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 Administration and the
general medical community. As medical research and practice continue to advance, however,
therapeutic standards may change. Moreover, specific situations may require 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 advice 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 policies and
opinions of American Psychiatric Association Publishing or the American Psychiatric 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 Publishing,
[2020] | Series: Core competencies in psychotherapy | Includes bibliographical references and
index. |
Identifiers: LCCN 2019037391 (print) | LCCN 2019037392 (ebook) | ISBN 9781615372348
(paperback ; alk. paper) | ISBN 9781615372874 (ebook)
Subjects: MESH: Psychotherapy—methods | Professional-Patient Relations | Psychotherapeutic
Processes
Classification: LCC RC480.5 (print) | LCC RC480.5 (ebook) | NLM WM 420 | DDC 616.89/14—
dc23
LC record available at https://lccn.loc.gov/2019037391
LC ebook record available at https://lccn.loc.gov/2019037392
British Library Cataloguing in Publication Data
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
Acknowledgments
Video Guide
1 Evolution of the Concept of Supportive Psychotherapy
2 Principles and Mode of Action
3 Assessment, Case Formulation, and Goal Setting
4 Techniques
5 General Framework of Supportive Psychotherapy
6 The Therapeutic Relationship
7 Crisis Intervention
8 Applicability to Special Populations
9 Evaluating Competence and Outcome Research
10 Questions for Self-Study
References
Index
Introduction

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

Supportive Psychotherapy, first published in 2004 as Introduction to
Supportive Psychotherapy 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 conduct and
progression of psychotherapy from beginning to end. Accordingly, 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 present

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
psychopathology. 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
relationship issues (transference, countertransference, therapeutic alliance)
and self-disclosure guidelines.
We then discuss crisis intervention, which uses many supportive
psychotherapy approaches, and the applicability of supportive
psychotherapy 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 presentation of the evidence for the efficacy of supportive
psychotherapy, including 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 Hospital

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
Psychotherapy 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
development of this most recent edition.
Video Guide

The videos in this book provide detailed examples of supportive

psychotherapy. Each video includes text boxes at the bottom of the screen
highlighting 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,
including 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.

Chapter 4. Techniques
Vignette 2: Severe, Persistent Mental Illness in an Uncooperative
Patient (13:42)
This vignette illustrates a highly supportive approach with an uncooperative
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
substance 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
become larger in recent years, reflecting changes in the definition, and even
more so in the practice, of psychotherapy. Today, supportive psychotherapy
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 century
as a treatment approach with more limited objectives than psychoanalysis,
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 unconscious
attempt to solve a psychological conflict. As psychotherapy became 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 affordability, a course of treatment often
consisted of a small number of visits, and the objective was limited to relief
of the presenting problem. Therapists found it necessary to be more
interactive and responsive with patients. 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
concepts 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
psychoanalysis but that instead was based on theories developed by
psychoanalysts became known as psychodynamic psychotherapy. This
therapy has been called psychoanalytically oriented psychotherapy,
intensive psychotherapy, uncovering psychotherapy, change-oriented
psychotherapy, insight-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
development, 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 stability
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
psychotherapy (Douglas 2008; Winston et al. 1986) and continue to hold
different opinions about whether or not supportive psychotherapy is a
psychodynamic therapy or a distinctive form of therapy. The problem of
definition is compounded by the coexistence of two incompatible
definitions of psychodynamic therapy. Some writers use the term
psychodynamic 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
capacities (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
circumstances (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
subtracted 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 therapy,
explaining that all psychotherapies involve both supportive and exploratory
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
relations” (p. 7). Although Rockland’s acronym has not caught on, his
thinking reflects the views of most people who have written about
supportive psychotherapy in the past 25 years.
A therapist who accepts the following tenets of modern psychodynamic
therapy is a psychodynamically oriented therapist (Fonagy and Target
2009):

Assumption of psychological causation

Assumption of limitations of consciousness and the influence of
unconscious mental states
 Assumption of internal representations of interpersonal relationships
Assumption of ubiquity of psychological conflict
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

psychodynamic 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 therapist’s

actions, or to the conduct of the treatment:

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

understanding.
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

psychotherapy 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 therapist would be pleased to achieve the outcome described
in the last point, the formal objectives of supportive psychotherapy are
limited to symptom 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
explained 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)
explained the contrast between supportive psychotherapy and insight-
directed therapy (i.e., expressive therapy, in our terminology), observing
that a patient’s treatment usually falls somewhere in between the two
(Figure 1–1). As Dewald (1964) noted, “The ends of the continuum can be
clearly distinguished 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 elements, which must be used in a coherent,
integrated fashion” (p. 97).
Figure 1–1. Supportive-expressive continuum.

