonable clinical
or environmental justification. Choosing not to extend a session also mod­
els behavior for the patient. The therapist must balance limit setting with
promotion of autonomy and independence (Misch 2000) (see Chapter 2,
“Principles and Mode of Action”). Sometimes, the therapist must get up,
open the door, and firmly show the patient out. If the patient continually
resists the therapist’s efforts to stop on time, the therapist can choose to cue
the patient at intervals about how much time is remaining in the session,
thus offering anticipatory guidance. The experienced therapist uses these
strategies to wind down a session before time is up so that patients are not
in the middle of a hot topic at the session’s end (Pinsker 1997).

Timing and Intensity of Treatment Sessions

The timing and intensity of treatment sessions should be set through an
agreement between patient and therapist, with the proviso that timing
and intensity may change on the basis of clinical need, such as when a cri­
sis arises. In expressive treatments, the ideal is to have a constant interval
between sessions, which are held at the same time and on the same day of
the week, creating a stable frame. Although the frequency of visits is less
fixed in supportive psychotherapy, setting a specific, repeated time to
meet tends to reduce anxiety. Similarly, the length of a session should
generally be fixed but may be subject to variation when clinically appro­
priate and based on when the therapist can accommodate the patient.
Fixed frequency and length bring stability to the framework of the ther­
apeutic interactions.

Phases of Treatment
Beginning
In the beginning of therapy, the therapist pays a great deal of attention to
supporting the formation of a therapeutic alliance because the therapeu­
tic alliance increases the likelihood that the patient will remain in treat­
ment 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 patient’s target complaints and
presenting symptoms and acquire a working knowledge of the patient’s
general level of ego function and object relatedness, 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 should be
directly addressed through supportive interventions (see Chapter 3). As
General Framework of Supportive Psychotherapy 99

the therapist gets to know the patient better, the therapist fine-tunes his
or her understanding of the patient’s ego functioning and adjusts the in­
tensity of supportive and expressive interventions accordingly. The ther­
apist may require an extended amount of time to develop a clear
understanding of the issues of patients who are cognitively impaired be­
cause of psychosis, severe obsessive thinking, or mood disorder or of pa­
tients who become flooded with anxiety or dysphoria when focusing on
certain details during therapy. Once the therapist and patient agree on
the goals and objectives of therapy (see Chapter 3), the therapist must
consider issues of acuity and timing. For example, after a recent psychi­
atric hospitalization for psychosis, a patient arrives in therapy wanting to
talk about whether he should return to college in the fall. The therapist’s
clinical understanding is that the patient must secure a stable and struc­
tured environment in which to live so that he can plan his near-term fu­
ture appropriately. Without that stability, the patient runs the risk of
increased stress, disorganization, and decompensation. However, the pa­
tient has brought up neither the imminent loss of his housing nor his
plans to deal with that loss. The therapist understands, before the patient
does, the need to address issues in a different order.
Allowing the patient to “see the map” before exploring the territory is
an important supportive approach that reduces anxiety and emphasizes
that therapy is a rational and collaborative process (Rosenthal 2002). The
therapist can explain how the topic about to be discussed is specifically
connected to self-esteem, to a specified ego function, or to a specified
adaptive skill for dealing with psychiatric symptoms or general social in­
teraction. Such explanation is also consistent with motivational inter­
viewing approaches, in that the therapist asks the patient’s permission
before giving direct advice or prescribing solutions to problems (Rollnick
and Miller 1995). The therapist must accept that at times, however, the
patient will reject the proposed agenda.

Middle
The therapeutic alliance usually functions as a foundation for treatment in
supportive psychotherapy rather than as the vehicle for change (Hellerstein
et al. 1998). The therapist continues to monitor the alliance with the pa­
tient during the course of treatment and attempts to optimize the alliance
by continuing to use the same attention as in the initial phase of treatment.
This therapeutic attunement to the patient contributes to the patient’s ex­
perience 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.
100 Learning Supportive Psychotherapy

Positive transference and regard for the therapist are allowed to accumulate
unless they become grossly pathological.
In supportive treatment, the middle stage can and often does go on indef­
initely, especially with patients for whom support helps to maintain adaptive
skills or ego functions. During the course of treatment, new intermediate
goals may arise for the patient in the context of life events or increases in
adaptive function. An increase in a patient’s adaptive function presents an
opportunity for the therapist to review goals and to offer praise for meeting
goals, as well as an opportunity to offer the patient reassurance and other sup­
port for self-esteem regarding goals that have not been accomplished.
In supportive psychotherapy, the therapist can use well-structured psy­
choeducational and skills-building interventions and can encourage the pa­
tient to pursue his or her interests and initiatives. The therapist can present
expert knowledge about the patient’s disorder and its effect on functioning
in order to increase awareness so that the patient’s decisions are better in­
formed. The supportive psychotherapist uses these kinds of educational in­
terventions early and frequently when working with patients living with
addiction, which may increase patients’ motivation for behavioral change.
If the patient arrives with a pressing agenda in relation to an acute interper­
sonal conflict or an inner need, the supportive therapist can shift the bal­
ance from therapist-directed to patient-directed processes, keeping both
the patient’s goals and the therapist’s objectives in mind.

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. If the therapist believes that the patient’s de­
cision to stop is a product of ego-function disturbance (e.g., grandiosity),
symptoms (e.g., hopelessness), or faulty adaptive skills (e.g., inability to
manage regular visits), the therapist attempts, without arguing, to explore
the problem. Even when the therapist has a psychodynamic hypothesis
about the patient’s motivation, the therapist must balance this hypothesis
against the principle that the patient is free to stop when he or she wishes.
Therapy may also terminate because of external factors, such as relocation
or another life event that forces an end to the current scope of work.
At the end of formal treatment, gains are summarized and an agenda is
articulated for the patient’s continued work without regular visits to the
therapist. An important part of concluding treatment is for the patient to
reflect on and celebrate important milestones that he or she has achieved
(Rosenthal 2002).
Supportive psychotherapy differs from expressive treatment with re­
gard to termination. In supportive psychotherapy, the patient and therapist
General Framework of Supportive Psychotherapy 101

do not work through their relationship and the patient is not asked to
mourn the loss of an important object or work through ambivalent feelings
(Rosenthal 2002). Because constant, positively held objects are frequently
too few in the lives of many patients in supportive psychotherapy, the ther­
apist does not encourage the patient to let go of the relationship, which is
based on the real relationship and not on transference.
The analogy of school is useful for supportive psychotherapy. The
teacher works in the school even when the student is not enrolled in
classes; likewise, the therapist continues to work even when a particular
patient has moved on from treatment. The patient’s treatment can be
framed as an organized set of courses, each with a beginning, middle, and
end. When the patient’s goals are achieved, the course of treatment is
concluded. Just as the student who has a worthwhile experience may re­
turn for more courses (Pinsker and Rosenthal 1988), the patient is always
told that he or she can return if the need arises.

Long-Term Versus Brief Psychotherapy

For patients with chronic mental disorders for whom supportive psycho­
therapy is primarily aimed at maintaining adaptive and ego functioning
toward overall health and well-being, treatment is likely to be framed as
an ongoing relationship without a time limit unless constrained by exter­
nal factors, such as the patient’s financial resources, insurance coverage,
or continued-stay criteria in a mental health clinic. Treatment does not
need to go on interminably if the goals of therapy have been met.
Brief therapy is typically indicated when the psychopathology is expected
to be time limited, such as when the patient has an adjustment disorder or a
terminal illness, or when an acute loss or crisis overwhelms a patient’s de­
fenses and he or she becomes symptomatic. In supportive psychotherapy,
the model of treatment does not focus on character change through emo­
tional insight, so treatment is complete not when core conflicts have been re­
solved but rather when symptoms have been reduced to comfortable levels
or when more competent coping strategies have been developed. A patient
may return for more treatment when in a crisis or in order to strengthen fail­
ing defensive operations or in order to work on something new.

Professional Boundaries
The therapist guides the dialogue with the patient’s therapeutic needs in
mind. The therapist never takes a turn to discuss his or her own needs.
The dialogue is conversational to reduce awkward, anxiety-provoking si­
lences. The therapist’s empathic relatedness allows him or her to know
when silence will make the patient withdraw and feel overwhelmed and
102 Learning Supportive Psychotherapy

when his or her quietness will allow the patient to manifest an important
affective response, as shown in the following examples.

PATIENT 1 [after a long pause, a tentative smile]: Boy, it’s been raining non­
stop for so long.
THERAPIST 1: Sure has! Isn’t it interesting? Folks often chat about the
weather when they’re not sure what else they have in common to
talk about. It’s kind of neat—there’s always going to be weather.
I wonder if you’d like to talk about how all that rain has affected
you, but we can also discuss strategies to talk with people; you told
me that’s been a problem (normalizing, generalizing, collaborat­
ing, anticipatory guidance).

PATIENT 2 [after a long pause, tears well up]: I can’t believe she’s really gone.
THERAPIST 2: [silent] (attentive, quiet; empathic concern)

In expressive treatment, to prevent gratification of the patient’s wishes

and to promote elaboration of transference material, the therapist typically
avoids self-disclosure of any sort. In supportive psychotherapy, the thera­
pist may judiciously disclose personal information to the patient in a pur­
poseful and supportive manner. The paradigmatic model of therapeutic
self-disclosure is found in Alcoholics Anonymous and other self-help
groups, in which a speaker’s lived experience becomes an object lesson for lis­
teners seeking support for their recovery efforts. Many reports on individual
behavioral, cognitive, and cognitive-behavioral therapies suggest that delib­
erate self-disclosure can be clinically useful (Psychopathology Committee
of the Group for the Advancement of Psychiatry 2001). Simon (1988)
observed that therapists’ decisions about deliberate self-disclosure are
generally related to several criteria: modeling and educating, promoting
the therapeutic alliance, validating reality, and fostering the patient’s
sense of autonomy. As a rule, self-disclosure by the therapist is appropri­
ate when it is in the interest of the patient’s treatment. If self-disclosure is
in the therapist’s interest (e.g., when it takes the form of venting, brag­
ging, complaining, or seductiveness), it is exploitation. Information that is
a matter of public record is typically the easiest to reveal in the context of
supportive treatment. More private information or personal experience
requires more deliberation (Roberts 2016).
In supportive psychotherapy, the therapist looks for ways to add facilitat­
ing comments or interjections that normalize the interaction and to respond
to inquiries in a manner that is both appropriate and technically supportive.

PATIENT [after a long pause]: I was thinking, are you married?

THERAPIST 1 [if the therapist chooses to answer]: What are your thoughts
about this? (traditional expressive psychotherapy–style response)
General Framework of Supportive Psychotherapy 103

THERAPIST 2: Yes, I am. I noticed you seemed to think a while before you
asked me. Was it a little uncomfortable to think of asking me that?
(empathic concern)
PATIENT [short pause, blushing]: Yes, I thought it might be weird to ask.
THERAPIST 2: One of the rules here is that you get to speak your mind. It’s
good you were able to ask me, even though it made you uncomfort­
able. People who are able to master their fears tend to get more ac­
complished (praise with modeling of adaptive behavior).

At times, a patient will ask a question that is that is obviously inappro­

priate or extremely personal in nature in order to annoy or provoke anx­
iety in the therapist.

PATIENT: I know you’re married, but do you still masturbate?

THERAPIST: My sexual habits are personal, but we should talk about sex­
ual issues if you are having concerns or problems with sex (clearly
reiterating a boundary rule and then offering the patient a chance
to discuss sexual concerns).

Patients with more severe disorders may have difficulty at times dif­
ferentiating the friendly but professional relationship from friendship.
The therapist clarifies and reinforces the boundaries in a respectful, non­
demeaning way, without being evasive or insincere.

PATIENT: I’ve got some Aerosmith tickets! So, we could meet at the box
office and I could give you one. How about that?
THERAPIST: That’s really kind of you. I know that the tickets are special to
you, and I want you to understand that I really appreciate that
you’re thinking of me. It makes me think that our work together is
valued by you. But for future reference, I’m not allowed to receive
gifts of more than nominal value from my patients. Also, people
who have given a lot of thought to these things have decided that
it’s probably best to keep therapy relationships separate from other
kinds of relationships, like friendships, so that nothing interferes.
PATIENT: Ah, c’mon, doc. It’s just a concert ticket! It would be fun.
THERAPIST 1: You know, I was never much into heavy metal music. I didn’t
like it when I was younger, so I really wouldn’t want to go now even
if we knew each other under different circumstances (responds
truthfully but evasively).
THERAPIST 2: I’d prefer to keep our time together focused on our work,
which is about getting things done in a very special and professional
way, not about friendship. I’m sorry if that’s a disappointment. Can
we talk about this some more? (takes responsibility for the thera­
peutic boundary but is real and empathic in the relationship)

Because supportive psychotherapy is more verbally interactive than

traditional expressive treatment and because the therapist has more op­
104 Learning Supportive Psychotherapy

portunity to be a real figure in relating to the patient, greater flexibility is

allowed for moving traditional boundaries. For example, to normalize
what a patient is struggling with during day-to-day functioning after los­
ing a parent, the therapist may empathically disclose his or her own pain
and loss of motivation during a state of grieving. Although the repertoire
of therapist behavior and speech is broader in supportive psychotherapy,
with a less abstemious relationship, more opportunities arise for the ther­
apist to use the therapy to gratify his or her own needs and violate the pa­
tient’s boundaries. The therapist must always avoid the narrow but clear
domain of unacceptable behaviors that can exploit patients, including
sexual contact, borrowing money, or accepting favors or information
from the patient that benefit the therapist (e.g., stock tips, chores, or ad­
vice based on nonpublic information) (AMA Council on Ethical and Ju­
dicial Affairs 2015; American Psychiatric Association 2013b; American
Psychological Association 2017).

Conclusion
Supportive psychotherapy is generally indicated as the starting place for a
treatment relationship between therapist and patient and thus has few
contraindications. Other forms of treatment are undertaken only if spe­
cifically indicated and only with the patient’s agreement. The length and
intensity of supportive treatment vary according to a patient’s need and
motivation, and termination does not require working through ambiva­
lent feelings about the therapist. Treatment is focused on real relation­
ships, including the patient’s relationship with the therapist, but the
patient-therapist relationship should be discussed only when it becomes
problematic. Compared with expressive treatment, supportive psycho­
therapy allows a broader range of supportive behaviors by the therapist;
however, supportive psychotherapy is still constrained by clear guidelines
about permissible patient and therapist behavior in the treatment setting.
The Therapeutic
Relationship
6
Pinsker (1997) and others (Misch 2000; Novalis et al. 1993) described
general principles of supportive psychotherapy that are related to the pa­
tient-therapist relationship. Some of these principles are listed here and
are discussed more fully in this chapter.

1. To help sustain the therapeutic alliance, positive feelings toward and

positive transferences to the therapist are generally not a focus in sup­
portive psychotherapy.
2. To anticipate and avoid a disruption in treatment, the therapist is alert
to negative, distancing patient responses.
3. When a patient-therapist problem is not resolved through practical
discussion, the therapist moves to a discussion of the therapeutic re­
lationship.
4. The therapist can modify the patient’s distorted perceptions using
clarification and confrontation but not interpretation.
5. If indirect means fail to address negative transference or therapeutic im­
passes, more explicit discussion about the relationship may be warranted.
6. The therapist uses only the amount of expressive technique necessary
to address negative transference.

105
106 Learning Supportive Psychotherapy

7. The therapeutic alliance may allow the patient to listen to the therapist
present material that the patient would not accept from anyone else.
8. When making a statement that the patient will experience as criti­
cism, the therapist at times might have to frame the statement in a pal­
atable or supportive manner or first offer anticipatory guidance.

Transference: Supportive and Expressive

Approaches
Transference refers to the feelings, fantasies, beliefs, assumptions, and ex­
periences concerning the therapist that do not originate in the therapist or
in the patient’s relationship with the therapist but rather are outgrowths
from the patient’s earlier relationships, unconsciously displaced onto the
therapist. Transference phenomena arise in all therapies, but the role as­
signed to transference in supportive psychotherapy is different from the
role assigned to it in expressive psychotherapy.
In the most expressive psychotherapies and psychoanalysis (one end of
the expressive-supportive psychotherapy continuum described in Chapter 1,
“Evolution of the Concept of Supportive Psychotherapy”), transference
phenomena are of pivotal importance for identifying intrapsychic conflicts,
and therapeutic gain is ascribed to the emotional working-through of these
relationships. The patient-therapist relationship as expressed through
transference phenomena is a major area of focus and engagement, whereas
the working alliance or real relationship serves as a backdrop from which
the patient’s observing ego can peer onto the stage (Figure 6–1).
When working at the supportive end of the supportive-expressive psy­
chotherapy continuum, the dynamically aware therapist recognizes trans­
ferences and uses them to guide therapeutic interventions. Transferences
are not generally discussed, however, unless negative transference threatens
to disrupt treatment. The real relationship between the patient and the
therapist takes center stage (see the “Supportive” diagram in Figure 6–1).
Between supportive and expressive psychotherapies, where almost all
psychotherapy takes place, a mixture of approaches to transference ma­
terial occurs. Supportive and expressive techniques can emerge at appro­
priate times in treatment (Gorton 2000), but both the rationale for and
content of transference interventions by the therapist are different in sup­
portive and expressive treatments.
Supportive therapists track transference material but address it only
when necessary. Focusing on positive transference material in supportive
psychotherapy is generally unnecessary.

PATIENT: Doctor, you always give me the right advice, even when I’m not
on the ball or I have some wrong idea. How’d you get so smart?
 Supportive Expressive

Transference Transference
object object
Transference Transference
relationship relationship

Patient Patient
The Therapeutic Relationship

Real Real
relationship relationship
Therapist Therapist

Patient’s communications Arrow lengths correspond to relative intensity

of communication focus.

Therapist’s communications Thickness of borders around interpersonal objects

varies with intensity of treatment focus.

Figure 6–1. Roles of transference and the real relationship in expressive and supportive psychotherapy.
Source. Adapted from Pinsker et al. 1991.
107
108 Learning Supportive Psychotherapy

THERAPIST: Thanks, but I can’t take all the credit. I had good teachers, and
I have learned a lot of effective principles from working with pa­
tients (accepts the positive statement but modulates it slightly with
reality testing).

Negative transference is more typically a focus in supportive psycho­

therapy because such transference can be a threat to the integrity of the
treatment and normally adds to the patient’s suffering when acted on out­
side the treatment setting. In supportive and supportive-expressive psy­
chotherapy, the therapist clarifies often and confronts at intervals but
interprets infrequently, if at all. The therapist’s interventions assist the pa­
tient in recognizing and addressing maladaptive behavioral or construal
patterns that are reflected in behavior with the therapist; a goal of these
interventions is to increase the patient’s self-esteem and adaptive func­
tioning. The patient’s behavior with the therapist in supportive treatment
is understood to be illustrative of the patient’s behavior with others.
In expressive treatment, transference clarification and interpretation
are important interventions. In this treatment, the patient’s character­
ological and core neurotic defenses are often expressed through positive
and negative transference phenomena. The therapist’s transference inter­
pretations and clarifications assist the patient in gaining insight and work­
ing through unconscious conflicts; a goal of these interventions is
character change. In expressive therapy, relationships between the patient
and other people are used to illuminate the central patient-therapist re­
lationship.
The content of the therapist’s transference interpretations also differs
in expressive versus supportive modes. The precision and comprehen­
siveness of an interpretation may vary depending on the level of the pa­
tient’s object relations and defensive functioning, the patient’s progress in
treatment, and the strength of the therapeutic alliance. Interpretations of­
ten resemble clarifications and confrontations rather than interpretations
in the strict sense. Typically, the healthier the patient, the better he or she
will tolerate a precise and comprehensive interpretation without damag­
ing the therapeutic alliance. The therapist can present interpretive ideas
in a supportive manner (Winston et al. 1986). In working with patients
who are more impaired on the continuum, the therapist rarely makes full
interpretations but may make incomplete interpretations (leaving out ge­
netic references and generalizing [Pinsker et al. 1991]) or inexact inter­
pretations (diluting infantile fears with other plausible explanations
[Glover 1931]).

THERAPIST 1: So, keeping your room messy is a way for you to in a sense be
independent and to do things in your own way in your own space,
The Therapeutic Relationship 109

as compared with how it is at work, where everything must be an­

noyingly in its place and on time. Is there a downside? (supports
self-esteem, makes a connection to angry feeling, contrasts pa­
tient’s style with real-world expectation, opens a dialogue on
adaptive skills)

In the midst of an expressive treatment, the therapist might use interpre­

tation.

THERAPIST 2: So, keeping your room messy is a way of setting things up,
hoping your mother cleans it up. She’s supposed to make it OK, and
you get anxious about it. Then you become enraged and feel you
have little control (makes a primary connection to a genetic figure
and to the role of aggression in staving off anxiety when depen­
dency needs are not met).

The Therapeutic Alliance

In supportive and supportive-expressive psychotherapies—for example,
brief supportive psychotherapy (Hellerstein et al. 1998), brief adaptive
psychotherapy (Pollack et al. 1991), and supportive-expressive psycho­
therapy (Luborsky 1984)—an early and strong therapeutic alliance
(which is reflective of the real relationship) is predictive of positive out­
come in treatment and thus is a major focus of treatment (Westerman et
al. 1995; Winston and Winston 2002). Because patients with a weaker
therapeutic alliance are more likely to drop out of psychotherapy (Sharf
et al. 2010), purposely promoting and maintaining a strong alliance has
practical utility.
In the early days of psychoanalysis, Freud acknowledged that transfer­
ence included a personal relationship with the patient, which he called
rapport or unobjectionable positive transference. He considered this rela­
tionship necessary to maintain the motivation needed to collaborate ef­
fectively and therefore maintained that the relationship was not to be
interpreted (Gill and Muslin 1976; Safran and Muran 2000). This view is
the earliest evidence of a principle within psychodynamic treatments for
managing a strong therapeutic alliance, and Freud’s view provides a basis
for not interpreting positive transference in supportive psychotherapy. As
the concept of the therapeutic alliance began to develop, the focus shifted
to the working relationship between the patient and therapist and began
to be framed as a working alliance, with elements of the real relationship
separate from the transference (Greenson 1965, 1967; Zetzel 1956).
Current conceptions of the alliance are broader and include all collabo­
rative elements within the therapeutic relationship. Current conceptions
110 Learning Supportive Psychotherapy

seem a commonsense fit with the construct of supportive psychotherapy

(Horvath et al. 2011). The strength of the therapeutic alliance hinges on
the extent of patient-therapist agreement on therapeutic tasks and goals,
the patient’s capacity to perform the therapeutic work, the therapist’s
empathic relatedness and involvement, and the robustness of the affec­
tive bond between patient and therapist (Bordin 1979; Gaston 1990).
The patient’s perception of collaboration toward a common therapeutic
goal may be related to treatment outcome (Cailhol et al. 2009).
The therapeutic alliance is most likely the therapeutic foundation for
change rather than the vehicle for change, as hypothesized for more ex­
pressive treatments (Gaston 1990; Hellerstein et al. 1998; Horvath and
Symonds 1991). The tacit emotional learning that occurs as a result of the
interaction with the therapist appears to form the core of the growing ther­
apeutic alliance (Scaturo 2010). Therefore, the therapist fosters the alliance
through active measures, acting as a tolerant and nonjudgmental role model
(Misch 2000). Direct measures that support the patient’s self-esteem fur­
ther support the therapeutic alliance, which has a basis in the real relation­
ship. The patient may have a fantasy about the therapist’s capacities
(transference), but the therapist is actively engaged with the patient in a
real relationship and is often providing concrete help to the patient.

Misalliance: Recognition and Repair

To promote effective psychotherapy, the therapist must pay attention to
rifts in the patient-therapist alliance and make concerted efforts to repair
them. In supportive treatment, because the therapist is active, there is
greater opportunity to say the wrong thing or to step on the patient’s toes.
At the same time, to avoid anxiety that might interfere with a positive al­
liance, supportive psychotherapy does not emphasize exploration of con­
flict. In the event of a rupture, the supportive psychotherapist has ample
opportunity, as well as breadth of strategies, to intervene effectively. Less
constraint is placed on the ways in which the therapist might communi­
cate his or her distress at being misunderstood by the patient, as well as
his or her sincere regret at having unwittingly impugned or patronized the
patient or raised a subject that the patient found intrusive, anxiety pro­
voking, or simply unpalatable. Supportive measures are the first line of
repair for ruptures in the alliance (Bond et al. 1998). When the therapist
anticipates or notices a misalliance, he or she attempts to address the
problem practically, in the context of the current situation, before mov­
ing to symbolic or transference issues (Pinsker 1997). The following vi­
gnette demonstrates how a therapist addressed a misalliance (see Video
Vignette 4, available at www.appi.org/Winston).
The Therapeutic Relationship 111

Video Vignette 4: Addressing a Misalliance

Rachel is a 35-year-old single woman, a computer engineer, who has

been treated successfully with antidepressants for major depression,
with resulting increased energy, libido, and concentration. She is
typically passive and compliant in her interpersonal dealings and has
had difficulty long-term communicating directly what she wants in
social and intimate relationships.
Rachel has had several serious long-term relationships with men
that demonstrate a pattern of her being too accommodating, with a
resultant loss of self-esteem and a buildup of resentment. Because
she is passive and dependent, she has often tolerated a significant
lack of reciprocity in her relationships, frequently reporting having
been “bossed around,” yet she stayed in them even when she was no
longer happy. Rachel’s current boyfriend of 8 months, another com­
puter engineer, is irritable, perfectionistic, and critical, frequently
blaming her when things don’t go as planned. When her needs and
desires are frustrated, she becomes sullen, sarcastic, and full of self­
recrimination, which further lowers her self-esteem.

