Choosing Appropriate Techniques
Published on Physicians Practice (http://www.physicianspractice.com)
Choosing Appropriate Techniques
July 01, 2003
By Frederick S. Mendelsohn, MD [1]
The use of supportive psychotherapy, where the clinician acts as a watchful parent, may be of some
use to certain patients as opposed to traditional psychoanalysis. This paper gives some examples of
cases in which supportive psychotherapy may be more effective.
When today's psychiatrist does psychotherapy, it is most likely supportive psychotherapy. Because it
is well-tolerated by patients and its results are at least equal to those of other psychotherapies,
David Hellerstein and colleagues (1994) called supportive psychotherapy the default model and
believed it should be the therapy of first choice.
Robert Knight, M.D., one of the first psychiatrists to discuss supportive psychotherapy, wrote (Knight,
1949):
Suppressive or supportive psychotherapy, also called superficial psychotherapy, utilizes such
devices as inspiration, reassurance, suggestion, persuasion, counseling, reeducation, and the
like and avoids investigative and exploratory measures.
He later added a list of techniques to use for supportive psychotherapy (Knight, 1952):
Instruction of the patient in areas of knowledge and adaptation where he is deficient
encouragement, advice, active help in feasible management of the environment; appropriate
coaxing, exhortation, kidding and praise; prescription of daily activities, including mental
hygiene reading; provisions of support through a nurse or companion; long range support
through less frequent continuing supportive interviews as the patient improves.
He also included hospitalization as an option.
Knight had a psychoanalytic perspective. For healthier patients, expressive, exploratory or
psychoanalytic therapy was preferred. For the more psychologically impaired patient, supportive
therapy was the treatment of choice. The purpose of supportive therapy was to "reconstruct the
defense mechanisms and adaptive methods [of the patient] before his decompensation" (Knight,
1952).
The model for supportive psychotherapy Knight proposed is similar to the one we use today. Knight's
devices, now called techniques, however, have steadily increased in number as each subsequent
author has added new ones.
One of Misch's (2000) suggested techniques, for instance, is to capitalize on the therapist as a role
model: Let the patient see how the therapist handles anger, confusion, embarrassment,
disappointment and failure. He noted:
The supportive therapist is a good selfobject, providing needed mirroring, idealizing, and
twinship experiences that allow the patient to internalize important psychological functions
that are currently deficient.
Additional techniques include self-esteem maintenance through the use of empathy (Luborsky,
1984), help in dealing with a severe conscience (Luborsky, 1984), modulating affect (Misch, 2000),
developing a liking for the patient (Luborsky, 1984), facilitating the helping or working alliance
(Luborsky, 1984), achieving emancipation from parents (Andreasen and Black, 1991), gratification of
dependency needs (Kaplan and Sadock, 1985), reframing (Rockland, 1989), and many more.
It is important to distinguish between supportive techniques and supportive psychotherapy. The
terms are often used interchangeably, leading to confusion. Almost all psychotherapies use some
supportive techniques. For instance, the therapist's avoidance of value judgments, present in
virtually all therapies, is very supportive for most patients. Only when a therapy is primarily
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Choosing Appropriate Techniques
Published on Physicians Practice (http://www.physicianspractice.com)
composed of supportive techniques does it become supportive psychotherapy (Luborsky, 1984).
Considering the large and often disparate number of techniques described, therapists need a
method or underlying theoretical formulation to guide them in their choice of appropriate supportive
techniques, whether it is supportive or any other therapy.
Knight's original guideline, using techniques that will strengthen the patient's defenses, has
remained intact (Knight, 1949). Recent additional guidelines tend to be similar to the one
recommended by Misch (2000): Do for the patient what a good, mature and loving parent would do.
These guidelines are useful; however, they are often insufficient.
The supportive psychotherapist is the gratifying therapist, as opposed to the psychoanalyst who, for
the purpose of achieving an eventual cure, withholds from the patient and eschews fulfilling the
patient's dependency needs. The supportive therapist is active, talks more to the patient, does
things for the patient and engages in direct actions to help the patient. To accomplish this, a variety
of techniques are used. I have found it helpful to conceptualize the techniques on a continuum,
based on whether the therapist's activity is directed to environmental change or to improving the
patient's adaptive capacity.
In this "Outer-Inner Continuum," there are five points (Figure). The range is from outer, which refers
to the external world of the patient, to inner, which refers to the conscious thinking and feeling of the
patient. The positive changes the patient is able to make based upon more adaptive ways of
handling thoughts and feelings will have a greater therapeutic effect than will simply following the
therapist's instructions. For some patients, however, there can be little doubt that frequent
monitoring by a therapist is very beneficial.