Dewald described supportive psychotherapy as generally aimed at

symptom relief and overt behavior change, without emphasis on modifying
personality 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 psychotherapy. Instead they are more suitably and expeditiously
treated by a dynamically 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 previously
unrecognized feelings, thoughts, needs, and conflicts, which the patient
must attempt to consciously resolve and better integrate. We prefer using
the term expressive therapy in order to avoid using the word psychodynamic
with two different meanings.
To emphasize that the treatment of each patient involves both supportive
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
exploratory intervention is low. At the other end, the frequency of
supportive interventions is low. The supportive and expressive stances, or
points of view, are very different. The most supportive stance involves
guidance, whereas 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 understanding.” 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 treatment of a patient, must be primarily
one or the other. When the stance is expressive, 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
“psychotherapy” 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 cognitive-behavioral therapy, for example, without raising
significant theoretical or practical problems. The graphic representation in
Figure 1–1 is not an indication 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 expressive
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,
cognitive-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 development, or
symptom formation that is thought to be novel or especially significant.
Although, as Winston and Winston (2002) said, theories “are described
separately to maintain clarity, these various models come together to inform
the psychotherapy approach for a given patient” (p. 13).
“Therapists . . . should be able to transition from one approach to another.
Such transitioning involves combining various interventions from different
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
relationship or supportive contact but not supportive psychotherapy.
Supportive 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 diagnostic
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 expressions of
gratitude or from using the patient as an audience. In everyday 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 because
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 always 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
direct 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
examine 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
Beres (1956, pp. 164–235), Bellak (1958, pp. 1–40), and other authors.
Ego functions could alternatively be called psychological functions
because they are addressed by behavior therapists and cognitive
therapists whose formulations do not include the ego as a component of
a mental apparatus. Ego functions are often categorized as psychic
structure. 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
between ego functions and adaptive skills is not sharply defined. The
patient’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
continuum. 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
psychodynamic 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 unskilled 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 increased
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 program and his clinic visits are his only
structured activity. The treating resident discusses the recommendations of the other
physicians with Juan and talks about the effects of his medications, encouraging Juan to tell
the other physicians if he has any problems. The resident responds empathically 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 involve 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 entirely supportive approach, involving
encouragement, praise, and advice about adaptive skills. Success will be measured by the
patient’s continued 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 defend 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 responds 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 possible 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
transferential origin, the therapist suggests a link between past and present relationships—
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
psychotherapy poses challenges. Supportive psychotherapy is not based on
rigorous and internally consistent or appealing theory, and it does not offer
solutions to intractable clinical problems. The field has no conferences, no
stars, and relatively few books.
Education of psychotherapists throughout much of the twentieth century
was based primarily on principles developed by psychoanalysts. In a short
text for beginners, Balsam and Balsam (1984) wrote, “The
psychotherapist’s central task is learning to understand . . . the emotional
experience of the patient” (p. 1). Treatment techniques that had specific
rationales in psychoanalysis were presented as universal techniques
required 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
intended “to relieve the patient of distressing neurotic symptoms or
discordant 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 expected to
drop out after a few monthly or bimonthly visits. Psychotherapists 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
sophisticated approach to teaching supportive psychotherapy in the twenty-
first century. He suggested that the mandate for competence in supportive
psychotherapy, 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
spectrum 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
psychotherapy, including helping patients with emotional regulation, grief,
impulsivity, reality-testing, self-esteem, responsibility-taking, and healthy
self-identification. Moreover, Brenner recommended teaching supportive
psychotherapy in diverse clinical rotations, including inpatient and
consultation-liaison services as well as ambulatory settings.
In time, residents who have received training in supportive
psychotherapy 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 undergo expressive therapy does not mean that
expressive therapy is indicated. Providing more support than needed may be
effective but may deprive 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
objectives of supportive psychotherapy can be achieved by early career
clinicians 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 consultant
enters the patient’s world, develops a picture of him, of his experience 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
psychotherapist is that the clinician improves and continues to improve as
the decades pass. Supervisors working with residents who are learning
supportive psychotherapy approaches may help establish the groundwork
for such professional growth.