The therapist has been trying over several months to support Rachel
in “finding her voice” so that she might be better able to navigate get­
ting her needs served in the current relationship and “make it work.”
The therapist is using a model of what he deems to be adult behavior
in a committed relationship.

RACHEL: I don’t know why I’m here [sullen].

THERAPIST: Could you clarify what you mean?

RACHEL: All we do is argue, and he never owns up to anything. Just

asks me questions, expects me to do whatever he wants, and

never tells me what he really thinks. I try to be reasonable, but
it’s always his way, and it’s always my fault. Now it looks like it’s
over—the relationship’s just over.
THERAPIST: I still don’t understand. You’ve described this pattern to
me many times before: having a good time, followed by strug­
gling with your boyfriend, and then thinking that it was over.
RACHEL: That’s right.
THERAPIST: OK, but I’m unclear as to what you mean by your statement
that you don’t know why you’re here (attempts, through clar­
ification and confrontation, to get the patient to become
more specific).
RACHEL: What good is this? I talk and talk here, and now another re­
lationship is blowing up because I can’t sustain it. I try to do the
right thing, and it doesn’t make any difference. I can’t do it
right enough.
THERAPIST: And?
112 Learning Supportive Psychotherapy

RACHEL: So, I don’t know why I’m here. (Again, the patient lodges a
complaint about the treatment not giving her what she
needs, despite her doing what she believes she is asked.)
THERAPIST: We look at these patterns in your relationship so that you
can learn ways to change them or learn how to do things differ­
ently, which can improve your relationship and your self-esteem
(indirect attempt to strengthen the therapeutic alliance
by reiterating common goals).
RACHEL: Big words.
THERAPIST: I thought I was being clear in talking to you about this, but
perhaps I’m missing something.
RACHEL: [frowns and shrugs her shoulders]
THERAPIST: You’ve been working hard the past few months in our
work together so that you might be better able to get more of
what you want out of this relationship (praise for hard work
in therapy).
RACHEL: See, you’re just like him. I try to do things right, and it still
doesn’t work out [looks down, sullen] (states that therapist
behaves similarly to boyfriend, with similar impact).
THERAPIST: Are you saying that you see me as having expectations of you
here and that when you try to do the right thing, it doesn’t seem
to work out, and you still feel low and frustrated? (clarifies)
RACHEL [nods her head and frowns]: Yes.
THERAPIST: I see. I’ve been supporting you in working on this relation­
ship, “doing the right thing,” but I think you’re stuck in a process
that has you feeling down, and not just with him but here, too.
And it’s not good for you and it’s not good for your self-esteem.
I can own up to that, and I want to be better able to assist you in
our work together. (Therapist “owns up” to supporting the
patient’s staying in the relationship, which the patient
feels diminishes her autonomy because the relationship
with the boyfriend reduces her self-esteem.) If there is a
strategy that I’m using that is actually lowering your self-esteem,
I’ll consider changing it for something that works better for you
(directly allies with the patient; demonstrates responsive,
adult behavior).
RACHEL: You can do that? [looks up at the therapist, alert]
THERAPIST: Yes, of course.
RACHEL: That’s different from him (recognizes a component of the
real relationship with the therapist as contrasted with
transference or her boyfriend).
THERAPIST: In the past I’ve supported your attempts on working on
this relationship with this man, but you continue to have these
powerful disputes where you end up feeling disempowered
and blamed. While I can understand your disappointment and
sadness in ending it, I do think that you are correct. Staying
with this man is damaging to your self-esteem. Here I’ve been
trying to help you to stay and figure out a way to work it out
because I thought I had your best interests in mind, but now I
The Therapeutic Relationship 113

think that you know better about your own life. I’m sorry that
I didn’t catch on to this earlier. Where do we go from here? (At
times, the therapist may have to change his or her posi­
tion, as people normally do when talking with someone
who is becoming angry or distant.)

Rachel’s talk about the relationship blowing up is also a transfer­

ential statement about her experience of the therapy and the ther­
apist. Up to this point, she expressed herself as helpless to reveal to
him that the strategy was not working and that she was feeling
worse. When the therapist discloses to Rachel that he has been using
a model that sets up the expectation that she “do the right thing,”
he sidesteps the transferential bind he may have put himself in with
respect to this patient. Rachel begins to experience the therapist dif­
ferently, such that the alliance is strengthened and she feels that she
has been heard.

Resistance
Many therapists might say that the concept of resistance is relevant only
to the expressive element of therapy, in which uncovering is essential.
However, some of these therapists use the term resistance broadly to sig­
nify any patient-produced obstacle to achieving the goals of therapy. In
this sense, resistance may be characterized as the nearly universal out-of­
awareness fear of new ways and the tendency to cling to familiar patterns
even when they are maladaptive. Because supportive treatment aims to
support adaptive defenses and build self-esteem, the therapist’s strategy
in relation to resistance is to increase the patient’s motivation for action
by encouraging problem solving and new adaptive skills.
Another obstacle to treatment is a traitlike disposition to avoid painful
affects, which can interfere with treatment even when the therapist makes
every effort to mitigate discomfort or anxiety. In examining the traitlike
components of resistance, Beutler et al. (2002b) presented evidence from
several studies indicating that measures of patient characteristics typically
associated with trait resistance—such as defensiveness, anger, impulsivity,
and direct avoidance—are negatively correlated with psychotherapy out­
comes. These findings have direct relevance for supportive psychotherapy:
patients with high levels of trait resistance tend to have better outcomes
with dynamic nondirective, self-directed, or relationship-oriented thera­
pies (e.g., supportive-expressive psychotherapies) than with structured
cognitive or behavioral treatments (Beutler et al. 2002b).
114 Learning Supportive Psychotherapy

“Joining the Resistance”

Supportive treatment aims to support defenses unless they are maladap­
tive. Again, a primary principle in supportive psychotherapy is to support
the therapeutic alliance. When a patient is resistant to looking at dysfunc­
tional patterns, the fact that the therapist reflects the patient’s despair
and hopelessness or empathizes with his or her tough life or work situa­
tion might give the patient a strong sense of being understood and thus in­
crease his or her willingness to work in therapy (Messer 2002).
Supportive psychotherapy can provide, without coercion, an active em­
pathic environment and can reinforce the patient’s stated goals.
In supportive-expressive treatment, when a patient is struggling to rec­
ognize his or her own feelings or impulses, the therapist can follow the pa­
tient’s lead and make empathic statements about how difficult and
anxiety provoking it is to reveal oneself (Messer 2002).

PATIENT: Mom was usually pretty good about getting to games on time,
but Dad used to show up sometimes... usually after the fact. He
was always really busy [looks sad], and we got along...OK [pause].
Hey, you know why I was late today? The cabdriver on the way
here—the stupid guy couldn’t drive worth a damn! What a joke.
How’d he get a license?
THERAPIST: It seems that it’s making you anxious to focus on how you re­
ally feel toward your father.
PATIENT: This is hard. I don’t think I can do this [tearing up]. What if I
can’t do this? (increased anxiety, self-doubt)
THERAPIST: Talking about this kind of difficult stuff makes people anx­
ious, but they get through it in psychotherapy. I want you to know
that your pursuing it and revealing it here takes courage. I think
you’re clearly capable of doing it. I wouldn’t support your looking
at your feelings toward your father if I thought you weren’t capable
(empathy, normalization, accurate praise, reassurance).

Reducing Anxiety to Facilitate Discussion

Showing the patient a map before exploring the territory reiterates that
the engagement is collaborative and centers on agreed-on goals. Anxiety
is often diminished when the patient becomes cognitively aware of what
is being offered for discussion.

PATIENT: Sorry I’m late. I started out with plenty of time, but some things
came up, and before I knew it, it was 20 after.
THERAPIST: Have you noticed that over the last few weeks, you’ve come
into the session about 20 minutes before our time is up? I feel bad
that you may not be getting what you are paying for. Could we talk
about it? (With other patients, the therapist might be uncertain if
consistent lateness is related to feelings about the therapy or the
The Therapeutic Relationship 115

therapist or if it is due to deficits in ego function or adaptive skills.

In this case, the therapist knows from earlier sessions that the pa­
tient’s lateness is related to the therapist.)
PATIENT: Sure, but I just had stuff to do, and I lost track of the time (ra­
tionalizes, deflects, and plays the lateness off as a result of making
more important choices).
THERAPIST: In psychotherapy, when someone creates a pattern of some­
how getting to the session with only a little time left, it may mean
that there is something the person is wrestling with inside that is
showing up in this behavior pattern. People do well with looking at
what’s inside them, exploring it, though sometimes it brings up un­
comfortable emotions. I’m happy to explore it with you if you are
interested. It might be helpful (clarifies, confronts, normalizes, of­
fers guidance about the cost of exploring this issue).
PATIENT: It’s not just here, doc. I’m late for everything [sheepish grin] (gen­
eralizes away from the therapy situation but owns the pattern).
THERAPIST: So, as a bonus, if we can explore that pattern here, maybe you
can learn a skill or a principle that helps you to get along better out
there. Is that something you’d be interested in? (supports motiva­
tion, enlists collaboration)
PATIENT: Sure.

Reframing Resistance as Healthy Self-Assertion

The therapist can address opposition to his or her efforts by framing it as
a healthy function of the patient’s need for control and self-assertion; the
therapist may reduce the resistance by becoming more accepting and au­
thentic (Beutler et al. 2002a).

PATIENT: I didn’t ask my mom to enroll me for the spring semester like we
talked about last time. I decided to put it off until the fall. I’m just
not ready to do that yet. Are you angry?
THERAPIST: It’s good that you know your own mind and can make a de­
finitive decision. You must feel some relief about taking a stand. I’m
not angry because I don’t get to make the decisions about your life,
only to look at the decisions together with you and try to help you
with how you make them.

Dealing With Distance and Withdrawal

Patients frequently demonstrate resistance in sessions through with­
drawal and noninteraction. Because the therapist’s verbal responsiveness
is a characteristic of supportive psychotherapy, the therapist does not
wait for things to unfold if the patient is silent. Silence from the therapist
supports resistance and may increase the patient’s anxiety. In supportive
psychotherapy, when the patient is silent or unresponsive, the therapist
selects an issue for attention. The issue may be directly related to the pa­
tient’s lack of verbal engagement, which the therapist might choose to ad­
116 Learning Supportive Psychotherapy

dress indirectly. Alternatively, the therapist might switch to another

topic entirely.

PATIENT: Hello again [sits down]. I don’t really have much to talk about
today [sits quietly, looking at the therapist blankly].
THERAPIST 1 [warmly]: It’s good to see you again. So, can we get back to
the topic you were discussing with me before I left on vacation? You
were describing how hard it was to follow through on asking for a
transfer at work and how those “Why bother?” thoughts were get­
ting in your way. (The therapist picks up the patient’s topic from be­
fore the therapist’s absence, reconnecting with the patient and
supporting the patient’s self-esteem by showing that the patient
was important enough for the therapist to remember the issue. This
approach focuses indirectly on the patient’s distancing maneuvers
and sidesteps what the therapist assumes are the patient’s nega­
tive emotions about the therapist’s absence and increased anxiety
about revealing them.)
THERAPIST 2: Hello. It’s good to see you again. Well, it’s been 3 weeks
since our last session. Although I had someone covering for emer­
gencies, it’s not the same as coming for therapy.
PATIENT: That’s right [looks at the therapist less blankly] (engages a bit, re­
inforces the therapist’s coming in closer).
THERAPIST 2: Sometimes, when people say they don’t have anything on
their mind or much to talk about, they actually do but aren’t quite
sure whether to or how to say something. Patients often find them­
selves in that situation when their therapists come back after a va­
cation (clarifies the situation but generalizes away from the
specifics of the patient and the therapist before confronting the pa­
tient’s denial and withdrawal).

The therapist must be alert to distancing negative responses and must

be able to anticipate and avoid a disruption in treatment. Not addressing
misalliance may lead to a treatment disruption. The therapist must decide
whether the situation requires intervention through confrontation or
whether indirect means will suffice. The therapist must always evaluate
the situation, through introspection, to ensure he or she is not becoming
involved in a countertransference enactment (Robbins 2000).

Countertransference
As aptly stated by Clever and Tulsky (2002), “Asking patients to tell us
what they want potentially opens an imagined Pandora’s box of outrageous
requests, and it requires energy both to negotiate this tactfully and to manage
the countertransference such negotiation produces in ourselves” (p. 893).
The Therapeutic Relationship 117

Defining Countertransference
In considering countertransference, the therapist must make a distinction be­
tween 1) emotional reactions to a patient’s behavior that are due to the ther­
apist’s issues and 2) emotional reactions that are the therapist’s response to
the patient’s unconscious attempt to provoke a reaction, which might be a
manifestation of transference, coming from the patient’s internal world
(Messer 2002). The first type of countertransference is what has been de­
scribed as the narrow or classical view of countertransference—essentially,
the therapist’s transference to the patient (Gabbard 2001). A broader defi­
nition of countertransference includes the real relationship, consisting of re­
actions most people would have to the patient, as determined by moment­
to-moment patient behavior in the therapeutic relationship. On a related
note, when the therapist is lacking in expertise or when the type of therapy is
not helpful for the patient or problem, the therapist might mistakenly iden­
tify his or her bad feelings about the patient and treatment as countertrans­
ference, or the therapist might misperceive the problem as the patient’s
resistance. The therapist makes an attribution that the patient is being resis­
tant, but actually, the therapist or treatment is not effective.
Because we describe supportive psychotherapy as a dynamically in­
formed treatment, the second or broader view of countertransference has
a place in our discussion of technical work with patients. This view is that
emotional reactions of the therapist to the patient represent useful infor­
mation related to the patient’s inner world and unconscious processes
(Gabbard 2001). Currently, many psychoanalytic theorists from varying
perspectives hold a consensus view that countertransference is a transac­
tional construct, affected by what the therapist brings to the situation as
well as by what the patient projects (Gabbard 2001; Kiesler 2001). A dis­
cussion of therapist transference is beyond the scope of this chapter, but it
is incumbent on the therapist to attempt to distinguish his or her own
feelings from those provoked by the patient or, in the case of projective
identification, those that arise in the patient.
Supportive psychotherapy aims to improve adaptive skills. Maladaptive
behavior patterns in the patient’s real life frequently manifest as counter­
transference elicitations in the therapy session. When the therapist recog­
nizes that his or her reactions to the patient are the same as others’
reactions, sharing this awareness with the patient may be useful in framing
practical interventions to assist the patient with better interpersonal adap­
tation. The therapist must be aware, however, that his or her intent to self­
disclose feelings toward the patient could represent the therapist’s own
needs, not the requirements of the therapeutic situation. Such an aware­
ness is more important in supportive psychotherapy, in which the flow of
118 Learning Supportive Psychotherapy

dialogue is conversational, than in expressive treatment, in which the ther­

apist may at times abstain from responding. Gelso et al. (1995, 2002)
demonstrated that better countertransference management correlated pos­
itively with better outcome in brief therapy (consisting of 12 sessions).
The therapist in the following dialogue recognizes the patient’s mal­
adaptive behavior pattern.

PATIENT: Everyone always blows me off. I try to be nice—you know, join

in, tell stories and stuff—then I see them look at each other, and
they throw it in my face, and they make excuses and leave. Like
they’re so cool. That Andy—he’s a piece of work, and I told him so.
THERAPIST: It must be hard to try joining in and be rejected like that (em­
pathic).
PATIENT: Stop talking down to me. Jeez, you shrinks always act like you’re
Mother Teresa, but she didn’t take the money for herself, did she?
(feels impugned, attacks by questioning the therapist’s motives)
THERAPIST: Hmm. It sounds like how you are being here with me is how
you’ve described interacting with Andy and Fred at work. I’m find­
ing my temperature rising with your criticisms of me, and I can’t
help but wonder if you get the guys at work to feel the same way—
except I won’t act on my feelings the way that they do. I’ll continue
to sit and talk with you; I won’t make excuses and leave. (Modu­
lated confrontation and drawing of parallels. The therapist re­
states her commitment to the process and offers disconfirmation of
the patient’s expected rejection in spite of the pressure to reject the
patient.)
PATIENT: Oh, sure! Now you’re saying it’s my fault you’re angry? (continues
the verbal assault, feels criticized anyway)
THERAPIST: I think if we get into an argument, I won’t be doing my job of
being helpful to you, and you’ll keep feeling put down. No, what
I’m asking you to do is to see if there’s a pattern here that we can
work on to help you to get along better with people, because you’ve
told me you would like that (clarifies; does not get pulled into acting
out of countertransference feeling but uses the countertransference
knowledge productively by recommitting to the work, focusing on
the alliance in spite of heightened feelings, and reinforcing the pa­
tient’s treatment goal).

From the vantage point of interpersonal communication theory, Kiesler

(2001) described effective feedback of countertransference feelings as ap­
plying the principle that disclosing metaphors or fantasies has the least
threatening effect, compared with sharing direct feelings or tending toward
action. This principle is highly consistent with supportive psychotherapy
approaches, in which it is safer, more respectful, and more protective of the
therapeutic alliance to say, “I’m finding my temperature rising” than to say,
“I’m so angry, I feel like punching you out.” The therapist’s modulated ex­
The Therapeutic Relationship 119

pression of countertransference feeling not only offers disconfirmation of

the patient’s maladaptive construal style but also models adult restraint and
containment (but not denial) of affect. The therapist who responds to the
patient’s hostility in a complementarily hostile way is arguing. Besides be­
ing bad supportive technique, a therapist’s hostile response is predictive of
poor outcome (Henry et al. 1986, 1990).

Handling Devaluation
Being devalued by a patient can be painful and is sometimes a frequent
experience for therapists working with patients diagnosed with border­
line or narcissistic psychopathology. The therapist adaptively responds
and encourages the patient to understand the response as helpful and
consistent with the goals of treatment rather than as retaliatory or as a
way for the therapist to remove himself or herself as the object of the pa­
tient’s aggression (Robbins 2000). The therapist must bind the affects
and be aware of countertransference responses elicited by the attack,
which may include anger over the patient’s display of narcissism.

PATIENT: I needed that note from you, and you screwed up! I left word on
your voice mail that I needed it by Monday [vindictive tone]. Figures.
You could only get into medical school at a state school.
THERAPIST 1 [feels guilty]: I’m really sorry. Next time I’ll try to be more
sensitive to your needs, but I was out on Monday (masochistic
countertransference response to what was actually an unreason­
able demand, a mea culpa gratifying the patient’s grandiose self).
THERAPIST 2 [feels irritated]: You’re pretty quick to blame me and make
critical comments, but you take no responsibility at all for what
happened. You left the request over the weekend, and I was out on
Monday (accurate but critical rebuttal, which may leave the patient
feeling demeaned and angry).
PATIENT: I’ve heard those excuses before! I needed you. Now, how can
I trust you? I knew I should have gone to that Park Avenue shrink
my mother told me about! He went to Harvard. He’s quoted in the
newspaper all the time.
THERAPIST 3: Sometimes I’m going to disappoint you. It happens, even in
the best relationships. It might scare you or make you angry that I’m
not perfectly attuned to your needs, but fortunately, I don’t need to
be perfect to be helpful to you. I’ll bet that other psychiatrist doesn’t
need to be perfect either to be effective (authentic but measured re­
sponse; models healthy, adult behavior that is neither retaliating
nor capitulating; clarifies the role of a “good-enough” therapist).

The therapist must have appropriate training and the ability to under­
stand feelings of irritation, frustration, and helplessness generated in re­
sponse to a patient’s chronic criticism and devaluation. Without adequate
120 Learning Supportive Psychotherapy

peer support or professional supervision, the therapist may become clin­

ically disenchanted or disempowered and become either bored or overly
confrontational (Rosenthal 2002).
Distancing from empathic connection is a common response by the
therapist to a patient’s projective identifications (Kaufman 1992). Rather
than identifying with the patient’s projections and either capitulating or
counterattacking, the therapist manages vulnerability and aggression in the
context of being devalued. Such management is in concordance with sup­
portive principles (Robbins 2000) and can allow the patient to establish an
idealizing transference. The idealizing transference can enable the patient to
experience safety in the relationship with the idealized therapist, which can
serve as a corrective emotional experience (Alexander and French 1946).
Certain patients, such as individuals who seek help but chronically reject all
help that is offered (see Chapter 5, “General Framework of Supportive Psy­
chotherapy”), will maintain a transference position that is impermeable to
therapist intervention and disclosure. These patients’ pathogenic beliefs re­
garding self and others are confirmed by the therapist’s repeated attempts
to engage and problem solve (Sampson and Weiss 1986).

Conclusion
A robust therapeutic alliance is a strong predicator of positive outcome in
psychotherapy. In supportive psychotherapy, the alliance is posited as the
foundation for therapeutic change; therefore, the clinician actively pro­
motes and maintains the therapeutic alliance. In supportive psychother­
apy, as in expressive psychotherapy, the clinician observes and tracks
transference phenomena, but these phenomena are generally not a topic
of discussion or interpretation in supportive psychotherapy unless the im­
pact of negative transference is likely to interrupt treatment. The thera­
pist typically uses clarification and confrontation in supportive treatment,
but when interpretations are made, they tend to be incomplete or inex­
act. Because defenses are not confronted in supportive psychotherapy un­
less they are maladaptive, the clinician can learn to manage resistance
with supportive techniques. The clinician must always be alert to the po­
tential role of countertransference so that it can be properly managed.
Crisis Intervention 7
History and Theory
Crisis intervention began during World War II out of the necessity of
treating soldiers exposed to battlefield conditions. In World War I, sol­
diers with combat fatigue or “shell shock” were quickly evacuated from
the front lines, without treatment, despite observations that early inter­
vention might reduce psychiatric morbidity (Salmon 1919). These sol­
diers often regressed or even became chronically impaired. In World War
II, soldiers were treated at or near the front lines with crisis intervention
techniques and were quickly returned to their combat units (Glass 1954).
During the time of World War II, Lindemann began working with sur­
vivors of the Cocoanut Grove nightclub fire in Boston and their relatives.
These individuals were experiencing acute grief and were unable to cope
with their bereavement. In his pioneering article, Lindemann (1994) de­
scribed and contrasted normal and morbid grief. Survivors and their families
were helped to do the necessary grief work, which involved going through
the mourning process and experiencing the loss. One of Lindemann’s col­
leagues, Gerald Caplan (1961), began to work in the field of preventive psy­
chiatry and helped develop the theoretical basis for the community mental
health movement. Lindemann and Caplan were among the most important
early theoreticians of the crisis intervention approach.
Parad and Parad (1990) define crisis as an “upset in a steady state, a turn­
ing point leading to better or worse, a disruption or breakdown in a person’s
or family’s normal or usual pattern of functioning” (pp. 3–4). A crisis occurs

121
122 Learning Supportive Psychotherapy

when an individual encounters a situation that leads to a collapse in his or

her usual pattern of functioning, entering a state of psychological disequi­
librium. Generally, a crisis is precipitated by a hazardous event or a stressor,
such as a catastrophe or disaster (e.g., earthquake, fire, war, terrorism), a re­
lationship rupture or loss, sexual assault, or abuse. A crisis may also result
from a series of difficult events or mishaps rather than from one major oc­
currence, and a crisis can be a response to external and internal stress.
During crises, individuals perceive their lives, needs, security, relationships,
and sense of well-being to be at risk. Crises tend to be time limited, gener­
ally lasting no more than a few months; the duration depends on the
stressor and on the individual’s perception of and response to the stressor.
Crisis states can lead to personal growth rather than physical and psycho­
logical deterioration (Caplan 1961). Crisis makes growth possible because it
assaults the individual’s psychic structure and defenses, throwing them into a
state of flux, which can make the resilient individual more open to treat­
ment. Davanloo (1980) incorporated production of a crisis into his short­
term dynamic psychotherapy approach, viewing crisis as a means of disrupt­
ing ingrained defenses in order for patients to gain access to their inner lives
and thereby change maladaptive ways of feeling, thinking, and behaving.
Crisis intervention is a therapeutic process aimed at restoring homeo­
static balance and diminishing vulnerability to the stressor. The therapist
helps the individual to accomplish homeostasis by mobilizing the individ­
ual’s abilities and social network and promoting adaptive coping mecha­
nisms to reestablish equilibrium. Crisis intervention is a short-term
approach that focuses on solving the immediate problem and includes the
entire therapeutic repertoire for helping patients deal with the challenges
and threats of overwhelming stress.
An individual’s reaction to stress is the result of a number of factors, in­
cluding age, health, personality issues, prior experience with stressful
events, emotional support, resources, belief systems, and underlying bio­
logical or genetic strengths or vulnerabilities. Traumatic events are com­
mon and varied and can be personal, such as the death of a loved one,
sexual assault, the experience of being robbed, or involvement in a traffic
accident. Other types of trauma, such as natural disasters or terrorist at­
tacks, may involve large numbers of individuals, including persons not on
the scene. The intensity and type of traumatic event is important, as is an
individual’s coping ability. At times, a series of traumatic events may pro­
duce a crisis that a single event would not have provoked. For example, a
series of losses might result in a crisis that did not occur after the first few
losses. Losses include death; separation; illness; financial loss; and loss of
employment, function, or status.
Crisis Intervention 123

The distinction between crisis intervention and psychotherapy is often

blurred because the approaches may overlap in technique and length of
treatment. Crisis intervention is generally expected to involve one to three
contacts, whereas the duration of brief psychotherapy can extend from a
few visits to 20 or more sessions. In this chapter, the term crisis intervention
is also used for crisis-related treatment lasting longer than just a few ses­
sions. This more inclusive form of crisis therapy is based on a number of dif­
ferent treatments, including dynamic supportive, cognitive-behavioral, hu­
manistic, family, and systems approaches, as well as the use of medication
when indicated. Systems approaches can be broad and can encompass ac­
tions such as working with and referral to social service agencies, clergy,
mobile crisis units, suicide hotlines, and law enforcement agencies. In re­
cent years, the focus of crisis intervention has been on emergency manage­
ment and prevention through the use of various forms of debriefing.