At the outer end of the continuum the therapist is acting on behalf of the patient. This includes
hospitalizing the patient, prescribing medication and advising the family to make environmental
changes. The patient is primarily passive. All the activity is done for the patient, by the therapist.
At the next stage along the continuum, the therapist is not acting on behalf of the patient. The
therapist is advising and guiding the patient to take actions the therapist believes will be beneficial.
The therapist's activity is limited to directing the patient, but it is the patient who is performing the
actions. The patient makes a behavioral change under the direction of the therapist.
At the middle of the continuum, the therapist no longer acts for the patient or offers advice. The
therapist's sole activity is to reinforce or praise what the patient has already done on their own
initiative.
At the inner end of the continuum, the therapist does not focus on behavior but helps the patient
develop more mature ways of thinking about important areas of their life, such as improving
relationships or setting realistic goals.
Finally, at the innermost end of the continuum the therapist helps the patient deal with feelings such
as unrealistic severe guilt, anger or anxiety.
To the extent that it does not create anxiety for the patient, the therapist should use techniques that
are toward the inner end of the continuum. The assumption is that inner-continuum techniques will
help patients improve their adaptive capacities, resulting in more autonomy and greater therapeutic
success.
The following case illustrates the advantages of shifting from an outer-continuum technique to an
inner-continuum technique (Blanco et al., 2001). This case used interpersonal psychotherapy, not
supportive therapy, but many standard supportive techniques are used in the case description.
Ms. A, a 38-year-old married mother of three daughters, became moderately depressed after
learning her husband had a second wife and two children in a foreign country. At the start of
treatment, "the therapist repeatedly raised the possibility of reconsidering the marital arrangement,
but Ms. A made it very clear that leaving her husband was not an alternative she was willing to
entertain." This advice or suggestion, a standard supportive technique, belongs in Category 2. This
intervention was unsuccessful.
The therapist then shifted the approach. Using supportive techniques from Category 4, he reviewed
with the patient many of her assumptions and customary ways of thinking about important aspects
of her life. Some examples of this were: 1) He "helped the patient explore ways of initiating change
in the relationship"; 2) The patient "worried that bringing up her feelings would lead to fights
between [her and her husband], resulting in her eventually receiving less attention from him. The
therapist examined this assumption and helped her explore ways of saying [to her husband] how she
felt"; and 3) difficult situations were discussed and "how she felt in those situations and what could
be alternative, more adaptive behaviors in response to such situations."
The supportive psychotherapy techniques were used within the context of an interpersonal
psychotherapy. The patient improved when the therapist moved from an outer, Category 2,
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Choosing Appropriate Techniques
Published on Physicians Practice (http://www.physicianspractice.com)
supportive technique to an inner, Category 4 technique. Her Hamilton Rating Scale for Depression
(HAM-D) score decreased from 25 to 6.
This case tends to support the theory that the use of supportive techniques, which are intended to
increase the patient's adaptive capabilities, can be more therapeutically beneficial than are
techniques designed to guide the patient's behavior based on decisions made by the therapist.
References: References
1. Andreasen NC, Black DW (1991), Introductory Textbook of Psychiatry. Washington, D.C.:
American Psychiatric Press.
2. Blanco C, Lipsitz J, Caligor E (2001), Clinical case conference: treatment of chronic depression
with a 12-week program of interpersonal psychotherapy. Am J Psychiatry 158(3):371-375.
3. Hellerstein DJ, Rosenthal RN, Klee S (1994), Supportive therapy as the treatment model of
choice. J Psychother Pract Res 3(4):300-306.
4. Kaplan HI, Sadock BJ (1985), Modern Synopsis of Comprehensive Textbook of Psychiatry, 4th ed.
Baltimore: Williams & Wilkins.
5. Knight RP (1949), A critique of the present status of the psychotherapies. Bull N Y Acad Med
25:100-114.
6. Knight RP (1952), An evaluation of psychotherapeutic techniques. Bull Menninger Clin
16:113-124.
7. Luborsky L (1984), Principles of Psychoanalytic Psychotherapy: A Manual for
Supportive-Expressive Treatment. New York: Basic Books.
8. Misch DA (2000), Basic strategies of dynamic supportive therapy. J Psychother Pract Res
9(4):173-189.
9. Rockland LH (1989), Supportive Psychotherapy: A Psychodynamic Approach. New York: Basic
Books.
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