Evaluation
According to Caplan (1961), ego assessment is key in the evaluation of an
individual in a crisis situation. The evaluation consists of 1) examining the
individual’s capacity to deal with stress, maintain ego structure and equi­
librium, and deal with reality, and 2) assessing problem-solving and cop­
ing abilities.
The evaluation of an individual in a crisis situation should be thorough
and systematic but should also essentially be completed within the first
session. A timely evaluation is critical because it enables the therapist to
develop a case formulation and treatment plan and initiate treatment im­
mediately. Even the evaluation session itself should be therapeutic to as­
sist the patient in crisis. The evaluation should follow the process outlined
in Chapter 3, “Assessment, Case Formulation, and Goal Setting,” but also
should focus on the traumatic situation, the precipitating event, and any
possible danger the patient might pose to himself or herself or to others.
The individual’s experience of the trauma, including perceptions and
feelings, and whether the person was a victim of or a witness to the trau­
matic event is important. The therapist should assess 1) the individual’s
current affect, anxiety level, and sense of hopefulness and 2) the way in
which he or she attempts to deal with the trauma.
The following vignette illustrates the evaluation process in a broad­
based, supportive psychotherapy–crisis intervention approach (see Video
Vignette 5, Session 1, available at www.appi.org/Winston). The vignette
includes excerpts from four sessions that began 6 months following the
2001 World Trade Center attack.
124 Learning Supportive Psychotherapy

Video Vignette 5: Crisis Intervention

Session 1

William is a 44-year-old police officer with anxiety, depressive feel­

ings, an inability to work, and difficulty enjoying anything about his
life. He is tall, muscular, and physically imposing. In his first session,
William reveals that he recently had a traumatic experience.

THERAPIST: So what’s troubling you?

WILLIAM: I’ve just been having all kinds of problems in my life.
I can’t work; I can’t sleep; I just don’t enjoy anything
anymore (responds with multiple complaints).
THERAPIST: So you’re having trouble working and sleeping,
and you’re not finding any enjoyment in your life. How
long have you been having these difficulties? (summa­
rizes and attempts to find out when the patient’s
difficulties began)
WILLIAM: It’s been going on for about 6 months, but it’s got­
ten worse over the last couple of months, I’d say.
T HERAPIST : I see that your problems began 6 months ago.
What was happening at that time? (begins to focus
on the beginning of the episode of illness)
WILLIAM: Well, 9/11 happened. I was sent down there right at
the beginning with three other policemen. It was terri­
ble. I still can’t believe what happened (begins to talk
about the traumatic events that occurred on Sep­
tember 11, 2001).
THERAPIST: Well, you know it is important that we try to go
into as much detail as we can (attempts to get de­
tails of the traumatic event and its effect on the
patient). I know it might be difficult for you, but can
you tell me what happened when you were at the
World Trade Center? (empathic)
WILLIAM: We got down there. I was told to wait outside, and
the other guys went in. They never came out.... I should
have been there with them [begins to cry] (is filled
with emotion and perhaps feelings of guilt).
T HERAPIST : I can see that this is very difficult for you (re­
sponds in an empathic manner).
WILLIAM: Yeah. I was told to stay outside and monitor traffic,
to make sure that no civilians got into the buildings.
THERAPIST: So you were outside, and they went in...and then
what happened?
WILLIAM: Well, I was standing there just looking up, and I was
stunned.... I saw people jumping.
Crisis Intervention 125

THERAPIST: Oh my God! That must have been so frightening (re­

sponds with emotion and in an empathic manner).
WILLIAM : Yeah . . . I saw a man and a woman . . . . They were
holding hands. .. . They were jumping [begins to sob]
(gives further information).
THERAPIST: I’m so sorry you went through such a terrible or­
deal. What a horror! I’m very, very sorry (responds
with emotion and in an empathic manner).
WILLIAM: That was only the first part of it. Then all of a sud­
den, the buildings began to shake and then—I couldn’t
believe it—one building started to come down, and I
was buried. And all of a sudden, I looked up, and I saw
my wife and my son holding hands and smiling and
waving at me.... I thought I was dead.
THERAPIST: So you were buried, and you saw your wife and
your son. You thought you were dead. How did you get
through that experience? (responds with a clarifica­
tion, tracking, and admiration, and continues ex­
ploring)
WILLIAM: At first I was completely paralyzed. I couldn’t reason.
My mind was totally confused. I felt like a mummy. I
didn’t move right away.
THERAPIST: And then what happened?
WILLIAM: I reached for my eyes, and I started to pull the stuff
out of my eyes and out of my ears, and I stood up and I
realized I was actually alive. I don’t know how I got out.
I saw a woman, and she was on her knees, and she had
blood coming out of her forehead. I picked her up, and
I took her to a rescue area. Then I went back in and
found another man, and I carried him out also. (Despite
his horrendous ordeal, the patient behaved in a
heroic manner.)
THERAPIST: So you helped rescue two people! After everything
you’d gone through, you rescued two people! (praises
and expresses admiration for his heroic behavior)
WILLIAM: Yes, but I...the guys I came with...they never got
out. I should have been there with them. I keep think­
ing about it. (Despite his heroic behavior and the
therapist’s praise and admiration, the patient in­
dicates that he feels guilty about not going in
with the other policemen.)
THERAPIST: You were a hero—and yet you still believe that you
should have been there with them. Losing three fellow
officers must have been very devastating for you (praises
the patient and begins to address the issue of his
surviving while his fellow officers all died).

This vignette illustrates part of the process of evaluating a patient

who is in a crisis situation and has a traumatic stress disorder. In the
126 Learning Supportive Psychotherapy

remainder of the evaluation, the therapist explores William’s guilt

about staying behind while others went in, his level of anxiety, and
the extent of his depression. William’s current family situation is ex­
amined, as well as his history. The following information emerges.

William has been extremely anxious and tearful following his trau­
matic experience. He has been pacing back and forth in his home
and thinking constantly about what happened to him on September
11, 2001. He has startle reactions to loud noises and has flashbacks
about the building collapsing, people jumping, and seeing his wife
and son. William has nightmares and thus avoids sleep. He can no
longer concentrate, has little energy, feels helpless, and no longer
enjoys anything in his life. He has been unable to return to work and
tries to avoid anything that might remind him of September 11. His
previous performance at work was quite good, and he was deco­
rated on several occasions for heroism.
William grew up in a middle-class family and had a good relation­
ship with his mother. When he was 15 years old, his father died. Wil­
liam’s relationship with his father had been difficult and filled with
conflict, which resulted in mixed feelings toward his father. These
feelings did not resolve when his father was dying, and they may
have played a role in William’s emphasis on bodybuilding and on
presenting a strong manly image.

The therapist concludes that William has posttraumatic stress dis­

order (PTSD). Before the trauma, William was functioning at a high
level and had good coping skills despite unresolved problems with
his father. At present, his coping skills are no longer adequate, but
he has a supportive spouse and appears to be motivated for psycho­
therapy. The treatment goals, formulated with William, include
amelioration of his symptoms and a return to work. The treatment
plan includes development of a supportive, positive therapeutic re­
lationship at the onset of treatment, followed by work on symptom
reduction with the use of exposure therapy, along with cognitive re­
structuring. Medication for anxiety and depression, such as a selec­
tive serotonin reuptake inhibitor, may also be indicated. As
treatment progresses, a major focus will be to help William return to
work as soon as possible.

Treatment
The therapeutic approaches used in crisis intervention are primarily those
of brief supportive psychotherapy, consisting of maintenance of focus and
a high therapist activity level; use of clearly established goals, a time limit,
Crisis Intervention 127

and a number of supportive and cognitive-behavioral interventions; and,

most importantly, establishment of a solid therapeutic alliance. A num­
ber of systematic approaches to crisis intervention have been described
(James and Gilliland 2001; Puryear 1979; Roberts 2000).
Systematic approaches to crisis intervention include stress assessment,
patient safety, establishment of rapport and hopefulness, supportive in­
terventions, and positive actions and plans. The importance of assessment
was discussed in the previous section, “Evaluation.” Patient safety is part
of the assessment process and should be monitored throughout therapy if
the individual’s safety is in question (see the section “Suicide” later in this
chapter). Establishing rapport and promoting hopefulness are important
in all forms of psychotherapy and are major factors in fostering the ther­
apeutic alliance. The major elements of the alliance (Gaston 1990) are
the patient’s affective bond with the therapist, the patient’s ability to
work purposefully and collaboratively with the therapist, the therapist’s
empathic understanding and involvement, and the agreement of patient
and therapist on the goals and tasks of therapy. The use of supportive or
empathic interventions helps promote the alliance, making it possible to
use exposure techniques to help work through the patient’s reaction to
trauma. Positive actions and plans provide the patient with structure and
improve self-esteem and hope for the future. Video Vignette 5 continues
with sessions 2, 4, and 5 with William, the police officer with PTSD re­
sulting from the events of September 11, 2001. These sessions illustrate
the treatment process in a broad-based supportive psychotherapy crisis
intervention approach.

Video Vignette 5: Crisis Intervention (continued)

Session 2

William has completed his first session of supportive psychotherapy

crisis intervention. In addition, treatment with a selective serotonin
reuptake inhibitor has been started, with the dose gradually being
increased to a therapeutic level during the course of treatment. The
next two sessions are primarily directed at forming a secure and pos­
itive therapeutic alliance through the use of supportive interven­
tions. Part of William’s second session follows.

WILLIAM: My wife told me that I don’t bother with her anymore, that
I just ignore her—but I don’t feel like talking about anything,
128 Learning Supportive Psychotherapy

doing anything.... I just don’t feel like talking (begins with a

complaint from his wife rather than continuing to dis­
cuss the traumatic event—possibly a defensive move).
THERAPIST: You know last week at our first meeting, we explored
what happened to you on that terrible day of 9/11, and some­
thing about your past life, and a bit concerning your relation­
ship with your wife and son, and maybe today we can go into
your current relationship with Cathy more in-depth (chooses
to address the patient’s current issue with his wife to
build a therapeutic relationship before going back to
the traumatic event, which he may not be ready for at
the current time; presents agenda).
WILLIAM: Well, Cathy comes over to me and tries to talk to me, to get me
started talking, but I don’t feel like talking; it’s still too difficult
(indicates that he is overwhelmed, which may have impli­
cations for his feelings about talking to the therapist).
THERAPIST: OK. So it’s really hard for you to talk, and I understand this.
But perhaps there are some things that would be easier for you
to talk about (responds in an empathic manner and asks
the patient to focus on areas that are less painful, anx­
iety provoking, and conflictual).
WILLIAM: It is really hard to talk about 9/11.... I like to talk about my
son. I guess some things around the house. I like to do some
gardening.
THERAPIST: So you could talk to Cathy about those things—about the
house, your son, and so forth. Can you give me an example of
what you might feel comfortable talking with Cathy about?
(always look for concrete examples)

The therapist has recognized that William is having difficulty

talking at home and is possibly having difficulty talking with the
therapist. However, because William is talking spontaneously, the
therapist has decided not to address the therapeutic relationship
and instead has begun to focus on concrete areas that William can
discuss with his wife. Focusing on concrete areas helps to reduce
anxiety, which is important in both supportive psychotherapy and
crisis intervention.

WILLIAM: Cathy wants Billy to go to sleep-away camp. I don’t know—

he’s not much of an athlete, but he does like to play the saxo­
phone. I kind of think it would be better if he just stayed home
(indicates his wish to have his son at home with him).
THERAPIST: Could it be that you disagree with Cathy because you
would really like Billy to stay home with you? (clarification,
expressed tentatively)
WILLIAM: I do like having him around (ignores his conflict with his
wife and focuses on his son).
Crisis Intervention 129

THERAPIST: Yeah. So maybe I would be correct in saying that you want

Billy to be with you, but you find it difficult to speak to Cathy
about this directly? (using a supportive approach, brings
the patient back to his conflict with his wife; requests
feedback)
WILLIAM: That makes sense. I just can’t be clear about what it is that
I want, because I just really don’t know (agrees but indicates
that he becomes passive and indecisive with his wife).
THERAPIST: It sounds like you would like to have Billy home this sum­
mer, but it’s hard for you to be direct with Cathy, so you hang
back and yet get annoyed with her. Is this correct? Do you
agree with that? (interprets the patient’s wish to have his
son home and his defensive posture of passivity and dis­
traction accompanied by annoyance with his wife; again
employs the supportive technique of asking for feed­
back so that the patient is not overwhelmed)

The therapist has asked for a specific example of William’s diffi­

culty in communicating with his wife. Obtaining specific concrete
examples from patients is always preferable to leaving things on a
general level. When patients generalize, it is difficult to understand
what they have in mind. In addition, it is not helpful to patients to
remain in a confused or unclear state.
Having understood that William wishes to have his son at home,
the therapist has been able to clarify this wish with William. The
therapist has used a number of supportive approaches. Instead of
addressing the transference, the therapist has continued to concen­
trate on William’s current life and his difficulty with his wife, Cathy.
In supportive psychotherapy, the transference generally is not ad­
dressed unless it is negative. Instead, the therapist concentrates on
current issues in the patient’s life and on the real relationship with
the therapist. Clarification is used as a supportive technique because
it does not place demands or expectations on the patient. In addi­
tion, the therapist has been able to link William’s avoidance and an­
noyance with Cathy to his wish to keep Billy home for the summer
and not have him go off to camp as Cathy wishes.
The pursuit of affect is generally avoided in supportive psycho­
therapy and has been avoided in this session. However, William’s
emotional experiences resulting from the World Trade Center tragedy
will need to be addressed when exposure techniques are used later
in therapy.
The therapist has determined that a good therapeutic relation­
ship was established during the first three sessions (session 3 is not
shown). Therefore, exposure therapy within a supportive frame­
130 Learning Supportive Psychotherapy

work can now be attempted to enable the patient to work through

his traumatic experience, as shown in the following sessions 4 and 5.

Session 4

THERAPIST: William, I thought that we might go back and explore what

happened to you on 9/11. If we can look at your experience to­
gether, it should help you to better deal with it and move on
with your life. How do you feel about doing that now? (The
therapist asks for the patient’s agreement to explore his
traumatic experience. Asking for agreement constitutes
the supportive technique of agenda setting.)
WILLIAM: If it can help. I think I’m more ready.
THERAPIST: It’s good that you feel ready and that we’re able to pro­
ceed. Let’s go back to that day when you went to the World
Trade Center. OK? (praises the patient and continues to in­
volve him as a partner in planning the discussion)
WILLIAM: OK.
THERAPIST: You and your fellow officers were sent to the World Trade
Center about when? (begins a detailed exploration of the
patient’s traumatic experience)
WILLIAM: In the morning, after the second plane hit, we drove up.
Therapist: And as you were driving up, what were you experiencing?
WILLIAM: The fires were just raging. We knew by then that it was an
attack. We met the sergeant, and he told me I should stay out­
side to keep people out, as I said before.
THERAPIST: What was it like for you, remaining outside while the oth­
ers went in? (is aware of the patient’s not wanting to re­
main behind and his guilt feelings about being the only
survivor from his group)
WILLIAM: I wanted to go in with them.
THERAPIST: So how did you feel? (For the first time the therapist
asks about the patient’s feelings. Exposure therapy relies
on the patient’s experiencing and exploring feelings, in a
somewhat controlled fashion, during the session.)
WILLIAM: Standing around, I felt useless. I was annoyed. I didn’t want
to stay behind.
THERAPIST: That’s understandable, but you were ordered to stay behind
(absolution as a supportive technique).

The therapist has emphasized that William was ordered to stay

behind because during the evaluation session, William indicated
that he felt guilty and conflicted about staying outside. The thera­
pist is preparing the groundwork for addressing William’s cognitive
distortion of this issue and his possible survivor guilt.
The session continues with a recounting of the traumatic events
that followed.
Crisis Intervention 131

WILLIAM: I was standing there in the street. Then all of a sudden,

I saw people jumping from the building. Some of them were
on fire.
THERAPIST: That’s horrible! What were you feeling? (asks William
for his feelings in an empathic manner to promote ex­
ploration and desensitization)
WILLIAM: It was hard to look...[begins to sob]. I couldn’t believe it.
Then I saw a man and a woman jumping, and they were hold­
ing hands! [becomes visibly shaken and anxious]
THERAPIST: Who wouldn’t be devastated, shaken, and tearful? (clarifies
in an empathic manner using the supportive technique of
normalizing)

The therapist has been obtaining a detailed account of William’s

traumatic experience and has also been monitoring his level of anx­
iety to ensure that it remains within manageable limits. If a patient’s
anxiety level gets too high, the therapist can slow down the account
and initiate anxiety-lowering interventions, such as having the pa­
tient engage in progressive muscular relaxation and deep breathing
or meditation. In addition to these techniques, which are generally
used in exposure therapy, supportive interventions such as reassur­
ance can also be used.
The session continues with a detailed exploration of William’s ex­
periences of that day, including the collapse of the buildings, his
near burial in the debris, his hallucination of his wife and son, and
his belief that he was dead. The therapist elicits these experiences in
great detail and in an empathic manner, with careful monitoring of
William’s anxiety level. During the exploration of William’s vision of
his wife and son—the vision in which he saw them holding hands
and waving good-bye to him—William becomes visibly shaken and
anxious because at that time he believed he was dead. The therapist
stops the exploration and begins anxiety-lowering techniques of
meditation with deep breathing and the use of a mantra.

Session 5

Session 5 begins with a discussion of the patient’s anxiety level

during the interval between sessions. This information is important
because the aim in supportive therapy is to keep anxiety level as low
as possible. William indicates that he has not been experiencing a
significant amount of anxiety between sessions.

THERAPIST: Do you think you feel ready now to continue exploring

what happened to you on that day on 9/11? (checks to see if
132 Learning Supportive Psychotherapy

the patient is ready to continue exposure therapy; again

uses the supportive technique of agenda setting)
WILLIAM: Yeah...I can keep going.
THERAPIST: You’re very strong, and you have a lot of resilience. So,
let’s pick up where we left off: after you saw your wife and son.
Is that OK? (offers praise—a supportive intervention—
and then resumes exploration of the patient’s traumatic
experience)
WILLIAM: Yeah, I began to realize that I wasn’t actually dead, and
I started to push away all the stuff off me . .. out of my face,
ears, and eyes. It was all over me (continues without much
difficulty).
THERAPIST: So as you began to realize you were not dead, how did you
feel?
WILLIAM: I certainly felt some relief.... I thought, thank God—thank
God, I’m all right. Then I got up and I saw a woman on her
knees. She was bleeding from her scalp, blood was coming
down her face. All I thought to do was help her up and carry
her out to the rescue area.
THERAPIST: Yeah. So despite your being battered and even thinking
you were dead just a few minutes earlier, you were still able to
pull a woman out of the rubble and rescue her. That’s amaz­
ing! (offers praise and expresses admiration—both use­
ful supportive interventions, provided that the praise
and admiration are clearly reality based and deserved)

The therapist goes on to explore the details of William’s next few

hours after he picked himself up from the rubble. These details in­
clude rescuing a man, going to the hospital to have lacerations su­
tured, and finding out that the three policemen who went into the
building had died. All these experiences are fully explored during
the next few sessions, until William can talk about his experience
without too much anxiety or overwhelming sadness.
William’s treatment involves the use of exposure therapy in the
context of a supportive relationship. The therapist is able to take
William through his traumatic experience in a slow and detailed
manner over the course of several meetings. The therapist monitors
William’s anxiety level so that he is not overwhelmed. If William be­
gins to become overly aroused, the therapist stops the exposure
work and uses a number of supportive techniques, such as praise, re­
assurance, and relaxation therapy along with meditation. At the
same time, a great deal of work is required to restructure William’s
excessive feelings of guilt about being the only survivor of his group
of four policemen. The therapist challenges William’s self-blaming
cognitions to help him reframe his idea that he should have been in­
side the World Trade Center with his fellow officers (cognitive re­
Crisis Intervention 133

structuring). The therapist points out that William was ordered to

remain outside the building and helps him understand the concept
of survivor guilt when she states, “Many people who survive trage­
dies as you did feel guilty.”
After 10 sessions, William gradually improves and is able to return
to work and to feel comfortable with his wife and son. He still has ep­
isodes of anxiety and sadness, which he is able to manage, and he
continues taking medication. He has two follow-up sessions, 1 month
later and then 3 months later, to prevent relapse.

Treatment Approaches for PTSD

In this chapter we have described the treatment of PTSD using supportive
psychotherapy combined with exposure therapy and cognitive restructur­
ing, along with the anxiety-reducing techniques of progressive muscular re­
laxation and meditation. A number of other treatment approaches have
been used in PTSD with good results. These include cognitive therapy (Foa
et al. 2005); eye movement desensitization and reprocessing (van der Kolk
et al. 2007); interpersonal therapy (Markowitz et al. 2015); mantram rep­
etition (Bormann et al. 2018); and the use of virtual reality for patients
with treatment-resistant PTSD, especially military veterans (van Gelderen
et al. 2018). Cusack et al. (2016) completed a systematic review and meta­
analysis assessing the efficacy and comparative effectiveness of a number of
these therapies and found that exposure therapy had the greatest strength of
evidence for effectiveness. Unfortunately, most psychotherapy approaches
do not combine different treatments to form an integrated psychotherapy.
The treatment of William’s PTSD used an integrated psychotherapy ap­
proach combining supportive psychotherapy, exposure treatment, cognitive
restructuring, and anxiety-reducing techniques. Supportive psychotherapy
easily lends itself to an integrated, multifaceted psychotherapy.

Suicide
The prediction of suicide is problematic because there is no reliable way
of determining suicidal risk in a given individual within a given time
frame (Chiles et al. 2019; Fawcett et al. 1993; Pokorny 1983). Two major
problems occur when attempts are made to predict suicide: 1) too many
false-positive cases are identified and 2) many instances of completed sui­
cide are overlooked. Nevertheless, more than 90% of completed suicides
occur in individuals with a recent major psychiatric illness (Fawcett et al.
1993). The most common diagnoses are major depression, chronic alco­
holism and drug abuse, schizophrenia, borderline personality disorder,
134 Learning Supportive Psychotherapy

bipolar disorder, and eating disorders. Retrospective case review studies

of completed suicides suggest heightened suicide risk in the context of a
recent traumatic loss, such as a breakup in an important relationship, be­
ing fired from a job, or losing status or a place of belonging (Joiner 2005).
A careful and thorough assessment of the suicidal patient is critical to de­
termine the diagnosis and the proper treatment approach. Crisis inter­
vention approaches, generally accompanied by the use of medication, of­
ten play an important role in the treatment of suicidal individuals.

Assessment of Risk
Suicidal thoughts and behaviors are so common that it is essential to ask
all patients about suicidal ideas and attempts. A history of suicide at­
tempts increases a person’s risk for completing suicide. Individuals who
have well-defined plans to kill themselves are at greater risk than individ­
uals with vague or poorly formulated plans. When a suicidal person has
the means to end his or her life and has great familiarity with the means
(e.g., owns and uses a firearm), the patient is at greater and often signif­
icant risk. The presence of strong family support or a significant other can
have a mitigating effect on suicidal risk. Hopelessness, pessimism, aggres­
sion, impulsiveness, and psychic anxiety are poor prognostic signs. An­
other factor to be considered, as noted earlier, is the loss of a significant
other through separation, divorce, or death.
Paradoxically, it was found that more than half of patients who died by
suicide had consulted clinicians within 1 year before death and had de­
nied suicidal thoughts or indicated that they rarely occurred (Clark and
Fawcett 1992). Often, these same patients communicated directly or in­
directly to a close friend or relative that they were thinking of ending their
lives. This information suggests that physicians should routinely question
close relatives and friends of patients who may be at risk for suicide.
Fawcett et al. (1990, 1993) divided suicidal risk into acute and chronic
categories. Individuals who are at acute risk often have severe anxiety,
thoughts about negative events occurring, insomnia, anhedonia, agita­
tion, and alcohol abuse (Busch et al. 2003). Persons at more chronic risk
have more typical risk factors, such as suicidal ideation and plans and a
history of suicide attempts.
The risk of suicide is often greatest during the week after hospital ad­
mission and the month after discharge and during the early period of re­
covery from a psychiatric disorder (Hawton 1987). For a comprehensive
review and discussion of imminent suicide risk, see the book The Suicidal
Crisis: A Clinical Guide to the Assessment of Imminent Suicide Risk by Igor
Galynker (2017).
Crisis Intervention 135

Treatment
Suicidal thoughts represent a form of problem-solving by patients in tre­
mendous and unrelenting psychological pain. Acknowledging the pa­
tient’s pain, helping him or her to find ways to reduce the burden of pain,
and assisting the patient in identifying alternative solutions to suicide are
important tasks in establishing a therapeutic alliance and implementing
treatment during the suicidal crisis (Chiles et al. 2019). The therapist
should explore the patient’s perspective and life story along several con­
siderations: the patient’s belief in suicide as a solution to a particular
problem; the patient’s past history of suicidal behavior and its impact on
others; the patient’s ability to tolerate significant pain; the patient’s rea­
sons for not committing suicide, should this be possible; and the patient’s
perceptions of a future that could be positive (Chiles et al. 2019).
Therapists, especially those who are very sensitive to the inner experi­
ences of their patients and those who are early in their training or clinical
practice, may feel overwhelmed by the suffering felt and expressed by sui­
cidal patients. To be effective in working in crisis settings with suicidal pa­
tients, it is very important that therapists recognize their own feelings and
ensure that they are able to respond in an open and constructive manner
that creates physical and emotional safety for the patient.
Once an individual has been determined to be acutely suicidal, hospi­
talization may be indicated. If hospitalization is not feasible or not abso­
lutely necessary, the therapist should enlist the aid of significant others who
can spend time with the patient and not leave the patient alone. The ther­
apist needs to be available for contact either by the patient or by the pa­
tient’s family or friends and should provide them with information
regarding 24-hour hotlines and the nearest emergency department. Medi­
cation is often necessary in the short term to relieve the patient’s anxiety,
agitation, or depression. The frequency of treatment sessions will vary de­
pending on the patient’s needs. Some patients may need to be seen daily for
ongoing support and structure. Accordingly, it is important that the same
clinician see the patient throughout the period of crisis intervention. Im­
portant issues on which to focus are patient hopelessness and pessimism.
Supportive approaches involving praise, reassurance, and cognitive restruc­
turing are often useful to help enhance self-esteem by counteracting nega­
tive or distorted cognitions about the self. As always, establishment and
maintenance of a positive therapeutic alliance are essential.

Crisis Intervention Versus Psychotherapy

As stated in the section “History and Theory” at the beginning of this chapter,
crisis intervention theory is based on a number of psychological approaches,
136 Learning Supportive Psychotherapy

including dynamic supportive psychotherapy, cognitive-behavioral therapy,

humanistic treatments, family therapy, and systems approaches. Crisis in­
tervention is time limited and is not focused on psychological insight, per­
sonality issues, or psychiatric disorders. An individual receiving crisis
intervention is generally in transition or has lost his or her equilibrium be­
cause of a traumatic experience that has disrupted his or her life. Patients
vary in their resilience and sources of support. The objective of crisis inter­
vention is to help the individual deal with the stressful period, achieve sta­
bility, and return to his or her precrisis level of functioning or, if the patient
needs further treatment, move on to the next level of care.
Crisis intervention differs from psychotherapy in a number of ways
(outlined in Table 7–1). Crisis treatment is given as soon as possible and in
close proximity to the stressor or traumatic event. It is time limited, and
the therapist is active, supportive, and directive. As in supportive psycho­
therapy (as opposed to expressive psychotherapy), the focus is on the
here and now rather than on the past or on transference issues.

Critical Incident Stress Management

Critical incident stress management (CISM) was originally developed for
use with emergency workers; however, its scope has been expanded to in­
clude anyone exposed to severe trauma (Everly and Mitchell 1999;
Mitchell and Everly 2003). CISM is a comprehensive and integrated crisis
intervention approach for individuals and groups. The components of
CISM are summarized in Table 7–2 and include the following: precrisis
preparation involving stress management education and training for indi­
viduals and groups of professional and emergency workers; briefings on
disasters and terrorist or other large-scale incidents for rescue workers and
civilians; defusing (i.e., immediate small-group discussion) to ensure as­
sessment and triage and to mitigate symptoms; critical incident stress de­
briefing (CISD; Mitchell and Everly 1996) to reduce impairments from
traumatic stress, facilitate closure, and mitigate symptoms for individuals
and groups; individual or family crisis intervention; and follow-up and re­
ferral for further assessment and treatment.
A typical CISD approach after a traumatic event involves a group of
victims who undergo the interventions, listed in Table 7–2, in a single
1- to 3-hour session. The efficacy of a single-session debriefing in prevent­
ing PTSD or other disorders came into question in 2002. In a meta-analysis
of single-session debriefing within 1 month after trauma, van Emmerik et
al. (2002) found that CISD interventions do not improve natural recovery
from psychological trauma. However, single-session approaches of this sort
may help reduce immediate distress and facilitate referral of patients for
Table 7–1. Crisis intervention versus psychotherapy
Crisis intervention Psychotherapy

Context Prevention Reparation

Timing Immediate; close temporal relationship to Delayed; distant from stressor or acute decompensation
Crisis Intervention

stressor or acute decompensation

Location Close proximity to stressor or acute Safe, secure environment
decompensation; anywhere needed
Duration Typically one to three contacts As long as needed or desired
Provider’s role Active, directive Guiding, collaborative, consultative
Strategic foci Conscious processes, environmental stressors Conscious and unconscious sources of pathogenesis
or factors
Temporal focus Here and now Present and past
Patient expectations Symptom reduction, reduction of impairment, Symptom reduction, reduction of impairment, personal
directive support growth, guidance, collaboration
Goals Stabilization, reduction of impairment, a return Symptom reduction, reduction of impairment,
to function or a shift to next level of care correction of pathogenesis, personal growth, personal
reconstruction
Source. Aguilera et al. 1970; Artiss 1963; Everly and Mitchell 1998; Koss and Shiang 1994; Salmon 1919; Sandoval 1985; Skaikeu 1990; Spiegel and Classen

1995; Wilkinson and Vera 1985.

Reprinted from Everly GS Jr, Mitchell JT: Critical Incident Stress Management (CISM): A New Era and Standard of Care in Crisis Intervention, 2nd Edition.

Ellicott City, MD, Chevron Publishing, 1999. Used with permission.

137
Table 7–2. Core components of critical incident stress management
138

Intervention Timing Activation Goals Recipients

Precrisis preparation Precrisis Driven by crisis Setting of expectations, Individuals, groups,

anticipation improved coping, organizations
stress management
Demobilization and staff Shift disengagement Event driven Presentation of information, Organizations,
consultation (rescuers) consultation, psychological large groups
decompression,
stress management
Crisis management briefing Anytime postcrisis Event driven Presentation of information, Organizations,
(civilians, schools, businesses) consultation, psychological large groups
decompression,
stress management
Defusing Postcrisis (within 12 hours) Usually symptom Symptom mitigation, Small groups
driven possible closure, triage
Critical incident stress debriefing Postcrisis (1–10 days; Usually symptom Facilitation of psychological Individuals, small
mass disasters: 3–4 weeks) driven; sometimes closure, symptom groups
event driven mitigation, triage
Individual crisis intervention Anytime, anywhere Symptom driven Symptom mitigation, Individuals
possible return to function,
referral if needed
Family crisis intervention Anytime Symptom or event Fostering of support and Families
driven communication
Learning Supportive Psychotherapy
Table 7–2. Core components of critical incident stress management (continued)
Intervention Timing Activation Goals Recipients

Community and organizational Anytime Symptom or event Symptom mitigation, possible Organizations
consultation driven closure, referral if needed
Crisis Intervention

Pastoral crisis intervention Anytime Usually symptom “Crisis of faith” mitigation, Individuals,
driven use of spiritual tools to assist families, groups
in recovery
Follow-up and referral Anytime Usually symptom Mental status assessment, Individuals,
driven a shift to higher level of care families
if needed
Source. Adapted from Everly GS Jr, Mitchell JT: Critical Incident Stress Management (CISM): A New Era and Standard of Care in Crisis Intervention, 2nd
Edition. Ellicott City, MD, Chevron Publishing, 1999. Used with permission.
139
140 Learning Supportive Psychotherapy

further treatment. Positive outcomes have been achieved with cognitive­

behavioral treatments that were administered within the first month of
the traumatic incident and that involved education, exposure, and cogni­
tive restructuring (Bryant et al. 1999; Foa 1997; Foa et al. 1991).

Conclusion
In this chapter, we provided a brief history and the theoretical back­
ground of crisis intervention. Individuals exposed to severe trauma can
react in a number of ways, and some of these reactions necessitate crisis
intervention. A thorough evaluation of a patient presenting in crisis is al­
ways necessary. Treatment approaches vary depending on the needs of
the patient but generally include supportive interventions, exposure ther­
apy, cognitive restructuring, and anxiety-reducing techniques. A pa­
tient’s suicidal thoughts represent a form of problem-solving—a way of
escaping tremendous and unrelenting psychological pain. Therapists
must pay particular attention to establishing and maintaining a positive
therapeutic alliance. Acknowledging and lessening the patient’s pain and
finding alternative solutions to suicide are important tasks in establishing
a therapeutic alliance and implementing treatment during a suicidal cri­
sis. The terrorist attacks of September 11, 2001, in New York and Wash­
ington, D.C.; the 2010 Haiti earthquake; and the increased number of
terrorist attacks, tornadoes, hurricanes, and floods in recent years, as well
as battlefield injuries, have made both the general public and mental
health professionals more aware of these issues and the need for crisis in­
tervention services.
Applicability to
Special Populations
8
Severe Mental Illness
As originally conceived, supportive psychotherapy was indicated for pa­
tients with severe mental illness, as well as for other patients for whom
expressive treatment was not indicated. The original indication for sup­
portive psychotherapy was treatment at the extreme supportive end of
the supportive-expressive psychotherapy continuum described in
Chapter 1, “Evolution of the Concept of Supportive Psychotherapy.”
This form of supportive treatment was focused primarily on improving
deficient ego functions, reducing anxiety, and preventing downward so­
cial drift due to loss of adaptive skills and increasing isolation. In addition
to offering the patient an understanding, supportive relationship, this ap­
proach contained many of the following techniques: advice, reassurance,
exhortation, praise, encouragement, lending ego, and environmental ma­
nipulation. Supporting defenses was the default mode, confrontation was
rare, and interpretation did not occur.
In current practice, even for patients who are quite impaired because of
severe mental illness, therapists should strive for a balance between support­
ive and expressive elements in supportive treatment. Depending on several
factors—including the degree of stabilization after acute exacerbation of ill­
ness, the strength of the therapeutic alliance (see Chapter 6, “The Thera­
peutic Relationship”), and the patient’s treatment goals—confrontation

141
142 Learning Supportive Psychotherapy

and, at times, interpretation can be useful techniques in supportive psycho­

therapy. Cognitive learning strategies, such as teaching, using slogans, mod­
eling, and giving anticipatory guidance, are commonly used. The treatment
components of psychoeducation and skills training, which have been
framed as independent interventions, are consistent with the model of sup­
portive treatment and are particularly useful in supportive psychotherapy
for chronic mental illness.

Schizophrenia
Schizophrenia is the prototypical severe mental illness. When treating a
patient who has schizophrenia, the therapist provides education about
the illness, promotes medication compliance, facilitates reality testing,
encourages problem solving by the patient, and reinforces adaptive be­
havior with praise (Lamberti and Herz 1995). Gunderson et al. (1984)
demonstrated that patients with schizophrenia have better treatment re­
tention and better outcome when given weekly supportive treatment
rather than more intensive expressive treatment.
Praise is a form of reinforcement that can support the patient’s self-esteem
and motivation for adaptive change. As described in detail in Chapter 4,
“Techniques,” praise is an important esteem-building technique. How­
ever, praise builds self-esteem only when the praised behavior is consid­
ered praiseworthy by the patient. Therefore, the therapist must
understand what the patient will find worthy of praise. The therapist also
must attempt to understand what the patient finds rewarding so that
these incentives can be enlisted to provide positive feedback. Determin­
ing what the patient finds rewarding is especially important in schizo­
phrenia and at the left side of the psychopathology continuum, where
positive reinforcement is an important factor in maintaining the thera­
peutic alliance and motivating engagement in treatment.
Positive reinforcement is helpful for patients with schizophrenia be­
cause they commonly have neurocognitive impairments; negative symp­
toms, such as apathy, anhedonia, and poor motivation; and poor insight.
A reinforcer can be a favorite food, activity, person, or social event that in­
creases the strength or frequency of the patient’s contingent behavior.
Properly assessed and delivered reinforcers increase patients’ skill acqui­
sition, achievement of goals, and self-esteem (Lecomte et al. 2000). Ex­
ternal rewards that patients value may be helpful in engaging and
maintaining these patients in treatment. Rewards can include subway to­
kens, certificates of accomplishment, a celebratory event, and gift certif­
icates. Administration of accurate praise, as described throughout this
book, is an effective and inexpensive reward.
Applicability to Special Populations 143

Psychoeducation
Typically, supportive psychotherapy for patients with severe mental ill­
ness includes psychoeducation about the illness, its trajectory, and its
treatment. The literature suggests that educating patients about schizo­
phrenia or substance dependence reinforces psychosocial rehabilitation
(Goldman and Quinn 1988). Most patients generally find learning new
information to be supportive. When provided in an empathic way, psy­
choeducation offers the patient a new cognitive structure on which to
base more realistic decision making. Psychoeducation also gives the pa­
tient an explanation of or rationale for symptoms and suffering; giving
such explanations or rationales may also bolster the patient’s self-esteem.
In addition, concrete information about the illness arms the patient
with practical knowledge that can help improve his or her ability to cope
with chronic illness—an adaptive skill. For example, early in an exacer­
bation of the manic phase of bipolar disorder, the patient frequently loses
the capacity to understand that his or her judgment is impaired by mania.
During a remission, the psychiatrist can teach the patient that sleeping
even 1 hour less than usual for 2 nights in a row may be an early sign of re­
lapse into mania. This information gives the patient an opportunity to
demonstrate some adaptive mastery over the illness and to act before an
exacerbation can impair judgment and destroy the chance to “step on the
brakes.” For example, when the symptom of impaired sleep occurs and
the patient contacts the psychiatrist for a dose escalation of antimanic
medication, the patient will likely experience increased self-efficacy and
self-esteem. These positive effects will occur as a result of the patient’s
sense of increased competence in anticipating potentially damaging fu­
ture events and will strengthen the therapeutic alliance.

Supporting Adaptive Skills

To help patients who have impairments in interpersonal functioning sec­
ondary to severe mental disorders such as schizophrenia, the therapist can
integrate behavioral skills training and other cognitive-behavioral tech­
niques into supportive psychotherapy. The model of change in support­
ive therapy is change through learning and through introjection of or
identification with an accepting, well-related therapist (Pinsker et al.
1991). Training in social and independent living skills for patients with
severe mental illness is an approach grounded in learning principles,
wherein the therapist breaks down complex social repertoires and models
correct behavior for the patient, who repeatedly practices the skills after
learning them. After the steps are assembled, the patient practices the
complex interaction—first with the therapist, then in the real world. The
144 Learning Supportive Psychotherapy

therapist uses supportive techniques, such as behavioral goal setting, en­

couragement, modeling, shaping, and praise (positive reinforcement), to
teach interpersonal skills (Glynn et al. 2002). This activity directly sup­
ports adaptive skills and builds patients’ self-esteem. Studies have demon­
strated the utility of these interventions in improving social competence
(Heinssen et al. 2000; Lauriello et al. 1999).
Patients with schizophrenia have social skills deficits, which may be a re­
sult of impaired information processing. Skills training uses the problem­
solving, repetitive, and practical approach of supportive psychotherapy and
is effective in improving basic conversational skills, recreational skills, med­
ication management, and management of symptoms (Liberman et al.
1998; Smith et al. 1999). A related cognitive-behavioral approach, relapse
prevention, is discussed in the subsection “Adaptive Skills and Relapse Pre­
vention” later in this chapter.
At times, the clinician must balance his or her focus on anxiety reduc­
tion as a major supportive strategy with the patient’s determination to
work through a particular problem, which could increase the patient’s
adaptive skills. For example, a patient might become anxious on hearing
certain information about schizophrenia from the therapist. However,
providing guidance about hearing the information and reframing the con­
tent in an attempt to strengthen the patient’s coping skills may reduce the
patient’s anxiety. Having more extensive coping strategies that use
higher-level defenses (e.g., rationalization) can mean that the patient has
a more flexible and adaptive approach to his or her illness. At other times,
when the patient signals that he or she is experiencing too much anxiety
to deal with a subject directly, it can be useful for the therapist to attempt
to “back into” discussion of the difficult topic.

THERAPIST: So, I would like to talk to you about what you understand
about your illness. Is that OK with you? (“shows the map” before
exploring the territory)
PATIENT: I guess.
THERAPIST: If what I’m saying doesn’t make sense to you, please tell me,
and I’ll try to clarify it. If it makes you more nervous, let me know,
and we’ll talk about something else. OK? (offers anticipatory guid­
ance about material to be explored, gives patient permission to
stop the exploration, sets a collaborative tone, and indicates that
the therapist is sensitive to the patient’s feelings)
PATIENT: All right.
THERAPIST: Has anyone discussed with you what your diagnosis is? That
means the medical name of the illness that’s bringing you into psy­
chiatric treatment.
PATIENT: Uh, depression. I have depression.

THERAPIST: That’s what they told you?

Applicability to Special Populations 145

PATIENT: I don’t know...um, I have depression.(Patient has been told

previously that his diagnosis is schizophrenia. He is either being
evasive or using denial.)
THERAPIST: Could you describe for me what the word depression means to
you?
PATIENT: Yeah, I couldn’t sleep, and I don’t do much. Don’t feel like it.
I used to do things.
THERAPIST: Any other problems, like in your thoughts or feelings?
PATIENT: I have depression (concrete, perseverative, nonelaborative
answer).
THERAPIST: Are you sad a lot? People who are depressed are often sad.
PATIENT: No, not sad. I just don’t feel much of anything. Tired. I don’t
know (disclaims a low mood associated with depression).
THERAPIST: OK. Now, other than being tired, are there things you’ve been
experiencing lately that have caused you problems?
PATIENT: Huh? Like what? [suspicious look]
THERAPIST: Well, you told the other doctor back in your intake evaluation
that you had been thinking that somebody or maybe some group was
trying to harm you, that you saw evidence of that. Is that accurate?
PATIENT: That was before. I don’t think about it now [looks away] (engages
in distancing and avoiding).
THERAPIST: Can you tell me a little about what you were thinking and ex­
periencing then? (asks about patient’s experience)
PATIENT: Scary, uh...don’t want to talk about it. I don’t think about it now
(focusing on persecutory delusion increases patient’s anxiety).
THERAPIST: OK, I won’t ask you about the details. So, now it’s not on your
mind. You said it was before. Before when? I didn’t understand
what you meant (moves away from past experience; asks for clar­
ification of patient’s statement).
PATIENT: You know, when I went on the pills for depression, it got better.
THERAPIST: Ah, so you don’t have those scary thoughts so much since you
started taking the medication? It’s good you’re taking it! (clarifies, con­
necting medication and relief from delusional thinking; adds praise)
PATIENT: Yeah. That’s true.
THERAPIST: So, let me clarify: the medication you’re taking seems to have
a good impact on scary thoughts and experiences. Is that accurate?
PATIENT: That’s true [eye contact, brightens a little].
THERAPIST: So I guess it’s a good idea to keep taking it? (ties what patient
experiences as beneficial to a motivating statement for medication
adherence)
PATIENT: Yeah! And I talk to people better. They don’t seem so negative to
me (validates therapist’s position).
THERAPIST: So the medication helps you communicate better, too? Does
that mean you get along with people better than before?
PATIENT: I keep to myself pretty much. But I don’t get into fights like I did
(the patient is more elaborative as anxiety is reduced in situ).
THERAPIST: You mean you got into physical fights?
PATIENT: Only one time. Mostly just yelling back at some of the people
when I knew what they were up to.
146 Learning Supportive Psychotherapy

THERAPIST: What were they up to? (asks for clarification)

PATIENT: They were trying to make me look bad—said bad things about
me from down the street [looks away]. Hmm, I don’t think about it
now (starts to demonstrate increased anxiety, repeating his reflexive
phrase).
THERAPIST: So that’s better now, too? That’s good. What else is better?
(goes along with the resistance; moves back to the present to reduce
anxiety)
PATIENT: My walls are quiet. I sleep better.
THERAPIST: How were they noisy?
PATIENT: The lady upstairs was making noise at night.
THERAPIST: What kind of noises? Like playing music too loud? Moving
furniture?
PATIENT: No, uh, she would say ugly, ugly things to me. I couldn’t sleep;
I’d have to stay up.
THERAPIST: How would she talk to you?
PATIENT: I don’t know—but it came from the wall.
THERAPIST: So you were hearing her voice telling you things you found
unpleasant and you couldn’t sleep? And it’s better now? (clarifies)
PATIENT: Yes, I can sleep again.
THERAPIST: That must have been a terrible time for you. I’m glad you’re
feeling better. What a relief that must be! (gives an empathic re­
sponse based on patient’s statements)
PATIENT: Uh-huh [smiles].
THERAPIST: I’m going to summarize what you’ve told me the medication
does for you, so we’re clear I have it right. It takes away scary
thoughts and experiences, takes away voices at night and helps you
to sleep, and lets you get along with people better.
PATIENT: That’s it.
THERAPIST: Sounds like good medicine!
PATIENT: It works.
THERAPIST: So can we get back to that illness that gave you the scary
thoughts and experiences like voices, that kept you up, and that
made it hard to get along with people? (again “shows the map”)
PATIENT: OK.
THERAPIST: The medicine you are taking treats those symptoms of a dis­
order called schizophrenia—and, as we’ve just talked about, treats
them pretty well: you’re feeling a lot better than before.
PATIENT: I don’t have that! My face didn’t change. I don’t attack people
and drink their blood. My face didn’t change (becomes anxious
and derails; reveals his delusional fears).
THERAPIST: I think maybe you’re confusing an idea you have about vam­
pires—that maybe you saw on TV—with schizophrenia. Vampires
aren’t real. Schizophrenia is, but it’s a treatable mental disorder that
has exactly the symptoms you’ve already described to me—symptoms
that the medicine you take is good at controlling. You are not some
kind of soulless monster (reality tests, clarifies, confronts, and re­
assures).
PATIENT: What’s going to happen to me? [tears up]
Applicability to Special Populations 147

THERAPIST: We have better medicines and better therapies than ever be­
fore, and I will be here and work with you so that you can improve
the quality of your life.

Family Psychoeducation
When supportive treatment is used with higher-functioning patients, en­
vironmental manipulation generally is not employed. With more im­
paired patients, however, the therapist can judiciously intervene in the
patient’s environment to support continued adaptation and reduce anxi­
ety and stress. A clear example of this approach is family psychoeduca­
tion, in which educating the family changes the patient’s environment.
Teaching the family about the nature of the patient’s disorder can help
stabilize the family members around the patient in a way that is more
supportive of the patient’s recovery. Family stabilization is in contrast to
the family making the patient the focus of their disappointment, failed
expectations, criticism, disbelief, and ignorance. Such family reactions
are unlikely to help a patient better cope with chronic illness; some family
behaviors, such as high expressed emotion, are clearly associated with ex­
acerbation of illness (Vaughn and Leff 1976). Indeed, short-term family
intervention in families with high expressed emotion reduces relapse
rates among patients with schizophrenia (Bellack and Mueser 1993).

Personality Disorders
For most therapists, the patients who are most difficult to treat are not the
sickest patients (i.e., those with psychotic symptoms and profound impair­
ment of ego functioning) but rather the patients who are highly angry, de­
manding, suspicious, or dependent (Horowitz and Marmar 1985).
Patients with personality disorders use pervasive, maladaptive interper­
sonal strategies, and their behaviors are sometimes dangerous or frighten­
ing. Therefore, these patients can provoke strong negative emotions in
people—including psychiatrists, who may avoid treating patients with per­
sonality disorders (Lewis and Appleby 1988). The treatability of this class
of disorders is contingent on several factors, including disorder severity; the
specific diagnosis; the patient’s degree of involvement with medical, social,
and criminal justice systems; comorbidity; the availability of appropriately
trained staff; and the state of scientific knowledge (Adshead 2001).
Clearly, persons administering supportive treatment to such patients
must have adequate training or supervision to deal with inevitable coun­
tertransference issues, as discussed in Chapter 6. Nonetheless, supportive
psychotherapy is particularly suited to the treatment of most personality
disorders because this therapy focuses on increasing self-esteem and
148 Learning Supportive Psychotherapy

adaptive skills while developing and maintaining a strong therapeutic al­

liance. As described in Chapter 3, “Assessment, Case Formulation, and
Goal Setting,” the psychiatrist must conduct an assessment of the patient
that allows for a case formulation, including an explication of ego func­
tioning, adaptive skills, object relations, and defensive operations.
In certain clusters of personality disorders, patients appear to make
greater use of particular groups of maladaptive defenses and defensive be­
haviors. For example, in the treatment of patients with avoidant personality
disorder, a major focus is on getting the patient to develop skills to over­
come passivity and fears of rejection. In contrast, in the treatment of pa­
tients with narcissistic personality disorder, the focus is on addressing and
reducing uses of externalization and criticism. The clinician decides at what
point to use more containing, anxiety-reducing supportive technique and
when to use more expressive technique. In particular, because clarification
is the expressive technique used most frequently in supportive psychother­
apy, within the supportive psychotherapy frame, clarification can elucidate
maladaptive constructs that contribute to the patient’s interpersonal prob­
lems and experienced loss of self-efficacy. Through implementation of
techniques focused on adaptive skills, patients may develop a less rigid and
more adaptive set of responses (Sachse and Kramer 2018).
Identifying comorbid mood and anxiety disorders is important in pa­
tients with personality disorders. In contrast to earlier concerns that med­
icating patients would deprive them of the motivation for engagement in
treatment, today it is recognized that judicious pharmacological treat­
ment of comorbid depression and anxiety disorders generally acts syner­
gistically with the patients’ attempts to learn and master new adaptive
skills. In depressed patients, pharmacotherapy reduces Cluster C person­
ality pathology—in particular, harm avoidance, which is associated with
poor social function (Hellerstein et al. 2000; Kool et al. 2003; Peselow et
al. 1994). When patients are less anxious or less depressed, they are more
willing to explore new strategies and may be better able to do so (see
Chapter 3 for an evaluation of a patient with major depressive disorder).
In a review of the effectiveness of psychotherapies for personality dis­
order, Perry et al. (1999) found that all studies of active psychotherapies
reported positive outcomes at termination and follow-up. In addition, pa­
tients receiving treatment have an accelerated rate of recovery from per­
sonality disorders compared with the natural course of the disorders.
Bateman and Fonagy (2000) conducted a systematic review of the evi­
dence for efficacy of psychotherapy in personality disorders. Although
psychotherapy was found to be effective, the evidence did not indicate
that one form of treatment was superior to another. Effective treatments
were found to have several factors in common, including encouragement
Applicability to Special Populations 149

of a strong patient-therapist relationship that would allow the therapist to

take an active rather than passive stance.
Rosenthal et al. (1999) demonstrated lasting change in interpersonal
functioning among patients with Cluster C personality disorders who
were treated with 40 sessions of manual-based supportive psychotherapy.
In patients with major depressive and personality disorders (especially
Cluster C personality disorders), short-term (16-session) supportive psy­
chotherapy in combination with antidepressant treatment led to greater
reduction in personality pathology compared with antidepressant treat­
ment alone (Kool et al. 2003). Patients with problems of hostile domi­
nance, such as patients with antisocial personality disorder, tend to
receive less demonstrable benefit from supportive psychotherapy than do
patients with other personality disorders (Kool et al. 2003; Woody et al.
1985); however, when patients with antisocial personality disorder have
comorbid depression, they may do well with supportive psychotherapy.
Gerstley et al. (1989) hypothesized that the benefit is related to the pa­
tients’ having some capacity to form a therapeutic alliance.
In supportive psychotherapy, it has been posited that when transfer­
ence interpretation does not occur, the character-transforming factor may
be the patient’s capacity to form an identification with the more benign,
accepting attitude of the therapist (Appelbaum and Levy 2002; Pinsker
et al. 1991). For example, patients with borderline personality disorder
typically must contend with what in structural terms is thought of as a
rigid, archaic, and punitive superego. Identification with the therapist
may allow the patient to be more tolerant of hateful and shameful aspects
of the self.
Holmes (1995) reported on borderline patients’ use of the commit­
ment, concern, and attention to the supportive technique during psycho­
analytic treatment and suggested that the development of secure
attachments fostered more autonomous functioning. By discouraging de­
structive behaviors, the therapist models more appropriate behavior and
demonstrates strength and concern for the patient (Appelbaum and Levy
2002). As the patient’s injurious behaviors and level of emotional inten­
sity diminish, the patient can identify with the reflective function and
mentalizing ability of the therapist. This can help the patient make better
sense of his or her own subjective states and mental processes, as well as
those of others.
Appelbaum and Levy (2002) pointed out that the supportive therapist
strives to establish an arousal level in the patient optimal for learning, fos­
tering a sense of self, and appreciating the consequences of behavior.
These factors help to address ego and adaptive dysfunction in patients
with borderline personality disorder. With such patients, the therapist
150 Learning Supportive Psychotherapy

works to create a sense of safety so as to reduce maladaptive defenses,

which are typically linked to fears of annihilation, abandonment, and hu­
miliation. Creating a sense of safety can help the patient begin to develop
a more integrated sense of self and other in the context of reduced anxi­
ety. Nevertheless, this sense of safety must be created without fostering
regression, which can escalate those behaviors that the therapist is trying
to address and reduce. Maladaptive or immature defenses, such as regres­
sion, denial, or projection, are not supported. As in much of supportive
psychotherapy, the therapist tries to maintain a balance of supportive and
expressive techniques.
An advance in the treatment of borderline personality disorder was the
development of dialectical behavior therapy (DBT), which initially fo­
cused on reducing parasuicidal behavior (Linehan 1993; Linehan et al.
1994). Although this practical, multicomponent approach to therapy
with borderline patients has been presented as an evolution of cognitive­
behavioral therapy, certain main components of the treatment are decid­
edly supportive, in that they directly address ego function and adaptive
skills. The open and explicit collaboration between patient and therapist
on here-and-now issues in DBT is consistent with the style of supportive
therapy. In particular, the use of mindfulness exercises is a direct measure
that addresses both ego functioning and adaptive skill in teaching patients
to develop intrapsychic distance from overwhelming emotional distress.
In addition, DBT makes liberal use of slogans and sayings that reframe pa­
tients’ isolated experience into shared experiential wisdom and that serve
as feedback for validating both subjective states and real responsibility
(Palmer 2002). Interestingly, a year-long clinical trial comparing DBT,
transference-focused psychotherapy, and supportive psychotherapy
demonstrated that those receiving supportive psychotherapy had signifi­
cant positive changes in depression, anxiety, global functioning, and social
adjustment. Compared with the DBT group, the supportive psychother­
apy group had significant reductions in anger, but supportive psychother­
apy was less effective in reducing suicidality, which is not surprising given
the specific focus of DBT on parasuicidal behavior (Clarkin et al. 2007).

Substance Use Disorders

Substance use disorders are among the most common mental disorders
(Hasin and Grant 2015). In the past, most psychiatry residents did not
treat patients presenting with substance use disorders unless the patients
presented with co-occurring psychiatric disorders (see the section “Co-
Occurring Mental Illness and Substance Use Disorders” later in this chap­
ter). Generally, residents learned about withdrawal syndromes and de­
Applicability to Special Populations 151

toxification while working on inpatient psychiatric units that admitted

patients with psychiatric disorders or substance-induced mental disor­
ders. In contrast, current residency training in psychiatry involves at least
1 month of full-time clinical work with patients who have substance use
disorders; thus, residents must learn about basic psychotherapeutic and
medication management of these patients.

Pharmacotherapy
There are relatively few pharmacotherapies that are effective for substance
use disorders, and these pharmacotherapies work best in the context of
psychosocial treatment. Therefore, psychotherapy is an important inter­
vention for substance use disorders. Some medications approved for use in
substance use disorders are maintenance medications for opioid use disor­
der, such as methadone and buprenorphine (Fudala et al. 2003; Kleber
2003); aversive medications for maintenance of abstinence for alcohol use
disorder, such as disulfiram (Fuller et al. 1986); heavy drinking and craving
reducers, such as naltrexone (O’Malley et al. 1992; Volpicelli et al. 1992);
or anticonvulsants such as topiramate that both support abstinence and
reduce episodes of craving and heavy drinking (Blodgett et al. 2014).
To conduct psychotherapy with substance-using patients, the therapist
must understand the psychopharmacology of classes of drugs that are
commonly used nonmedically, typical presentations of intoxication and
withdrawal, and the natural course of drug effects. The therapist also
needs to be familiar with common or street knowledge about the drugs,
including slang names and prices (Rounsaville and Carroll 1998). A good
working knowledge of these drugs and the lifestyle of the patient who
uses them can help the therapist begin to build a therapeutic alliance with
the patient.

Treatment Principles
In the past, individual expressive treatments were the standard interven­
tion for substance use disorders. Over time, it became clear that use of
uncovering psychotherapy as a sole mode of treatment for substance use
disorders was generally not effective. Other treatment approaches, such
as group therapies, pharmacotherapies (e.g., methadone maintenance),
and therapeutic communities, became mainstays of addiction treatment.
Rounsaville and Carroll (1998) underscored the rationale for supportive
psychotherapy when they described the reasons that expressive treat­
ments, when offered as the sole ambulatory treatment, are not well suited
to the needs of patients with substance use disorders. In expressive treat­
ments, symptom control and development of coping skills are often not
152 Learning Supportive Psychotherapy

the primary focus. Patients drop out frequently because of a lack of focus
on the patient’s presenting problem and because patients find the thera­
pist’s neutral, abstaining stance anxiety provoking. Today, it is under­
stood that interpretations of addictive behaviors are not sufficient to stop
the addictive process and that increasing the patient’s anxiety early in the
treatment of a substance use disorder is likely to trigger a relapse. There­
fore, the therapist should embark on a more uncovering type of treatment
only when the patient has established a concrete method for maintaining
abstinence or is being treated within a protected environment (Brill 1977;
Rosenthal and Westreich 1999).
Supportive psychotherapy with patients who have substance use dis­
order focuses on helping patients to develop effective coping strategies to
control or reduce substance use and stay engaged in treatment. Other im­
portant components of treatment are developing and maintaining a
strong therapeutic alliance and minimizing the risk of relapse by helping
the patient to both reduce and learn to manage anxiety and dysphoria.
Because supportive psychotherapy offers a broad and flexible foundation
for interventions with patients, work with addicted patients typically in­
cludes use of newer, more evidence-based strategies, such as motivational
interviewing, relapse prevention, and psychoeducation. General support­
ive principles are maintained during the course of addiction treatment,
even as patient and therapist embark on particular cognitive and behav­
ioral work, such as building cognitive skills. For a patient with a substance
use disorder, individual supportive psychotherapy is often augmented and
supported by the patient’s engagement in a 12-step program, group ther­
apy for substance use disorders, and other recovery-oriented therapeutic
activities.

Motivational Interviewing
If an individual is not interested in reducing or stopping the use of sub­
stances when he or she meets the criteria for a substance use disorder, the
individual may have a diagnosis but is not yet a patient. People who come
into treatment for substance use disorders typically have spent months to
years without severe consequences and have experienced drug use as fun
or beneficial. People generally show up for substance use treatment only
when the consequences of drug use have become threatening to their re­
lationships, employment, health, freedom, or life. When these people
then show up for treatment, most have beliefs about their drug use that
were constructed when their use appeared to be free of severe negative
consequences. A common belief is that drugs have played an essential
role in the individual’s ability to cope (Rounsaville and Carroll 1998). In
Applicability to Special Populations 153

this context, unless the patient sees the substance use as a problem and
can conceptualize getting along without drug use, setting appropriate
treatment goals is difficult.
Rollnick and Miller (1995) described motivational interviewing as a di­
rective, patient-centered intervention that helps patients to explore and re­
solve their ambivalence about changing. The main principles of motivational
interviewing include understanding the patient’s view accurately, avoiding or
deescalating resistance, and increasing the patient’s self-efficacy and per­
ception of the discrepancy between actual and ideal behavior (Miller and
Rollnick 1991). Motivational interviewing is explicitly empathic and does
not involve a coercive therapist position with respect to the patient’s ac­
tions about reducing or stopping substance use; the patient might expe­
rience such a position as demeaning and damaging to self-esteem. A
premise of motivational interviewing is that patients can decide to make
changes on the basis of their own shifts in motivation. The techniques of
motivational interviewing include listening reflectively and eliciting mo­
tivational statements from a patient, examining both sides of the patient’s
ambivalence, and reducing resistance by monitoring patient readiness and
not pushing for change prematurely (Miller and Rollnick 1991). When
the patient experiences that the negative consequences of substance use
outweigh the positives ones, the so-called decisional balance is tipped in
favor of engagement in treatment.
The respectful, collaborative, and empathic style of both motivational
interviewing and supportive psychotherapy supports the development of
a positive and healthy relationship that can reinforce reduction or cessa­
tion of substance use (Miller and Rose 2010). The supportive technique
of clarifying the patient’s role expectations and therapist’s objectives and
rationale early in treatment is advisable because discrepancy between role
expectations and experiences in therapy may correlate negatively with al­
liance in patients with substance use disorders (Frankl et al. 2014).

PATIENT: OK, so I’ll come in every week and you’ll tell me what I should
work on (patient demonstrates expectation of a passive role in
therapy).
THERAPIST: Not exactly. It sounds like you’re expecting to have a more di­
rected experience here, like in a classroom where the teacher lectures
you and maybe gives you homework assignments (uses metaphor to
clarify meaning of prior statement).
PATIENT: What’s wrong with that? Aren’t you are the addiction expert?
(deflects and challenges)
THERAPIST: Nothing is wrong with that (doesn’t argue).
PATIENT: I thought you’d figure out what’s wrong with me and fix it (re­
states the passive role expectation).
154 Learning Supportive Psychotherapy

THERAPIST: Well, actually, we’re both going to try to better understand

your problems with substances, and then we’ll collaborate on set­
ting your goals and helping you meet them. There will be plenty of
opportunity for me to give you information sometimes, but mostly
you’ll be learning through your community support services and
online sites I recommend. I’ll present my clinical objectives to you
so we can discuss them. But this is important: if you’re working ac­
tively with me and you feel responsible to pursue the goals that
make sense to you, you’re more likely to have a better outcome here
(informs about approach; supports agency).

Substantial evidence supports motivational interviewing as an effective

intervention for substance use disorders—especially with regard to promot­
ing entry into and engagement in more intensive treatments for substance
use—even when the technique is used by clinicians who are not specialists
in substance use treatment (Dunn et al. 2001). Therefore, motivational in­
terviewing is a mainstay of supportive treatment of substance use disorders.

Adaptive Skills and Relapse Prevention

The main content of supportive treatment of substance use disorders is the
work of achieving and maintaining abstinence from substances of abuse.
Patients must learn new strategies that assist them in coping with craving
states, negative emotions, general stress, and cues in the environment that
serve as high-risk triggers for substance use. Long ago, the proponents of
Alcoholics Anonymous identified exposure to the people, places, and
things associated with alcohol use as a primer to relapse. A commonly
heard maxim is that stopping the use of drugs is relatively easy, but remain­
ing drug-free is hard. The specific adaptive skills that must be learned in ad­
diction recovery are 1) identifying high-risk situations and cues,
2) anticipating exposure to these situations and cues, and 3) developing al­
ternative strategies for coping when exposed to these situations.
Relapse prevention involves a formal set of cognitive-behavioral ap­
proaches to maintaining abstinence that are easily woven into supportive
treatment. In relapse prevention, a systematic effort is made to identify the
patient’s specific relapse triggers and to devise and have the patient practice
alternative behaviors and coping skills to deal with these triggers, such as re­
fusal skills for when the patient is offered the target substance (Marlatt and
Gordon 1985). However, identification of risky situations and develop­
ment of coping skills to address these situations can also be done in a less
structured fashion in supportive and supportive-expressive psychotherapy
(Luborsky 1984). In any case, anticipatory guidance, encouragement, and
reassurance are key supportive techniques that are used when identifying
and rehearsing skills to cope with an expected situation. The therapist
Applicability to Special Populations 155

works to establish achievable intermediate goals, which help to reduce the

risk of failure and of further damage to the patient’s self-esteem.
When the patient reports that he or she has successfully negotiated
some element of a high-risk situation, praise from the therapist related to
the patient’s goals is meaningful and reinforces the improvement in adap­
tive skills. The patient should already have experienced some increase in
self-esteem through an experience of competence in achieving a life skill.
If the patient tries but does not succeed, some praise is indicated because
the patient tried to implement the adaptive skill. After some problem
solving together, the therapist encourages the patient to try the skill again
and reassures him or her about doing so. Thus, progress in executing new
skills may be incremental, and the therapist offers measured but increas­
ingly intense praise and positive feedback for each successive goal met.
Because a dysphoric mood is a frequently reported antecedent of re­
lapse, the supportive treatment of substance use disorders also must focus
on building adaptive skills for coping with negative or painful mood states
(Marlatt and Gordon 1980). Substance-using individuals often have a dif­
ficult time differentiating mood states into specific affects, in part per­
haps because they use the drugs to self-medicate dysphoria rather than
developing psychological means to cope with the painful affects (Keller
et al. 1995; Khantzian 1985). Therefore, therapists need to help patients
with substance use disorder begin to reduce alexithymia in distinguishing
one feeling from another. As Misch (2000) described, the ability to iden­
tify and label feelings makes it easier to reflect on these feelings and com­
municate about them to others. If the patient cannot notice and
discriminate feelings, he or she cannot make clear connections between
those feelings and the thoughts, behaviors, or events linked to drug use.
For example, if patients cannot recognize when they are irritable and sad,
they will not be able to connect either state to the automatic thoughts
that they generate in response (e.g., “I’m feeling irritated, so I must get a
bottle”). The ability to label feelings is essential for developing appropri­
ate adaptive skills to manage painful affects. As patients begin to identify
these feelings, they experience—in spite of increased awareness of nega­
tive affect—an increase in self-esteem that comes from mastery of the in­
ternal environment. The affects begin to be reframed as useful tools in
identifying risky states that set up patients for relapse.

Psychoeducation
In the area of substance use disorders, education efforts focus on teaching
patients about different classes of abused drugs, psychological and physical
effects of drugs, dangers of chronic abuse, the fact that drugs may be used
156 Learning Supportive Psychotherapy

to self-medicate, and a disease model of addiction. Most cultures implicitly

or explicitly operate out of a moral model of substance abuse and addic­
tion, which attributes the irresponsible or criminal behavior of the addicted
individual to his or her bad character. In contrast, the unitary disease con­
cept of addiction, variously attributed to Alcoholics Anonymous (1976) or
Jellinek (1952), stresses that addiction is a chronic, relapsing, and pro­
gressive illness. Furthermore, the advocates of the disease concept
thought it was a mistake to think of alcoholism as a symptom of another
disorder, such that if an underlying conflict were resolved in expressive
treatment, the patient would stop drinking (Rosenthal and Westreich
1999). Jellinek’s approach to alcoholism was not actually so reductionis­
tic; he in fact described several typologies, which differed regarding onset,
severity, pattern, and chronicity of use. Nonetheless, the psychothera­
peutic utility of this heuristic approach is that it increases self-esteem by
offering the patient a diagnosis rather than blame, helps the patient to
cope better with shame (given that most patients presume that the moral
model explains their own behavior), and offers another framework in
which to foster a therapeutic alliance.
The following vignette illustrates the use of psychoeducation with a
patient who uses substances nonmedically (see Video Vignette 6, avail­
able at www.appi.org/Winston).

Video Vignette 6: Substance Use Disorder

Kevin Waters is a 28-year-old single man who studied structural en­

gineering in college but is currently unemployed, having been fired
from his most recent of a string of jobs over the last few years, since
he began using cocaine. He typically gets caught up in cocaine
bingeing and fails to show up or notify his place of employment,
with predictable results. He was living with his younger sister, her
husband, and their 2-year-old daughter but was told to leave when
he returned after a 3-day cocaine binge. He comes to the session full
of regret and self-recrimination, a strong sense of the moral failure
he has been given as feedback from both employers and family, and
hopelessness.

In other cases, when a patient has less awareness of the negative

consequences of his or her substance use, a therapist might rely
more strongly on motivational interviewing techniques in the early
phases (including nonjudgmental feedback to help the patient con­
nect cause and effect) to assist the patient in deciding that his sub­
stance dependence is not worth what it costs in his life. In this
Applicability to Special Populations 157

session, the therapist instead uses psychoeducation to address

Kevin’s denial and uses a moral model to explain his addictive be­
havior. Because the moral model is intrinsically disempowering,
which decreases self-esteem, the objective is that Kevin understand
the disease concept and recognize that the loss of control is an in­
herent quality of substance dependence. Kevin may then feel more
empowered to make decisions that incorporate that reality rather
than channeling his energy into the self-blaming and unfruitful be­
havior that typically precedes or sustains a relapse.

KEVIN: I can’t stop the crack. I got thrown out of the house. I got no
job, I got no money, I got no girl. I got nothing, except crack.
I’ve blown up my life [sighs, looks at therapist]. Maybe they’re
right. Maybe I’m just no good [looks down, shakes head, tears
up] (attributes his drug-related losses and maladaptive
behavior to being a bad person).
THERAPIST: I know that the pain you’re in right now makes you want
to just blame yourself. And you’ve got a lot of reasons to feel
bad right now. But can I ask you to consider your intentions for
just a moment? It’s important, but it will take a bit of reflection
(Empathically focuses patient away from self-blame to
cognition).
KEVIN: OK.
THERAPIST: If you knew then what you know now—that your use re­
sults in the way your life is right now and the way you feel
now—would you have done it anyway? (clarification)
KEVIN: I don’t think so. No, of course not. I wouldn’t have done this if
I had known.... No. (takes rational position)
THERAPIST: So, what I’m saying to you is that your situation is predict­
able. This is what happens to people who become addicted to
crack. Addiction is like a runaway train: Once you get on
board, you don’t necessarily go where you want the train to
go. You go where the train takes you (generalizes to others
who have the same well-described problem; offers
teaching metaphor).
KEVIN: Yeah, but I’m the one who keeps doing it. I’m the one who
started this up. I’m the one who doesn’t stop. Like there’s
something’s wrong with me! I’m stupid! (retreats to moral
model explanation; holds on to denial of loss of control)
THERAPIST: Well, I guess blaming yourself gives you some sense that
you’re still in control of this situation and that it’s OK, when
clearly it’s not.
KEVIN: I don’t understand.
THERAPIST: Well, let me put it this way: If you were stupid and couldn’t
learn, then that would explain the situation, but you’re not
stupid. You studied engineering successfully in college. Right?
(confronts distortion in self-description; builds alliance
158 Learning Supportive Psychotherapy

through demonstrating knowledge of patient’s per­

sonal history)
KEVIN: Yeah, OK. So, I’m not stupid-stupid, but I’ve done such stupid
stuff! [scowls] Maybe my sister is right; maybe I’m just weak
and selfish (acknowledges distortion but retreats to a dif­
ferent form of self-blame).
THERAPIST: So you just told me that if you knew then what you know
now, you would not have made the same choices, and that
now you’re in a position where you can’t stop. That’s why we
call it a disease. Loss of control comes with the territory; it’s
part of the disease. Drugs are powerful that way (confronts
denial, which is maladaptive for this patient, and offers
a different explanation).
KEVIN: I understand what you’re saying, but you might be saying this
just to make me feel better—and that’s fine—but I’ve got the
rest of the world telling me I’m a waste of skin. I appreciate
that, but...
THERAPIST: Let me show you something. These are the criteria for sub­
stance dependence in DSM [substance use disorder in DSM-5].
What you see here is that loss of control is one of the major
symptoms. Right? [opens to criteria for substance use disorder
and points to the text while reading out loud] “The substance
is often taken in larger amounts or over a longer period than
was intended. There is a persistent desire or unsuccessful ef­
forts to cut down or control substance use” (American Psychi­
atric Association 2013a, p. 483) (uses props, if necessary, to
concretize the ideas and demonstrate expertise).
KEVIN: Huh. So I’ve tried so many times to just do only some, but I al­
ways spend everything I have (recognizes own loss of con­
trol; becomes sad).
THERAPIST: So, maybe initially when you started, you made the mis­
take of thinking that you could get away with just using, but
that was a long time ago. Things are a little different now.
What you have now is called a disorder. Addiction and alcohol­
ism are things that run in families. They are inherited. The risk
is inherited, and drug problems are very similar (supports pa­
tient’s understanding with clarification, normalizing, ra­
tionalizing, and new knowledge).
KEVIN: My dad was an alcoholic. So was my uncle. I think that’s what
killed my uncle (confirms understanding that his prob­
lems are more than about just willpower).
THERAPIST: So, that’s my point. It’s not your fault—but maybe now
you understand that you and I must work together in order to
help you fight this disease (sides with the patient against
the disease; supports the need for collaboration).
KEVIN: It just seems impossible. Do you think I really can get help with
this? (elicits reassurance)
THERAPIST: I know it seems that way now, particularly when you rec­
ognize the loss of control, but this is a very common experience
Applicability to Special Populations 159

for people who are in the early stages or in the beginnings of

recovery. But those who stay with treatments tend to have bet­
ter outcomes than those who don’t stay with treatments (of­
fers empathic reassurance based on expert knowledge,
normalizing).
KEVIN: I hope you’re right.
THERAPIST: I know right now it seems like there’s a very long way to
go. This is going to be difficult, but addiction is a treatable ill­
ness, like many other chronic illnesses. We don’t have a cure
for diabetes. We don’t have a cure for hypertension. But peo­
ple are able to recover from the more severe forms of the ill­
ness. Even with the illness being out of control, they can go on
to have better lives (expert opinion, normalizing, and of­
fering reassurance).

Co-occurring Mental Illness and Substance

Use Disorders
Prevalence and Treatment
About half of the population with severe mental disorders is affected by
substance use disorders (Regier et al. 1990). Clinical samples of psychi­
atric patients often have higher than usual rates of alcohol use disorders
and other substance use disorders (Fernandez-Pol et al. 1988; Fischer et
al. 1975; Galanter et al. 1988; Richard et al. 1985). In the National Co­
morbidity Survey, Kessler et al. (1994) found that of the population who
had psychosis or mania or who needed hospitalization for a mental disor­
der in a 12-month period, almost 90% met the criteria for three or more
lifetime alcohol or drug use disorders or mental disorders.
Co-occurrence of substance use and other mental disorders has a nega­
tive effect on the trajectory of and recovery from both disorders (Rosenthal
and Westreich 1999). Because patients with substance use disorders and
schizophrenia are difficult to engage in treatment, supportive psychother­
apy, with its focus on building and maintaining a therapeutic alliance, is a
good treatment approach for this population (Carey et al. 1996; Lehman
et al. 1993). Supportive treatment for those with both disorders inte­
grates the techniques that are useful for each problem, as delineated in
the sections “Severe Mental Illness” and “Substance Use Disorders” ear­
lier in this chapter. Improving adaptive skills by increasing competence
in basic conversational and recreational skills, using medication and
symptom management, and using relapse prevention for negotiating sit­
uations likely to trigger relapse to substance abuse are all generally
needed to treat co-occurring substance use disorders and other mental
160 Learning Supportive Psychotherapy

illnesses. Implementing these interventions has a beneficial effect on

treatment retention and substance use in patients with psychotic illness
and substance use disorders (Ho et al. 1999). Multiple studies have
shown that psychosocial treatment that integrates psychiatric and addic­
tion treatment components leads to better retention and better outcome
among patients with severe mental illness and substance use disorders
(Drake et al. 2001; Hellerstein et al. 1995).
Additional factors that work in concert with individual supportive
treatments are support for patient involvement in 12-step programs (es­
pecially programs that are less likely to reduce self-esteem, such as “dou­
ble trouble” or dual recovery groups) and family psychoeducation. In
addition to praise, support for access to concrete services, socialization,
recreation, and other opportunities can serve as positive reinforcement
for attendance and may support the development of a therapeutic alli­
ance and the engagement of patients in treatment (Rosenthal et al. 2000).

Psychoeducation
In the context of supportive treatment, patients with substance use dis­
orders and mental illness should be given information about both classes
of disorders. Like other supportive techniques, psychoeducation must be
formulated in the context of the therapist’s appraisal of the patient’s ca­
pacity to make use of the information in a way that supports ego function
or adaptive skills. For example, when a patient with a severe mental ill­
ness learns that he or she has another chronic illness such as substance de­
p e n de nc e , t h is k n ow l e d g e c a n be c o m e a f a c t o r i n h is o r h e r
demoralization (Rosenthal and Westreich 1999). The therapist teaches
about both the substance dependence and the other mental illness: their
symptoms, treatment, and natural history. Patients are encouraged to dis­
cuss their own symptoms and their own history of treatment responsive­
ness and to attempt to understand what role their substance abuse may
have played in either relieving or exacerbating psychotic, mood, and anx­
iety symptoms.
Most patients with co-occurring substance use disorders and severe
mental disorders who come into contact with treatment systems are not
motivated to stop the use of substances. With these patients, motivational
interviewing techniques can be useful within the context of supportive
psychotherapy (Ziedonis and Fisher 1996; Ziedonis and Trudeau 1997).
The process of recovery in patients with comorbid substance use disor­
ders and other mental disorders is not linear, and exacerbation of both dis­
orders is episodic. Patients may cycle repeatedly through different phases
of treatment—engagement, active treatment, maintenance, relapse, and
then reengagement. When patients come back into contact with treating
Applicability to Special Populations 161

clinicians after a relapse, they may be in an earlier motivational stage; they

may even be in denial that a substance abuse problem exists (Prochaska
and DiClemente 1984). Motivational techniques, which are traditionally
used at the beginning of therapy to engage patients with substance use
disorder in treatment, are thus used as a continuing component of sup­
portive treatment for patients with co-occurring substance use disorders
and severe mental illness. This approach is needed because patients cycle
between motivational levels, with the various flare-ups of substance use
disorders and other mental illness over time (Rosenthal and Westreich
1999). The time frame of recovery from substance use disorders is longer
for patients with dual diagnoses than for patients without comorbid se­
vere mental disorders. If a patient remains in treatment, however, reduc­
tion in severity of both disorders is a realistic prospect (Drake et al. 1993;
Hellerstein et al. 1995).

Conclusion
Supportive psychotherapy provides a broad basic platform for psycho­
therapeutic intervention; therefore, treatment strategies and approaches
such as motivational interviewing, psychoeducation, and relapse preven­
tion, which are typically associated with specific clinical subpopulations,
can be readily implemented in the context of treatment with supportive
psychotherapy. In patients with personality disorders, supportive psycho­
therapy has beneficial impact and can serve as a natural platform for in­
tegrating other treatment strategies (e.g., using dialectical behavior
therapy for patients with borderline personality disorder). In populations
such as those with co-occurring substance use and other mental disorders,
the alliance-building strategies of supportive psychotherapy plus motiva­
tional techniques can be applied over time to help maintain the patient’s
engagement in treatment through cycles of relapse and recovery.
Evaluating
Competence and
9
Outcome Research

The Accreditation Council for Graduate Medical Education (ACGME)

defined six areas of competence for medical trainees: 1) patient care,
2) medical knowledge, 3) practice-based learning and improvement,
4) interpersonal and communication skills, 5) professionalism, and
6) systems-based practice (Accreditation Council for Graduate Medical
Education 2014). Although outlining and describing areas of competence
are within grasp at the present time, the tasks of defining, evaluating, and
measuring competence of trainees are more complex. Development of
measurement tools and their application to specific areas of competence is
under way but still in an early stage.
The ACGME suggested a number of methods of measuring compe­
tence. These methods include various types of written, oral, and clinical
examinations; a combined assessment approach of patient, family, super­
visors, and others; record reviews; portfolios and case logs; simulations,
models, and use of standardized patients; and evaluation of live or re­
corded performance (Accreditation Council for Graduate Medical Edu­
cation 2015). The Residency Review Committee for Psychiatry chose

163
164 Learning Supportive Psychotherapy

five types of psychotherapy in which residents in psychiatry must be cer­

tified as competent by their training programs, but a few years later de­
creased this requirement to three types: supportive, psychodynamic (or,
in our terminology, expressive), and cognitive-behavioral psychothera­
pies (Accreditation Council for Graduate Medical Education 2014). In
this chapter, we outline our approach to evaluating competence of psy­
chiatry trainees in one of these three psychotherapies—namely, support­
ive psychotherapy.
The definition of competence is a major issue that needs to be ad­
dressed. An acceptable definition of competent is “having requisite or ad­
equate ability or qualities” (Merriam-Webster’s Collegiate Dictionary, 11th
Edition). Epstein and Hundert (2002) defined professional competence as
“the habitual and judicious use of communication, knowledge, technical
skills, clinical reasoning, emotions, values, and reflection in daily practice
for the benefit of the individual and community being served” (p. 226). In
assessments of psychotherapy trainees, supervisors should look for com­
petence, not a high level of expertise (Manring et al. 2003).
When addressing a resident’s competence, it is necessary to define what
will be assessed and the method or methods of assessment. The evaluation
process should be educational and promote resident learning. Professional
competence can be conceptualized as a continuum of levels of ability or
skill, from beginner to competent to expert. A trainee would be expected
to be competent and thus be at the middle of this continuum.

Research Studies on the Teaching

of Psychotherapy
There are a few relatively recent research studies on the teaching of psy­
chotherapy. Truong et al. (2015) identified and evaluated studies on
teaching psychotherapy to psychiatry residents and medical students.
They found nine studies, but only one trial was judged to be methodolog­
ically rigorous. They called for additional well-designed studies to evalu­
ate the teaching of psychotherapy to trainees.
Sudak and Goldberg (2012) reported their findings of a survey of U.S.
general psychiatry training directors about the amount of didactic training
and supervised clinical experience and the number of patients treated in the
models of psychotherapy mandated by the Residency Review Committee
for Psychiatry. They found expressive psychotherapy training to be the most
robust, with the greatest variability, and training in cognitive-behavioral
therapy was found to have advanced significantly. Supportive psychother­
apy was the most widely practiced but received the least amount of didactic
time and supervision.
Evaluating Competence and Outcome Research 165

Feinstein et al. (2015), at the University of Colorado, opted to teach

psychiatric residents about the common factors in psychotherapy that
positively affect psychotherapy outcomes. However, they did not study
how learning about common factors enables residents to produce better
psychotherapy outcome results. Gastelum et al. (2013) proposed an in­
tegrated approach for teaching psychodynamic psychotherapy to trainees
in which uncovering and supportive techniques are taught side by side
with specific guidelines for assessing when to use one set of interventions
or the other. Unfortunately, they did not describe or propose a study to
evaluate this approach.
As can be gleaned from these few studies, there are essentially no
methodologically sound studies of psychotherapy teaching. Therefore, in
the next few pages we will describe our approach to psychotherapy
teaching and supervision, which is based on the American Association of
Directors of Psychiatric Residency Training competencies for supportive
psychotherapy. We believe that our approach is in keeping with the
teaching of the core clinical principles of supportive psychotherapy,
which is accepted at most psychiatry teaching programs.

Psychotherapy Supervision
Assessment of residents’ competence in psychotherapy is an ongoing pro­
cess in many residency programs. Evaluations of residents are performed
by clinical supervisors during the process of psychotherapy supervision
and are formally discussed with the residents one or more times a year.
Clinical supervision, as well as more formal seminars and classroom
teaching, has long been a part of psychotherapy training. Seminars and class­
room approaches generally consist of reading courses, in which psychother­
apy theory and practice are taught, and clinical case seminars, which focus
on evaluation, case formulation, diagnosis, and ongoing psychotherapy.
Many training programs in psychiatry have established traditions of inten­
sive individual supervision of residents, particularly in long-term expressive
(exploratory) psychotherapy. The process of supervision may vary from one
program to another but generally involves the following:

1. Presentation of the case by the resident

2. Discussion of the diagnosis, case formulation, goals, and treatment plan
3. Ongoing summary of sessions by the resident, using an informal recall­
and-summary approach, process notes, video recordings, or a combi­
nation of these approaches
4. Discussion of the psychotherapy process, including resistance, dysfunc­
tional thinking, defenses, affect, and therapist interventions, as well as
166 Learning Supportive Psychotherapy

dynamics, genetics, psychological structure, cognitive-behavioral issues,

and the therapeutic relationship (transference, countertransference, and
the therapeutic alliance)

The supervisor has traditionally evaluated the resident’s work by not­

ing how well the resident performs the tasks listed above, as well as as­
sessing other areas such as the ability to listen and relate to the patient in
an empathic manner. The evaluation process by the supervisor is ongoing,
but formal evaluations are generally performed once or twice a year or
more. The formal evaluations are based on material discussed by the
trainee through the use of process notes. Traditionally, the entire process
has been somewhat informal and rarely standardized. In this chapter, we
propose a standardized evaluation approach, one based on the use of
video recordings during an ongoing course of psychotherapy.

Assessment
Focus
Assessment of competence in supportive psychotherapy should be eval­
uated within the broader context of general psychotherapy. The assess­
ment should encompass skills of, attitudes toward, and knowledge about
general psychotherapy and the more specific approach of supportive psy­
chotherapy. General psychotherapy skills, as described by the American
Association of Directors of Psychiatric Residency Training (AADPRT)
Psychotherapy Task Force (2000), include establishing and maintaining
boundaries and the therapeutic alliance, listening, addressing emotions,
understanding, using supervision, dealing with resistances and defenses,
and applying intervention techniques. Beitman and Yue (1999) described
a similar set of skills, which they called core psychotherapy skills. They in­
cluded other skills, such as identifying patterns and implementing strate­
gies for change. The AADPRT Psychotherapy Task Force also developed
psychotherapy competencies for the five psychotherapies originally man­
dated by the Residency Review Committee for Psychiatry, including sup­
portive psychotherapy. Table 9–1 includes the complete list of AADPRT
competencies for supportive psychotherapy (Pinsker et al. 2001).
The supportive psychotherapy competencies are divided into knowl­
edge about, skills of, and attitudes toward supportive psychotherapy. The
knowledge category encompasses knowledge about objectives, the pa­
tient-therapist relationship, and indications and contraindications for sup­
portive psychotherapy. The skills section contains 15 items, including the
ability to maintain a therapeutic alliance, the ability to use appropriate in­
terventions, and the ability to establish treatment goals. The attitudes sec­
Evaluating Competence and Outcome Research 167

Table 9–1. American Association of Directors of Psychiatric

Residency Training competencies for supportive
psychotherapy
Knowledge
1. The resident will demonstrate knowledge that the principal objectives of
supportive therapy are to maintain or improve the patient’s self-esteem,
minimize or prevent recurrence of symptoms, and maximize the patient’s
adaptive capacities.
2. The resident will demonstrate understanding that the practice of supportive
therapy is commonly used in many therapeutic encounters.
3. The resident will demonstrate knowledge that the patient-therapist

relationship is of paramount importance.

4. The resident will demonstrate knowledge of indications and

contraindications for supportive therapy.

5. The resident will demonstrate understanding that continued education in

supportive therapy is necessary for further skill development.
Skills
1. The resident will be able to establish and maintain a therapeutic alliance.
2. The resident will be able to establish treatment goals.
3. The resident will be able to interact in a direct and nonthreatening manner.
4. The resident will be able to be responsive to the patient and give feedback
and advice when appropriate.
5. The resident will demonstrate the ability to understand the patient as a
unique individual within his or her family and sociocultural community.
6. The resident will be able to determine which interventions are in the best
interest of the patient and will exercise caution about basing interventions
on his or her own beliefs and values.
7. The resident will be able to recognize and identify affects in the patient and
himself or herself.
8. The resident will be able to confront in a collaborative manner behaviors
that are dangerous or damaging to the patient.
9. The resident will be able to provide reassurance to reduce symptoms,

improve morale and adaptation, and prevent relapse.

10. The resident will be able to support, promote, and recognize the patient’s
ability to achieve goals that will promote his or her well-being.
11. The resident will be able to provide strategies to manage problems with
affect regulation, thought disorders, and impaired reality-testing.
12. The resident will be able to provide education and advice about the patient’s
psychiatric condition, treatment, and adaptation while being sensitive to
specific community systems of care and sociocultural issues.
168 Learning Supportive Psychotherapy

Table 9–1. American Association of Directors of Psychiatric

Residency Training competencies for supportive
psychotherapy (continued)
13. The resident will be able to demonstrate that in the care of patients with
chronic disorders, attention should be directed to adaptive skills,
relationships, morale, and potential sources of anxiety or worry.
14. The resident will be able to assist the patient in developing skills for self­
assessment.
15. The resident will be able to seek appropriate consultation and/or referral for
specialized treatment.
Attitudes
1. The resident will be empathic, respectful, curious, open, nonjudgmental,
collaborative, and able to tolerate ambiguity and display confidence in the
efficacy of supportive therapy.
2. The resident will be sensitive to sociocultural, socioeconomic, and

educational issues that arise in the therapeutic relationship.

3. The resident will be open to audiotaping, videotaping, or direct observation

of treatment sessions.
Source. Pinsker et al. 2001.

tion includes an empathic, respectful, nonjudgmental approach and sen­

sitivity to sociocultural, socioeconomic, and educational issues.

Method
Assessment of a trainee’s competence in supportive psychotherapy can
be accomplished using a number of different methodologies, including
administration of written and/or oral examinations that test the resident’s
knowledge base, use of simulated patients reading from standardized
scripts, the request that the resident respond to a patient vignette using a
supportive approach, and a supervisor’s evaluation of a resident perform­
ing supportive psychotherapy. A formal written evaluation of the resi­
dent by the supervisor should be completed at least twice a year. This
evaluation should be educative and be based on the supervisory work pre­
ceding the formal evaluation. The supervisor should provide the resident
with verbal feedback on a regular basis.
We have found that supervisor evaluations of ongoing, video-recorded
psychotherapy sessions are the best method of teaching and evaluating
residents. Video-recorded sessions enable the supervisor or resident eval­
uator to observe the conduct of psychotherapy directly. The more tradi­
tional method of summarizing a session or working from process notes is
less likely to convey what actually occurred in a psychotherapy session,
Evaluating Competence and Outcome Research 169

even under the best of circumstances. The availability of video recordings

opens the process of psychotherapy to an outside observer and makes
evaluation of therapy more objective.
Evaluation of video-recorded supportive psychotherapy sessions
should begin with the resident’s assessment of the patient and should
continue throughout a patient’s psychotherapy. Each supervision session
should begin with a brief summary by the resident, followed by a review
of the video recording. Because an entire video recording is likely too
lengthy for review in a supervisory hour, the supervisor and resident must
decide which segments to review. The choice of video segments for view­
ing can be made on the basis of the resident’s summary, which may point
to areas of difficulty or significance.
Having trainees view recordings of psychotherapy sessions conducted
by others essentially replaces a supervisory experience and can be used to
assess the trainee’s knowledge level, which cannot always be equated
with skill. This procedure allows for discussion of techniques and of the
broad range of possible therapeutic interventions.
A number of questions have been raised about the feasibility of using
video recordings of psychotherapy for supervision. Difficulties cited in­
clude the cost and maintenance of the equipment and the ability of resi­
dents to operate the recording equipment. The cost of video equipment
has decreased in recent years, enabling many training programs to offer
video recording to residents. Video equipment has become easy to oper­
ate, and residents are able to make good recordings. Therefore, it seems
feasible for residency programs to provide video equipment for residency
training in psychotherapy. In the event that video equipment cannot be
provided by the institution, it would not be unreasonable to require each
trainee to provide his or her own camera. After all, training programs gen­
erally do not provide each resident with textbooks. The main purpose of
recording is not to have a high-quality picture but rather an understand­
able audio that runs without attention from the therapist for the entire
session.
Some residency programs may not be ready to begin with evaluations
involving video. The evaluation form presented in the following subsec­
tion can be used to evaluate a trainee reporting on psychotherapy sessions
from process notes. Another approach would be to present a video re­
cording or written material from a supportive psychotherapy session and
ask the resident questions about the treatment plan, case formulation,
goals, technique, alliance, and so on. In addition, the resident could be
asked to respond to the patient’s complaints using a supportive psycho­
therapy approach.
170 Learning Supportive Psychotherapy

Assessment Instrument
The AADPRT supportive psychotherapy competencies provided the ba­
sis for our development of a rating form to be used as a measure of a res­
ident’s competence in supportive psychotherapy. Our form (Figure 9–1)
does not include all the items on the AADPRT list of competencies be­
cause it would not be practical or reasonable for training programs to use
lengthy evaluation forms for three different psychotherapies. In addition,
we modified or combined some items with other items from the support­
ive psychotherapy and general psychotherapy competencies.
The evaluation form covers three areas: knowledge (general psycho­
therapy competencies), attitudes, and skills. The rating is on a Likert scale
of 0–5 (0 = can’t say, 1 = unsatisfactory, 2 = approaching competence,
3 = competent, 4 = competent plus, 5 = expert). The advantages of this
evaluation form are that it can be scored and that it also includes space for
the supervisor’s comments. The final score is calculated by dividing the
number of questions scored into the total score. An average score of 3 or
better suggests that the resident has demonstrated competence in sup­
portive psychotherapy. In addition, the supervisor should write some
overall comments about the resident, including the resident’s strengths
and overall performance, the resident’s ability to work in and use super­
vision, and areas needing further work. The supervisor should discuss the
evaluation with the resident in a way that is supportive and promotes the
resident’s education.
Conferences in which supportive psychotherapy supervisors discuss
the supervisory and evaluation processes are important because they help
standardize the evaluation of competence in supportive psychotherapy.
One method of achieving reliability would be to have groups of supervi­
sors rate supportive psychotherapy video recordings and then discuss
their ratings. Discussions would be directed at reaching a consensus in the
evaluation ratings. This approach has been used in psychotherapy re­
search to measure therapist adherence to manual-based forms of psycho­
therapy (Waltz et al. 1993).
Supervisors in the Beth Israel Medical Center Psychotherapy Training
Program rated 51 residents on their supportive psychotherapy work using
the Resident Evaluation for Competence in Supportive Psychotherapy
(Figure 9–1). The vast majority of residents were rated as competent or
better. More important, the form served as a useful supportive psycho­
therapy evaluation guide for both residents and supervisors, and the su­
pervisors found the form to be useful and easy to use.
Evaluating Competence and Outcome Research 171

Resident Evaluation for Competence in Supportive Psychotherapy

Resident ________________________ Supervisor ___________________________

Date ___________________________ Period ______________________________

Instructions: Please evaluate the resident’s performance on the following items by

entering the appropriate number on the scoring line after each item.

Can’t Approaching Competent

say Unsatisfactory competence Competent plus Expert

0 1 2 3 4 5

Knowledge and attitudes Score

1. The resident demonstrates knowledge that the principal objectives of
supportive psychotherapy are to maintain or improve the patient’s self­
esteem, ameliorate or prevent recurrence of symptoms, improve
psychological or ego functioning, and enhance adaptive capacities. _____
2. The resident understands that supportive therapy is dynamically based
and is part of a continuum ranging from supportive to expressive
psychotherapy. ____
3. The resident demonstrates knowledge that the patient-therapist
relationship is of paramount importance and is not addressed unless it is
negative. ____
4. The resident demonstrates knowledge of indications and
contraindications for supportive psychotherapy. ____
5. The resident understands that appropriate boundaries (e.g., time, outside
agencies and relationships, confidentiality, professional attitude) must be
established and maintained. ____

Skills Score
1. The resident is able to establish and maintain a positive therapeutic
alliance and interact with the patient in an empathic, respectful, direct,
responsive, and nonthreatening manner. ____
2. The resident relates to the patient in a conversational manner (i.e., does
not interrogate or engage in passive listening). ____
3. The resident is able to establish realistic and appropriate treatment goals. ____
4. The resident uses supportive therapy interventions (clarification,
confrontation, interpretation, advice, reassurance, encouragement,
praise, rationalization, reframing) in an appropriate and timely manner. ____
5. The resident is able to respect and strengthen adaptive defenses,
distinguish between adaptive and maladaptive defenses, and work to
minimize anxiety in an appropriate and timely manner. ____
6. The resident provides education about the patient’s psychiatric
condition and medication, and if necessary, about community systems of
care and ancillary treatments. ____

Figure 9–1. Beth Israel resident evaluation form for competence

in supportive psychotherapy.
172 Learning Supportive Psychotherapy

7. The resident focuses on the patient’s present-day life while not ignoring
the past and consistently works at improving self-esteem, promoting
adaptation and ego functions, and ameliorating symptoms. ____

Total score: ____

Divided by number of items scored: ____ = ____

Supervisor’s comments (include comments on overall performance, strengths,

areas needing further work, and the ability to work in and use supervision):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Resident’s signature _______________________________________________________________

(This evaluation was discussed with me.)

Supervisor’s signature_______________________________________________________

Evaluation based on (check all that apply)

Weekly supervision ____ Review of psychotherapy video ____

Review of psychotherapy notes ____

Figure 9–1. Beth Israel resident evaluation form for competence

in supportive psychotherapy. (continued)

Outcome Research
In this section we report on a number of clinical trials of supportive psy­
chotherapy in the treatment of various psychiatric disorders. We discuss
some early uncontrolled studies and more recent controlled trials that ad­
dress the efficacy of supportive psychotherapy.

Menninger Psychotherapy Research Project

The psychotherapy research project of the Menninger Foundation was an
important early study comparing supportive and expressive psychother­
apy with psychoanalysis. Wallerstein (1986, 1989) studied the treat­
ment, clinical course, and posttreatment follow-up of 42 inpatients at the
Menninger Foundation. Findings included the following: psychoanalysis
produced more limited outcomes than predicted, whereas psychotherapy
including supportive psychotherapy often achieved more than predicted;
all the treatments became more supportive during the course of therapy;
Evaluating Competence and Outcome Research 173

and supportive interventions accounted for more of the change in out­

come. This study took a naturalistic approach, without control subjects or
random assignment of subjects, but it was noteworthy in calling attention
to the possible efficacy of supportive psychotherapy.

Schizophrenia Studies
In a National Institute of Mental Health study, patients with schizophrenia
were treated for 2 years with either exploratory, insight-oriented psycho­
therapy three times a week or the control therapy (called reality-adaptive,
supportive psychotherapy) once a week. Results provided clear evidence of
a better outcome for patients treated with the supportive psychotherapy
(Gunderson et al. 1984; Stanton et al. 1984). All patients were main­
tained on their usual medications throughout the study.
In another study, patients with schizophrenia were randomly assigned to
supportive psychotherapy or family treatment (Rea et al. 1991). Patients
were treated for 9 months and followed for 2 years. Supportive psycho­
therapy consisted of medication case management, crisis intervention,
and education about schizophrenia, whereas family treatment involved
problem-solving therapy and communication skills training. Patients in
supportive treatment had significant improvement in coping style com­
pared with patients in family therapy. However, the two groups were not
at comparable levels of coping skills at initiation of treatment, and this
fact was not considered in the statistical analysis.
Hogarty et al. (1997) stated that supportive psychotherapy fares less
well compared with other psychosocial approaches, such as family psy­
choeducation, skills training, or role therapy. Defining supportive psycho­
therapy as not including psychoeducation, skills training, or role therapy
approaches is problematic, however, because most therapists practicing
supportive psychotherapy commonly employ these approaches. Other
psychotherapy approaches with patients who have schizophrenia include
social skills training, which may be enhanced with amplified skills training
in the community (Glynn et al. 2002; Liberman et al. 1998).
A study in Copenhagen (Rosenbaum et al. 2012) compared support­
ive psychodynamic psychotherapy with treatment as usual, consisting of
psychoeducation: meetings with psychologists and social workers; group
meetings; and medical advice in patients with first-episode psychosis.
They found that the supportive psychotherapy group improved signifi­
cantly more than the treatment as usual group in social function and gen­
eral psychopathology.
In another study of first-episode psychosis using supportive psychody­
namic psychotherapy, Harder et al. (2014) found significant improve­
174 Learning Supportive Psychotherapy

ment on social functioning, overall symptoms, and positive psychotic

symptoms. The improvement found was not sustained at 5-year follow­
up. This finding is not surprising because most patients with psychotic
disorders require long-term follow-up to prevent relapse.
In a randomized controlled trial for young people at ultra high risk of
psychosis treated with cognitive therapy plus risperidone, cognitive ther­
apy plus placebo, or supportive therapy plus placebo, McGorry et al.
(2013) found that all groups improved substantially, particularly in terms
of negative symptoms and overall functioning.

Depressive Disorder Studies

In the National Institute of Mental Health Treatment of Depression Col­
laborative Research Program, two psychotherapies (cognitive-behavioral
therapy and interpersonal therapy) were compared with an antidepressant
(imipramine)–clinical management condition and a control condition con­
sisting of drug placebo and clinical management (Elkin 1994; Elkin et al.
1989; Imber et al. 1990). The clinical management was a low-level sup­
portive psychotherapy approach. The two psychotherapies were found to
be efficacious but not significantly different from the placebo–clinical
management condition on measures of depressive symptoms and overall
functioning.
Thompson and Gallagher (1985) studied 30 outpatients ranging in age
from 60 to 81 years. Patients were randomly assigned to a 16-week treat­
ment with cognitive therapy, behavior treatment, or supportive psycho­
therapy. Improvement was similar across the three treatment conditions
at termination, but at 1-year follow-up, more of the patients in supportive
psychotherapy received a diagnosis of depression. Unfortunately, the
small number of patients in each treatment group and the type of sup­
portive psychotherapy used make these findings of limited value.
In a randomized clinical trial involving 100 adolescents with depression,
Renaud et al. (1998) compared cognitive, family, and supportive psycho­
therapies and found that rapid responders to therapy had better outcomes
at 1-year follow-up and better scores on some measures at 2-year follow­
up. The investigators concluded that their findings suggest that patients
with milder forms of depression may benefit from initial supportive psy­
chotherapy or short trials of more specialized types of psychotherapy.
Maina et al. (2005) completed a randomized controlled trial compar­
ing brief dynamic therapy with supportive psychotherapy in treating pa­
tients with minor depressive disorders. Both therapies showed significant
improvement in comparison with nontreated control subjects, but brief
dynamic therapy was more effective at follow-up evaluation.
Evaluating Competence and Outcome Research 175

In a meta-analysis involving patients with major depression, de Maat et

al. (2008) compared short-term psychodynamic supportive psychotherapy
with antidepressant treatment and also with combined psychotherapy and
medication. The results of the meta-analysis indicated that combined ther­
apy is more efficacious than pharmacotherapy alone and that psychother­
apy alone and pharmacotherapy alone seem equally efficacious.
Kocsis et al. (2009) compared a cognitive-behavioral analysis system of
psychotherapy with brief supportive psychotherapy in their ability to
augment antidepressant nonresponse in patients with chronic depression.
Although 37.5% of subjects experienced partial response or remission,
neither form of adjunctive psychotherapy improved outcome compared
with a flexible, individualized pharmacotherapy regimen alone.
In a study comparing supportive psychotherapy and cognitive-behavioral
therapy for the treatment of depression following traumatic brain injury,
Ashman et al. (2014) found that both forms of psychotherapy were effi­
cacious in improving diagnoses of depression and anxiety and reducing
depressive symptoms.
Schramm et al. (2017) found that a specific form of cognitive-behavioral
therapy for chronic depression had somewhat better outcome results
than a nonspecific supportive psychotherapy. However, both forms of
psychotherapy produced good results, and the supportive psychotherapy
was not specific for depression.

Anxiety Disorder Studies

Systematic hierarchical desensitization was compared with supportive
psychotherapy in a 26-week treatment trial involving patients with vari­
ous types of phobias (Klein et al. 1983). Both treatments performed well,
and no difference was found between the two approaches. The authors
speculated that for individuals with phobia, psychotherapy serves as an
instigator of corrective activity outside the formal session by maintaining
exposure in vivo. In another study, patients with phobias and panic at­
tacks received either imipramine plus behavior therapy or imipramine
plus supportive psychotherapy (Zitrin et al. 1978). The majority of pa­
tients showed moderate to marked improvement, and there was no dif­
ference between behavior therapy and supportive psychotherapy in
terms of improvement rates.
In a study of social anxiety disorder (phobia), Alström et al. (1984)
found that supportive psychotherapy and prolonged exposure therapy
were equally effective. Herbert et al. (2009) compared individual cognitive­
behavioral therapy, group cognitive-behavioral therapy, and an educational­
supportive psychotherapy that did not contain specific cognitive-behavioral
176 Learning Supportive Psychotherapy

therapy elements in treating patients with social anxiety disorder. They

found that all three treatments produced significant reductions in symp­
toms and functional impairment, as well as improved social skills, with no
differences between treatments.
In another study of social anxiety disorder, Lipsitz et al. (2008) found
that supportive psychotherapy and interpersonal therapy produced sig­
nificant improvement from pretreatment to posttreatment, with neither
therapy being superior to the other. However, Shear et al. (2001) re­
ported that emotion-focused psychotherapy, a form of supportive psy­
chotherapy, has low efficacy for the treatment of panic disorder. They
compared emotion-focused psychotherapy with cognitive-behavioral
treatment, imipramine, or pill placebo in a study involving 112 subjects.
For studies on posttraumatic stress disorder, see the section on treat­
ment approaches in Chapter 7, “Crisis Intervention.”

Personality Disorder Studies

In a study comparing supportive with interpretive psychotherapy, Piper et
al. (1998) found no outcome differences between the two treatments. Pa­
tients presented with anxiety or depressive disorders, and 60.4% of subjects
had comorbid personality disorder. Hellerstein et al. (1998) compared
brief supportive psychotherapy with short-term dynamic psychotherapy
in treating patients with primarily Cluster C and not-otherwise-specified
personality disorders, as well as comorbid disorders such as depression or
anxiety. The authors reported similar efficacy on measures of symptom­
atology, presenting complaints, and interpersonal functioning. These
changes were found not only at termination but also at 6-month follow­
up. In a substudy of the study by Hellerstein et al. (1998), the authors
used the Inventory of Interpersonal Problems mapped to an interpersonal
circumplex model and graphically demonstrated lasting positive change
in interpersonal functioning in the subjects treated with supportive psy­
chotherapy (Rosenthal et al. 1999; Winston et al. 2001).
Clarkin et al. (2007) compared transference-focused psychotherapy,
dialectical behavior therapy, and supportive psychotherapy in patients
with borderline personality disorder and found significant positive change
in multiple domains after one year of treatment. They suggested that
these structured treatments for borderline personality disorder are gener­
ally equivalent with respect to broad positive change in these patients. In
another study of borderline personality patients, Jørgensen et al. (2013)
compared mentalization-based psychotherapy with supportive psycho­
therapy and found significant positive changes in both treatment groups
on general functioning, depression, and social functioning.
Evaluating Competence and Outcome Research 177

Eating Disorder Studies

An evaluation of the efficacy of family-based treatment compared with
supportive psychotherapy was undertaken by le Grange et al. (2007) for
adolescent bulimia nervosa. Family-based treatment was found to have a
clinical and statistical advantage over supportive psychotherapy.
Carter et al. (2011) examined the long-term efficacy of cognitive­
behavioral therapy, interpersonal therapy, and specialist supportive clinical
management in women with anorexia nervosa, with a mean follow-up of
6.7 years. They found no significant differences on outcome measures
among the three psychotherapies at long-term follow-up, although sup­
portive psychotherapy was associated with a more rapid response than in­
terpersonal therapy.

Medical Disorder Studies

Mumford et al. (1982) reviewed controlled studies of supportive psy­
chotherapy—including education about illness and treatments, cogni­
tive-behavioral techniques, and venting and reassurance in a supportive
relationship—in patients recovering from myocardial infarctions and sur­
gery. The authors found that compared with patients receiving only typ­
ical medical care, patients receiving psychological intervention had better
experiences with pain and increased patient compliance and speed of re­
covery, as well as fewer complications and fewer days in the hospital.

Conclusion
In this chapter, we have provided an overview of current efforts to eval­
uate the competence of residents engaged in various clinical tasks, and in
particular supportive psychotherapy, as well as a summary of outcome re­
search in supportive psychotherapy. We have presented a preliminary ap­
proach to evaluating psychiatry residents in supportive psychotherapy
using an adaptation of the AADPRT list of supportive psychotherapy
competencies. However, the process of evaluating competence is in an
early phase of development and will require a great deal of reflection,
planning, and study to achieve reliable and valid measurement systems.
The brief review of the efficacy of supportive psychotherapy indicates
that supportive treatment appears to be useful across a broad spectrum of
psychiatric and medical disorders. However, more research is needed to
clarify the indications for supportive psychotherapy and how this treat­
ment should be integrated with other psychotherapy approaches and
treatment with medication.
Questions for
Self-Study
10
Items 1–7
Match each of the following items with the form of psychotherapy with
which it is most closely aligned. Each item may be used once, more than
once, or not at all.

A. Supportive psychotherapy
B. Expressive psychotherapy
C. Both supportive and expressive psychotherapy
D. Neither supportive nor expressive psychotherapy

___ 1. Aims to help a patient to cope with symptoms

___ 2. Aims to change a patient’s fundamental personality
___ 3. Therapist plays an active and direct role
___ 4. Focuses on stability and adaptation
___ 5. The therapeutic relationship is important to the treatment process
___ 6. Focuses on resolution of unconscious conflict
___ 7. Its techniques are derived from a formal theory of mind

Items 8–10
Place each kind of therapeutic approach at the appropriate spot on the
supportive-expressive continuum.

179
180 Learning Supportive Psychotherapy

Supportive A Supportive B Expressive- C

relationship psychotherapy supportive
psychotherapy

___ 8. Psychoanalysis
___ 9. Counseling
___ 10. Supportive-expressive psychotherapy

Items 11–13
Identify the correct answer for each question.

___ 11. Which factor or combination of factors has been identified as

common to most forms of effective psychotherapy?

A. Atmosphere of warmth, hope, caring, and authenticity

B. Clear theoretical framework
C. Explicit and intense communication
D. Frequent confrontation and limit setting
E. Primary focus on behavior change

___ 12. Which of the following questions by a therapist is phrased in a

manner that is least supportive of the self-esteem of the patient?

A. What concerns do you have about your medication?

B. What happened when you stopped taking your medication?
C. When did you stop taking your medication?
D. When have you found it helpful to take your medication?
E. Why did you stop your medication?

___13. Which of the following are techniques associated with supportive

psychotherapy?

A. Advice, anticipatory guidance, naming the problem

B. Avoidance of discussions of practical issues
C. Cultivation of friendship between therapist and patient
D. Frequent interpretation of transference issues
E. Repeated self-disclosure by the therapist unrelated to patient
needs
Questions for Self-Study 181

Items 14–16
Match each of the following descriptions with the concept with which it
is most closely aligned. Each item may be used once, more than once, or
not at all.

A. Advice
B. Confrontation
C. Education
D. Reassurance
E. Reframing

___ 14. The therapist saying, “You really should do regular exercise.”
___ 15. The therapist saying, “Starting out slow with exercise is OK.”
___ 16. The therapist saying, “Exercise is important to overall health and
well-being.”

Items 17–21
Match each of the following items with the form of psychotherapy with
which it is most closely aligned. Each item may be used once, more than
once, or not at all.

A. Supportive psychotherapy
B. Expressive psychotherapy
C. Both supportive and expressive psychotherapy
D. Neither supportive nor expressive psychotherapy

___ 17. Involves active two-way communication between therapist and

patient
___ 18. Demonstrates respect for the patient as a person of worth and dignity
___ 19. Involves cultivation of friendship between therapist and patient
___ 20. Entails significant time and attention to the termination process
___ 21. May include adjuvant medication treatment

Items 22–25
Match each of the following descriptions with the concept with which it
is most closely aligned. Each item may be used once, more than once, or
not at all.

A. Advice
B. Confrontation
182 Learning Supportive Psychotherapy

C. Education
D. Reassurance
E. Praise

___ 22. The therapist saying, “Don’t quit your tennis team. Let’s keep
talking about it more before you decide.”
___ 23. The therapist saying, “Based on what we’ve discussed, my impres­
sion is that your tennis partner will still want to remain friends if
you make the decision to quit your tennis team.”
___ 24. The therapist saying, “It seems like you can’t handle the time de­
mands of being on the tennis team.”
___ 25. The therapist saying, “Transitioning from being on the tennis
team—spending less time on the courts and giving more time to
your studies and your relationship with your girlfriend—seems
like a really positive step forward in your life.”

Items 26–35
Identify the correct answer for each question.

___ 26. A 47-year-old woman seeks treatment 3 weeks after the sudden
death of her husband of 22 years. She is often tearful, has diffi­
culty sleeping, and feels worried about her future and the impact
of their father’s death on her teenage children. Which of the fol­
lowing is the most appropriate care?

A. Antidepressant medication
B. Benzodiazepine medication
C. Cognitive-behavioral therapy focused on negative cognitions
D. Long-term psychoanalytically oriented psychotherapy
E. Supportive therapy focused on grief and day-to-day coping

___ 27. Which of the following is necessary for supportive psychotherapy

to be effective?

A. Abstinence from all substances

B. Completion of a comprehensive medical evaluation
C. Compliance with medication treatment
D. Willingness to attend psychotherapy sessions
E. Withdrawal from all other forms of psychotherapy (e.g., couples
therapy)
Questions for Self-Study 183

___ 28. Which of the following patients is most likely to benefit from sup­
portive psychotherapy?

A. A patient who has been found to be malingering

B. A patient who has been recently diagnosed with cancer
C. A patient who is actively suicidal
D. A patient with factitious disorder
E. A patient with signs of acute alcohol withdrawal

___ 29. Establishing firm ground rules for behaviors and expectations in
therapy is especially important in supportive therapy involving
patients living with which of the following personality disorders?

A. Borderline
B. Dependent
C. Histrionic
D. Narcissistic
E. Schizoid

___ 30. Which of the following is the most accurate statement regarding
sexual involvement between a therapist and a patient in the con­
text of supportive psychotherapy, according to the American Psy­
chiatric Association and the American Psychological Association?

A. Always permitted
B. Never permitted
C. Not permitted while the patient is actively engaged in therapy
D. Permitted after the patient terminates the therapy
E. Permitted after the therapist terminates the therapy

___ 31. Examples of supportive psychotherapy techniques include which

of the following?

A. Advice
B. Disclosure
C. Homework
D. Reassurance
E. All of the above

___ 32. Which of the following is the most accurate statement regarding
self-disclosure by the therapist in the context of supportive psy­
chotherapy?
184 Learning Supportive Psychotherapy

A. Always permitted
B. Never permitted
C. Permitted when it serves to strengthen the therapeutic relation­
ship or advance therapeutic goals
D. Permitted when the patient appears to enjoy the therapist’s
personal story
E. Permitted when the patient consents to this part of the therapy

___ 33. Examples of social skills that can be developed in the context of
supportive psychotherapy include

A. Interviewing for a job

B. Making conversation and eye contact
C. Recognizing social cues
D. Rehearsing strategies for handling difficult situations
E. All of the above

___ 34. Which of the following may interfere with the effectiveness or
slow down the process of supportive psychotherapy?

A. Addiction issues experienced by the patient

B. Aggressive feelings toward the therapist
C. Negative transferential feelings experienced by the patient
D. Psychotic symptoms of the patient
E. All of the above

___ 35. Supportive psychotherapy is likely to be ineffective in the context

of which of the following conditions?

A. Adjustment disorders
B. Chronic medical conditions
C. Delirium
D. Early dementia
E. Substance use disorders

Items 36–42
Match each of the following descriptions with the concept with which it
is most closely aligned. Each item may be used once, more than once, or
not at all.

A. Supportive psychotherapy is valuable/indicated

B. Supportive psychotherapy may be valuable/indicated
Questions for Self-Study 185

C. Supportive psychotherapy is not valuable/indicated

D. Supportive psychotherapy is contraindicated

___ 36. Bereavement

___ 37. Factitious disorder
___ 38. Psychosis
___ 39. Depression
___ 40. “Baby blues”
___ 41. Locked-in syndrome
___ 42. Severe intellectual disability

Items 43–45
Identify the correct answer for each question.

___ 43. A 64-year-old man with long-standing bipolar disorder is encouraged

by his family to speak with a therapist about the challenges he is fac­
ing as he moves to a nursing home/residential treatment setting after
a recent hip replacement surgery. He has lived independently for
many years but accepts that the new living arrangement will be
helpful to him. Which of the following is the most accurate state­
ment about the goals of supportive psychotherapy treatment?

A. The goals should align with the issues that are most important
to the facility staff
B. The goals should align with the issues that are most important
to the family
C. The goals should align with the issues that are most important
to the patient
D. The goals should align with the issues that are most important
to the patient’s psychiatrist
E. The goals should align with the issues that are most important
to the patient’s surgeon

___ 44. A 28-year-old woman recently learned that she had been adopted
at birth and sought psychotherapy to deal with her feelings of an­
ger toward her biological parents and estrangement from her
adoptive parents. Which of the following is the most accurate
statement about the initial goals of the supportive psychotherapy
treatment?

A. Treatment should be fully directed toward eliminating the pa­

tient’s feelings of anger and estrangement
186 Learning Supportive Psychotherapy

B. Treatment should be fully directed toward issues other than the

patient’s feelings of anger and estrangement
C. Treatment should fully focus on helping the patient cope with
feelings of anger and estrangement
D. Treatment should fully guarantee a reduction in feelings of anger
and estrangement
E. Treatment should fully replace feelings of anger and estrange­
ment with feelings of joy and emotional connection

___ 45. An 18-year-old high school graduate feels unsettled by the pros­
pect of attending college across the country in just a few months.
Which of the following is the most accurate statement about psy­
chotherapy in this context?

A. Engaging in supportive psychotherapy for a few months is not

likely to be beneficial
B. Engaging in supportive psychotherapy in one state and then
moving to another state is not likely to be beneficial
C. Engaging in supportive psychotherapy focused on issues of sep­
aration and adaptation to the new college environment may be
helpful
D. Engaging in expressive psychotherapy with the goal of person­
ality change is recommended in this situation
E. Engaging in expressive psychotherapy with the goal of delaying
the transition to college out of state is recommended in this sit­
uation

Items 46–50
Match each of the following descriptions with the concept with which it
is most closely aligned. Each item may be used once, more than once, or
not at all.

A. Supportive psychotherapy is valuable and is indicated as a first-line

treatment
B. Supportive psychotherapy may be valuable and is indicated as a first­
line or adjuvant treatment
C. Supportive psychotherapy is not valuable and is not indicated as a
first-line treatment
D. Supportive psychotherapy is not valuable and is not indicated as a
first-line or adjuvant treatment
Questions for Self-Study 187

E. Supportive psychotherapy is contraindicated as a first-line or adjuvant

treatment

___ 46. An 18-year-old with new-onset psychosis who is acutely suicidal

___ 47. A 45-year-old with chronic schizoaffective disorder who is seeking
employment
___ 48. A 65-year-old experiencing grief and significant depressive symp­
toms after the loss of a lifelong partner
___ 49. A 25-year old with opioid dependence who requests substance
abuse detoxification
___ 50. A 35-year-old with symptoms of distress associated with gender
dysphoria who has been bullied at work

Items 51–55
Identify the correct answer for each question.

___ 51. Supportive psychotherapy is conducted in which of the following

communication styles?

A. Asymmetrical
B. Conversational
C. Formal
D. Oppositional
E. Technical

___ 52. Which of the following time frames is the focus of supportive psy­
chotherapy with a middle-age adult?

A. Adolescence
B. Childhood
C. Future
D. Past 5 years
E. Present

___ 53. For patients engaged in supportive psychotherapy, ongoing goals

of treatment should include which of the following?

A. Amelioration of symptoms
B. Enhancement of self-esteem
C. Improvement of adaptation to life circumstances
D. Improvement of overall functioning
E. All of the above
188 Learning Supportive Psychotherapy

___ 54. Positive prognostic features associated with decreased potential

for suicide include which of the following?

A. Aggressivity
B. Family support
C. Hopelessness
D. Pessimism
E. Recent psychiatric hospitalization

___ 55. Supportive psychotherapy for acute bereavement may include

which of the following?

A. Concrete assistance with routine activities

B. Diagnosis of underlying mental disorder affecting grief
C. Emotional support
D. Opportunity to express feelings of anger and loss
E. All of the above

Items 56–59
Match each of the following descriptions with the concept with which it
is most closely aligned. Each item may be used once, more than once, or
not at all.

A. Anticipatory guidance
B. Confrontation
C. Expressions of empathy
D. Praise
E. Silence

___ 56. Therapeutic relationship-building technique

___ 57. Esteem-building technique
___ 58. Skill-building technique
___ 59. Behavioral pattern recognition-building technique

Items 60–64
Match each of the following descriptions with the type of psychosocial in­
tervention or therapy with which it is most closely aligned. Each item
may be used once, more than once, or not at all.

A. Crisis intervention
B. Supportive psychotherapy
Questions for Self-Study 189

C. Both crisis intervention and supportive psychotherapy

D. Neither crisis intervention nor supportive psychotherapy

___ 60. Typically provided as soon as possible

___ 61. Focuses only on “here and now” issues
___ 62. Uses silence as a primary technique
___ 63. Typically involves one-to-one therapy
___ 64. Focuses only on unconscious processes

Items 65–68
Match each of the following descriptions with the psychotherapeutic ap­
proach with which it is most closely aligned. Each item may be used once,
more than once, or not at all.

A. Cognitive-behavioral approach
B. Dynamic approach
C. Genetic approach
D. Structural approach

___ 65. Focuses on fixed aspects of an individual’s personality

___ 66. Focuses on early development experiences that influence the pa­
tient’s current situation
___ 67. Focuses on current conflicts and their connection to primary or core
psychological conflicts
___ 68. Focuses on automatic thoughts and how they can be changed to
improve current life adaptation and behavior

Items 69–70
Identify the correct answer for each question.

___ 69. In supportive psychotherapy, treatment goals should not

A. Be defined mutually by the therapist and patient

B. Be documented in the patient’s health record
C. Ever require adjuvant medication
D. Evolve during the course of therapy
E. Remain fixed and unchangeable over time

___ 70. Occasional lateness by a patient in supportive psychotherapy is

handled by the therapist using
190 Learning Supportive Psychotherapy

A. A collaborative, problem-solving approach

B. A confrontational approach
C. An approach that focuses on addressing financial implications
D. An approach that focuses on therapy termination
E. An approach that focuses on unconscious conflicts

Items 71–75
Match each of the following descriptions with the concept with which it
is most closely aligned. Each item may be used once, more than once, or
not at all.

A. Likely to benefit: appropriate candidate for supportive psychotherapy

B. Uncertain: may or may not be appropriate candidate for supportive
psychotherapy
C. Not likely to benefit: not appropriate candidate for supportive psy­
chotherapy

___ 71. Individuals with impaired reality testing

___ 72. Individuals with mild intellectual disability
___ 73. Individuals with psychotic symptoms
___ 74. Individuals with alexithymia
___ 75. Individuals with advanced dementia

Answers
1 C; 2 B; 3 A; 4 A; 5 C; 6 B; 7 C; 8 C; 9 A; 10 B; 11 A; 12 E; 13 A; 14 A;
15 D; 16 C; 17 A; 18 C; 19 D; 20 C; 21 C; 22 A; 23 D; 24 B; 25 E; 26 E;
27 D; 28 B; 29 A; 30 B; 31 E; 32 C; 33 E; 34 E; 35 C; 36 B; 37 C; 38 B;
39 B; 40 A; 41 C; 42 C; 43 C; 44 C; 45 C; 46 E; 47 B; 48 A; 49 B; 50 A;
51 B; 52 E; 53 E; 54 B; 55 E; 56 C; 57 D; 58 A; 59 B; 60 A; 61 A; 62 D;
63 C; 64 D; 65 D; 66 C; 67 B; 68 A; 69 E; 70 A; 71 B; 72 B; 73 B; 74 B;
75 C
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 Index
Page numbers printed in boldface type refer to tables or figures.

Accreditation Council for Graduate unrecognized forms of, 25

Medical Education (ACGME), Anorexia nervosa, 177
163–164, 166 Anticipatory guidance, 64–65, 154
Activities of daily living, 63 Antidepressants
Acute bereavement, 92–93 chronic depression and, 175
Acute crisis, 91 personality disorders and, 149
Adaptive behavior Antisocial personality disorder, 149
advice and, 62–63 Anxiety
definition of supportive psycho­ reduction and prevention of,
therapy and, 9 65–69
supportive psychotherapy for severe resistance in therapeutic relation­
mental illness and, 143–147 ship and, 114–115
supportive treatment for substance schizophrenia and, 144
use disorders and, 154–155 Anxiety disorders, outcome research
techniques of supportive psycho­ on supportive psychotherapy for,
therapy and, 54, 60, 62–64 175–176
Adjustment disorders, 92 Assessment. See also Evaluation
Adolescents, and depression, 94 of competence in supportive
Affects, and structural approach to psychotherapy, 166, 170
case formulation, 44. See also diagnosis and, 33–34
Emotion(s) evaluation interview and, 34–35
Alcoholics Anonymous, 102, 154, 156 patient history and, 35–36
Alexithymia, 25, 93, 155 personality disorders and, 148
American Association of Directors of of suicidal patient, 134
Psychiatric Residency Training supportive-expressive continuum
(AADPRT), 165, 166, 167–168, and, 34, 35
170 therapeutic alliance and, 33
Anger triangle of conflict and triangle of
awareness-expanding interventions person, 36, 37

and, 70 video vignette of, 36–41

209
210 Learning Supportive Psychotherapy

Attacking questions, and self-esteem,

of psychodynamic formulations,

21
24

Automatic thoughts, and depression,

of structural case formulation, 45–

40
46

Autonomous functions, and case for­ of supportive-expressive continuum,

mulation, 45
9–10

Awareness, expansion of, 69–71 Change, concept of in literature on

psychotherapy, 29–30. See also
Beginning phase of treatment, 98–99. Personality change
See also Initiation Chronic pain, 92

Behavior. See Adaptive behavior; Clarification

Maladaptive behavior; Passive­ as awareness-expanding

aggressive behavior intervention, 69

Beth Israel Medical Center Psycho­ transference and, 14

therapy Training Program, 170,

Cognition, supportive psychotherapy

171–172
and faulty forms of, 29

Bipolar disorder, 143

Cognitive-behavioral approach, to case

Borderline personality disorder, 149–

formulation, 42, 48–49, 50–51

150, 176
Cognitive-behavioral therapy

Boundaries, professional, 101–104 depression following traumatic

Brief dynamic therapy, for depression,

brain injury and, 175

174
eating disorders and, 177

Brief psychotherapy
patterns of thought and maladaptive

crisis intervention and, 123

behaviors, 26

indications for, 101

relapse prevention for substance use

Bulimia nervosa, 94. See also Eating disorders and, 154

disorders supportive interventions and, 7

Buprenorphine, 151
Cognitive therapy, for PTSD, 133

Communication. See Conversational

Cancer, and depression, 90

style; Interpersonal communica­
Case formulation
tion theory

cognitive-behavioral approach to,

Community mental health movement,

42, 48–49, 50–51

and crisis intervention, 121

definition of, 41
Competence, in supportive psycho­
DSM-5 and, 41
therapy

dynamic approach to, 42, 46–48,

assessment of, 163, 166, 170

50
definition of, 164

genetic approach to, 42, 46, 50

methods of measuring, 163–164

personality disorders and, 148

psychotherapy supervision and,

structural approach to, 42–46, 49–

165–166, 168, 170

50
Conflict, triangle of, 36, 37

Case illustrations. See also Video

Confrontation

vignettes
as awareness-expanding technique,

of dynamic case formulation, 47–

69–70

48
transference and, 15

Index 211

Conscience, and case formulation, provision of food or small gifts in

45
office setting, 96

Contextual techniques, 53

Contraindications for supportive

Debriefing, and crisis intervention, 123,

psychotherapy, 94–95
136, 138, 140

Conversational style, in supportive

Defenses

psychotherapy, 16–19
approach to in supportive psycho­
Co-occurring mental disorders
therapy, 22–23

indications for supportive psycho­ case formulation and, 44

therapy and, 90
denial, 22

substance use disorders and, 159–

expressive approach to transference

161
and, 108

Coping skills
personality disorders and, 148

anxiety reduction in schizophrenia

Delayed grief, and schizophrenia,

patients and, 144

70

substance use disorders and, 152

Delirium, 94

Core beliefs, and case formulation,

Dementia, 94

48–49
Depression. See also Major depression

Core conflictual relationship theme

adaptive behavior and, 55

(CCRT), 47
indications for supportive psycho­
Core psychotherapy skills, 166
therapy for, 90

Corrective emotional experience, and

outcome research on supportive

transference, 28
psychotherapy for, 174–175

Counseling, and supportive-expressive

video vignette illustrating assess­
continuum, 6, 8
ment of, 37–41

Countertransference, and therapeutic

video vignette illustrating

relationship, 116–120
supportive-expressive

Crisis intervention
treatment of, 77–88

critical incident stress management

Desensitization, and behavioral

and, 136, 140

techniques in supportive

definition of crisis, 121

psychotherapy, 29

evaluation and, 123–126

Devaluation, and countertransference,
history and theory of psychiatric
119–120
care for, 121
Diagnosis, and assessment process,
indications for supportive psycho­ 33. See also Assessment; Case
therapy and, 91–93
formulation
psychotherapy as distinct from,
Dialectical behavior therapy, for
123, 135–136, 137–139 personality disorders, 150, 176

suicide and, 133–135 Disease model, of addiction, 156

therapeutic approaches to, 126–133 Disulfiram, 151

Critical incident stress management

“Doorknob issues,” and conduct of

(CISM), 136, 140

sessions, 97

Cultural context
DSM-5, and case formulation, 41

models of substance abuse and

Dynamic approach, to case

addiction, 156
formulation, 42, 46–48, 50

212 Learning Supportive Psychotherapy

Dysphoric mood, and substance use

termination phase of treatment

disorders, 155
and, 100–101

transference in, 106–109

Early life experiences, and psychody­ Expressive stance, in supportive

namic theory, 26–27

psychotherapy, 23

Eating disorders, 177. See also Bulimia

Eye movement desensitization and

nervosa
reprocessing, 133

Education. See also Psychoeducation

modes of action in supportive

Family. See also Interpersonal rela­
psychotherapy and, 28
tionships

psychotherapy supervision and,

assessment of risk of suicide and,

165–166, 168
134

teaching of supportive psycho­ psychoeducation on severe mental

therapy, 10–12, 164–165

illness for, 147

Ego functions
Family-based treatment, for eating

definition of supportive psycho­ disorders, 177

therapy and, 8–9

Fearfulness, and reassurance, 59

structural approach to case formu­ Food, and office arrangements, 96

lation and, 43
Freud, Sigmund, 13, 45, 109

techniques of supportive psycho­ Friends, and friendship. See also

therapy and, 54
Interpersonal relationships

Emotion(s). See also Anger; Corrective

assessment of suicide risk and, 134

emotional experience
professional boundaries and, 103

awareness-expanding interventions

and, 70
Genetic approach, to case evaluation,

countertransference and, 117

42, 46, 50

psychodynamic therapy and

Gifts, and therapist-patient relation­
unrecognized, 24–26
ship, 96

substance use disorders and, 155

Goals

Emotion-focused psychotherapy, for

of crisis intervention, 137

panic disorder, 176

definition of supportive psycho­
Encouragement, as technique, 60–61,
therapy and, 3

154
setting of in supportive psycho­
Evaluation, and crisis intervention,
therapy, 51–52

123–126. See also Assessment

Grief. See also Acute bereavement

Exhortation, as form of encourage­ crisis intervention and grief work,

ment, 61
121

Exposure therapy
unrecognized emotions and, 25, 70

PTSD and, 133

Ground rules of supportive psycho­
social anxiety disorder and, 175
therapy, 95

Expressive psychotherapy, 2, 5
Group therapy, for substance use

substance use disorders and, 151–

disorders, 152

152

supportive-expressive continuum
Harm avoidance, and personality

and, 6, 7, 9, 34
disorders, 148

Index 213

Help-rejecting, as contraindication
Lending ego, 64

for supportive psychotherapy, 94

Limit setting, and conduct of sessions,

HIV-positive patients, and depression,

98

92
Long-term psychotherapy, indications

Holding environment, and anxiety

for, 101

reduction, 66
Loss, and crisis intervention, 122

Homeostasis, and crisis intervention,

122
Major depression

Hospitalization, of suicidal patients,

contraindications for supportive

135
psychotherapy and, 94

outcome research on supportive

Ideals, and case formulation, 45

psychotherapy for, 175

Imipramine, 175, 176

video vignette of misalliance and,
Impulse control, and case formulation,
111–113
44
Maladaptive behavior
Initiation, of supportive psychotherapy,
countertransference and patterns of,
95. See also Beginning phase
117–118
Integrated psychotherapy, for PTSD,
psychodynamically oriented therapy
133
and, 26

Interpersonal communication theory,

Malingering, 94

and countertransference, 118–119

Mania, 143

Interpersonal relationships. See also

Maxims, and normalizing, 60

Family; Friends
Medical illness. See also Cancer

professional boundaries and, 103

indications for supportive psycho­
therapeutic alliance and, 55–56
therapy and, 92

Interpersonal therapy
outcome research on supportive

for eating disorders, 177

psychotherapy for, 177

for PTSD, 133

Medications. See also Self-medication

for social anxiety disorder, 176

personality disorders and, 148

Interpretation
substance use disorders and, 151

expressive approach to transference

suicidal patients and, 135

and, 108–109
Menninger psychotherapy research

techniques of supportive psycho­ project, 27, 89, 172–173

therapy and, 70–71

Mental illness. See also Anxiety
Interpretive psychotherapy, for
disorders; Bipolar disorder; Co­
personality disorders, 176
occurring mental disorders;
Interventions. See also Crisis interven­ Depression; Personality disorders;
tion; Techniques
Posttraumatic stress disorder;
specific techniques, 53
Psychopathology; Psychotic
transferences as guides to, 106
disorders
Inventory of Interpersonal Problems,
indications for supportive psycho­
176
therapy and chronic,
93–94
Lateness, of patients for sessions, 96–97 supportive psychotherapy for
Learning theory, 28–29 severe forms of, 141–142
214 Learning Supportive Psychotherapy

Mentalization-based psychotherapy, Overpowering statements, and

for personality disorders, 176
patient’s self-esteem, 20–21
Methadone, 151

Middle phase of treatment, 99–100

Panic disorder, and panic attacks, 94,

Mindfulness exercises, and dialectical

175, 176

behavior therapy, 150

Parents, as metaphor for supportive

Morals, and case formulation, 45

therapist, 31

Motivation and goal setting in

Paroxetine, 38

supportive psychotherapy, 51
Passive-aggressive behavior, 22

Motivational interviewing
Patient. See also Safety; Therapeutic

substance use disorders and, 152–

alliance; Therapeutic relationship
154, 161
goal setting in supportive psycho­
supportive conversational style and,
therapy and, 51–52
17
pattern of lateness to sessions, 96–97
Myocardial infarction, 177
video vignette of uncooperative,
71–77
Naltrexone, 151
Patient history, and assessment process,
Naming of problems, and reduction
35–36

of anxiety, 67
Person, triangle of, 36, 37

Narcissistic personality disorder, 148

Personal growth, and crisis states, 122

National Comorbidity Survey, 159

Personality change, and objectives of

National Institute of Mental Health,

supportive psychotherapy, 2, 51

173, 174
Personality disorders, 147–150, 176–

Negative transference, 108

177

Neurosis, 1–2
Pharmacotherapy. See Medications

Normalizing, and reassurance, 59–60

Phobia, 175

Positive reinforcement, and schizo­

Objectives, and definition of supportive
phrenia, 142

psychotherapy, 3
POST (psychodynamically oriented

Object relations, and case formulation,

supportive therapy), 3

43–44
Posttraumatic stress disorder (PTSD),

Observation, and transference, 14

and crisis intervention, 126, 133

Obsessive-compulsive disorder, 94
Praise, as technique, 56–57, 142, 155

Obstacles to treatment, and case

Prevalence, of co-occurring mental

formulation, 49
illness and substance use disorder,

Office arrangements, for supportive

159

psychotherapy, 95–96
Preventive psychiatry, and crisis inter­
Open-ended questions, and conversa­ vention, 121

tional style, 18
Problem list, and case formulation, 48

Origins
Prompts, and conversational style, 18

of core beliefs, 49
Psychoanalysis, and psychoanalytic

personal story of patient and, 30–31

theory

Outcome research, and clinical trials case formulation approaches and, 41

of supportive psychotherapy, development of supportive psycho­

172–177 therapy and, 1–2
Index 215

education of psychotherapists and, Questions

11 conversational style and patient’s
supportive-expressive continuum responses to, 17–18
and, 6 self-esteem of patient and, 21
Psychodynamic psychotherapy, 2, Rationalizing, and reduction of anxiety,
3–4 67–69
Psychodynamic theory Reality and reality testing, and case
psychoanalysis and development formulation, 42–43
of, 2 Reassurance, as technique, 58–60,
supportive-expressive continuum 154
and, 5–10 Reframing
supportive psychotherapy and reduction of anxiety and, 67–69
assumptions based on, 23–27 resistance in therapeutic relation­
Psychoeducation. See also Education ship and, 115
for family on severe mental illness, Rehabilitation, and encouragement,
147 60–61
substance use disorders and, 155– Rehearsal, and technique of anticipa­
159, 160–161 tory guidance, 64–65
supportive psychotherapy for severe Relapse
mental illness and, 143 prevention of as objective of sup­
Psychogenetics, 26–27 portive psychotherapy, 65
Psychological functions, and ego substance use disorders and risk of,
functions, 9 152, 154–155, 160
Psychopathology, supportive psycho­ Research
therapy and assessment of levels clinical trials on outcome of
of, 34, 35 supportive psychotherapy,
Psychopharmacology. See Medications 172–177
Psychotherapy. See also Expressive studies on teaching of psychother­
psychotherapy; Integrative psy­ apy, 164–165
chotherapy; Interpretive psycho­ Resentment, and negative emotions, 70
therapy; Psychodynamic Residency Review Committee for
psychotherapy; Short-term Psychiatry (ACGME), 163–164,
dynamic psychotherapy; Sup­ 166
portive psychotherapy; Transfer­ Resident Evaluation for Competence
ence-focused psychotherapy in Supportive Psychotherapy,
as distinct from crisis intervention, 170, 171–172
123, 135–136, 137–139 Resistance
efficacy of for personality disorders, elements of psychodynamic psycho­
148–149 therapy and, 4
research studies on teaching of, therapeutic relationship and, 113–
164–165 116
Psychotic disorders, supportive Respect, and patient’s self-esteem,
psychotherapy as adjuvant 21–22
treatment strategy for, 90. See Retelling, by individuals with trauma
also Schizophrenia history, 27
216 Learning Supportive Psychotherapy

Rewards, and positive reinforcement,

Skills building. See Adaptive behavior;
142
Problem solving; Social skills
Risk assessment, and crisis intervention,
training
134
Social anxiety disorder, 175–176
Social skills training, and schizophrenia,

Safety, of patient
144, 173. See also Interpersonal

borderline personality disorder and

relationships

sense of, 150

Somatization disorder, 92

crisis intervention and, 127

Stances

Schizoaffective disorder, 71–77

supportive-expressive continuum

Schizophrenia
and, 5, 7

anticipatory guidance and, 65

transference and expressive form

delayed grief and, 70

of, 14

outcome research on supportive

Stress, factors in individual response

psychotherapy and, 173–174

to, 122

reassurance and, 58
Structural approach, to case formula­
substance use disorders and, 159
tion, 42–46, 49–50

supportive psychotherapy for

Substance use disorders, and support­
severe mental illness and, 90,
ive psychotherapy, 92, 150–161

142–147 Suicide, and suicidal ideation

Seating, and office arrangement, 95–96 crisis intervention and, 133–135
Self-assertion, reframing of resistance dialectical behavior therapy and,
as, 115
150

Self-disclosure, of information by
prediction of, 133

therapist, 16, 102

Superego functions, and case formu­
Self-esteem
lation, 43, 45

adverse effects of anxiety on, 65

Supervision, and training in supportive

definition of supportive psycho­ psychotherapy, 165–166, 168,

therapy and, 8
170

development of as technique, 19–

Supportive-expressive continuum

22, 54, 56–61, 142

assessment process and, 34, 35

substance use disorders and, 155

psychodynamic theory and, 5–10

suicidal patients and, 135

Supportive-expressive treatment,
Self-help groups, and models of self­ video vignette of, 77–88
disclosure of information, 102
Supportive psychotherapy. See also
Self-medication, and substance use
Assessment; Competence; Crisis
disorders, 155, 156
intervention; Education; Tech­
Setting the agenda, as tactic in
niques; Therapeutic relationship
supportive psychotherapy, 22
contraindications for, 94–95
Short-term dynamic psychotherapy
conversational style and, 16–19
crisis intervention and, 122
defenses and, 22–23
for personality disorders, 176
definition of, 1, 2–3, 8–10
Showing the map, as tactic, 22
direct measures and, 13
Silence, and resistance in therapeutic
history of development, 1–5
relationship, 115
indications for, 89–94
Index 217

initiation of treatment, 95 therapeutic alliance and, 53, 54,

mode of action, 27–31 55–56
office arrangements for, 95–96 video vignettes of, 71–88
outcome research on, 172–177 Temporal framing, and initiation or
personality disorders and, 147–150 termination of sessions, 96–98
professional boundaries and, 101– Termination phase of treatment,
104
100–101
psychodynamic theory and
Therapeutic alliance. See also Thera­
assumptions in, 23–27 peutic relationship
schizophrenia and, 142–147 assessment and establishment of, 33
self-esteem and, 19–22 beginning phase of treatment and,
session initiation and termination, 98
96–98 crisis intervention and, 127
severe mental illness and, development of concept, 109–110
141–142 middle phase of treatment and, 99
substance use disorders and, 150– mode of action in supportive psy­
161 chotherapy and, 28

supportive-expressive continuum recognition and repair of

and, 5–10 misalliance, 110–113

therapist-patient relationship and, substance use disorders and, 152
13–14 techniques of supportive psycho­
timing and intensity of treatment therapy and, 53, 54, 55–56
sessions, 98–101 Therapeutic relationship. See also
transference and, 14–16, 106–109 Therapeutic alliance; Transference
Supportive therapy, as distinct from countertransference and, 116–120
supportive psychotherapy, 8 general principles of, 105–106
Synthetic function, and case formula­ resistance and, 113–116
tion, 45 underlying assumptions of sup­
Systematic approaches, to crisis portive psychotherapy and,
intervention, 123, 127 13–16
Systematic hierarchical desensitiza­ Thoughts, and thinking. See also Auto­
tion, 175 matic thoughts
cognitive-behavioral therapy and
Teaching, of adaptive behavior, 62. See patterns of, 26
also Education as focus of supportive psychother­
Techniques, of supportive psycho­ apy, 25
therapy structural approach to case formu­
anticipatory guidance, 64–65, 154 lation and, 44–45
building of self-esteem, 54, 56–61 Time limitation, of crisis intervention,
definition of, 3 136, 137
expanding of awareness, 69–71 Topiramate, 151
reduction and prevention of anxiety, Tourette’s disorder, 94
65–69 Transference. See also Therapeutic
skills building and adaptive relationship

behavior, 54, 60, 62–64 advice and, 62

218 Learning Supportive Psychotherapy

Transference (continued) Venting, 102, 177

elements of psychodynamic as curative technique, 29
psychotherapy, 4 early life experiences and, 27
expressive stance and, 14 Video recording, of psychotherapy
idealizing form of, 120 for supervision, 168–169
mode of action in supportive Video vignettes. See also Case
psychotherapy and, 28 illustrations
personality disorders and, 149 assessment and, 36–41
supportive and expressive crisis intervention and, 124–126,
approaches to, 106–109 127–133
underlying assumptions in substance use disorders and, 156–
supportive psychotherapy 159
and, 14–16 techniques of supportive psycho­
Transference cure, 27 therapy and, 71–88
Transference-focused psychotherapy, therapeutic alliance and, 111–113
for personality disorders, 176 Virtual reality, and PTSD, 133
Trauma, and crisis intervention, 122
Traumatic brain injury, 90, 175 Withdrawal, and resistance in thera­
Treatment plan, and case formula­ peutic relationship, 115–116
tion, 49 Working alliance, 109
12-step programs, and substance use
disorders, 152, 160. See also
Alcoholics Anonymous
 S E C O N D E D I T I O N
Learning Supportive Psychotherapy: An Illustrated Guide provides a

EDITION
SECOND
time-tested text accompanied by carefully scripted case vignette videos de-
signed to help beginning therapists learn how to build a relationship and es-
tablish rapport with psychotherapy patients. The authors, whose experience
conducting and teaching psychotherapy encompasses decades, provide clear
guidelines for practicing supportive psychotherapy, including how to establish
and maintain a positive therapeutic alliance, how to understand and formulate
patients’ problems, how to set realistic treatment goals, and how to effectively
use supportive psychotherapy interventions. This new second edition has been
thoroughly updated to offer clear and complete coverage of the concept and
LEARNING

Glen O. Gabbard, M.D., Series Editor

LEARNING SUPPORTIVE PSYCHOTHERAPY
principles of supportive psychotherapy, with emphasis on the therapeutic al-
liance, which is the best predictor of patient outcome. The authors have also
included a chapter of self-study questions to allow the reader to check compre-
hension and recall. SUPPORTIVE

AN ILLUSTRATED GUIDE
Learning Supportive Psychotherapy: An Illustrated Guide provides be-
ginning therapists, social workers, psychiatric nurses, and others with the prac-
tical instruction and real-world models they need to forge positive relationships
with a broad range of patients and deliver effective psychiatric interventions.
PSYCHOTHERAPY
Arnold Winston, M.D., is Chairman Emeritus, Department of Psychia- AN ILLUSTRATED GUIDE
try and Behavioral Sciences, Mount Sinai Beth Israel, New York, New York;
Professor Emeritus, Department of Psychiatry and Behavioral Sciences, Icahn
School of Medicine at Mount Sinai, New York, New York; and Professor 32 ISO 80

and Associate Chairman, Department of Psychiatry, St. George’s Univer- Video

sity School of Medicine, St. George’s, Grenada Illustrated
32 32B

Richard N. Rosenthal, M.D., M.A., is Director of Addiction Psychi-

atry, Department of Psychiatry and Behavioral Health, Stony Brook
Medicine, Stony Brook, New York; Professor of Psychiatry, Department
of Psychiatry and Behavioral Health, Renaissance School of Medicine at

WINSTON • ROSENTHAL • ROBERTS

Stony Brook University, Stony Brook, New York; and Adjunct Professor of
Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York

Laura Weiss Roberts, M.D., M.A., is Chairman and Katharine Dexter

McCormick and Stanley McCormick Memorial Professor, Department of
Psychiatry and Behavioral Sciences, Stanford University School of Medi-
cine, Stanford, California

ARNOLD WINSTON, M.D.

Cover design: Rick A. Prather
RICHARD N. ROSENTHAL, M.D., M.A.
Cover Image: © Elena Ray
Used under license from Shutterstock LAURA WEISS ROBERTS, M.D., M.A.