Conclusion
Supportive psychotherapy and the expressive psychotherapies have
different objectives and employ different techniques. The treatment of an
individual patient whose treatment plan calls for psychodynamically
oriented 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, aspects of
psychodynamically informed psychotherapy, and specifically definable
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
unconscious 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
conscious 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
professional relationships, one person provides a service that the other
requires. The professional person, the therapist, owes the patient respect,
full attention, 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 therapeutic relationship, there is greater symmetry
between the patient and therapist than in other therapeutic relationships.
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 therapist 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
associated with important figures in past or present life. This projection is
termed transference. The expressive stance avoids responses that might
encourage the patient to perceive the therapist as a person with opinions,
tastes, family, or even personality. It is this technical maneuver that has
produced 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
depends on the type of therapy. In expressive therapies, analysis of
transference 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
psychotherapy 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 interaction is a
major focus of the therapeutic process, and the therapist may disclose much
more than would be done in classical treatment. This is not an approach to
be undertaken by the novice therapist. Even at the supportive 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)
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

relationship 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
useful for maintaining the therapeutic alliance and potentially useful for
identification 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
because 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 offered

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.
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 recently 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 therapeutic 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
important 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 usually
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
normal conversation. In normal conversation, the speakers alternate: your
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
responsive, but it is always the patient’s turn.
Physicians who are new to psychotherapy often have had years of
practice polishing a style of communication that is not responsive and not
supportive. They have mastered the art of obtaining the history by asking
questions. When every utterance is a question, the process is interrogation.
Miller and Rollnick (1991, p. 66), writing about motivational interviewing,
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 passive
patient. To maintain a supportive conversational style, the therapist must be
responsive. In the act of responding, the therapist is giving something 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. Compare
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.
 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
patients who are diffuse and vague. To manage this problem, physicians
develop habits of asking leading questions, asking questions that include
prompted answers (including multiple-choice lists) or questions that invite
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
better question is “What is your usual use of alcohol?”)

The open-ended question has the greatest potential for eliciting

information. Prompts and suggestions are appropriate when the patient is
unable 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 easily 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.)
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 without paying much attention. (The prodding question
is asked in a supportive way. Although suggesting answers to
questions was described 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, provided
that the pursuit of additional information does not take on the quality 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
arguing 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
displeased 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
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 disapprovingly, finds in
the therapist a person who is accepting and interested. The therapist’s
acceptance and respect are unspoken. The therapist communicates interest
in the patient by making it evident that he or she remembers their
conversations; recalls what the patient has said; and is aware of the patient’s
likes, dislikes, and attitudes. Acceptance is communicated by avoidance of
arguing, denigrating, and criticizing—verbal interactions common to many
relationships, including, unfortunately, many contacts between patients and
health care providers.
Below are therapist responses that are negatively stated followed by
responses that are more positive, congenial, and encouraging.

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

resonance 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,
reassuring).

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

THERAPIST 2: OK, I am not sure I understand. Can you say more?
(encouraging 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
implication) 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.

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 triggered 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 certain
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

relationships, and they are certainly customary in conventional medical
practice, so reasonable use of them will not destroy the therapy. The
objective is to conduct therapy with finesse, thus enhancing the prospects
for success. When possible, it is better to ask a general question than a
narrow question. For example, “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 questions 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 answer “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
appetite? (dismissive)
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

attitudes and behavior from health care providers because patients are
dependent 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 potentially safe and beneficial treatment is maladaptive. In
expressive psychotherapy, passive-aggressive behavior might be explored
as an indicator of unconscious hostility and a need to control others; in
supportive psychotherapy, 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 defense early in treatment but question it later in treatment.
In maintaining the supportive stance in the therapist-patient relationship,
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
defensive position depends on the current situation, including the context of
the patient-therapist conversation (e.g., the therapist must consider 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

acting 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 control, 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 technique 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
patient’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 Concept
of Supportive Psychotherapy,” the therapist must know whether his or her
basic stance with a patient is supportive or expressive—the therapist 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 disseminated.
Trainees may not know what to talk about with a patient after completing
the history, hoping that improvement will occur, in some way, if the patient
talks about his or her past and feelings. For the absolute beginner (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
developing 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 matters most.
The following are a few examples of psychodynamic formulations.

Case Illustration 1
 David, a man who is ordinarily self-sufficient and cheerful, becomes demanding and
uncooperative when hospitalized following a heart attack, although he has been reassured that
his prognosis is very good. A psychodynamic hypothesis might be that the passive, somewhat
helpless role of hospital patient is anxiety provoking, and David is attempting to compensate
by assuming an overbearing attitude. Because he is unaware that the enforced passivity is
behind his unusual behavior, his behavior is considered 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
understanding. 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 dependent. 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 account 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
unrecognized emotions are often responsible for current unpleasant feelings
or maladaptive 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 patients’ symptoms were related to what they perceived as
unacceptable sexual 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 alexithymia, 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 explored if the
therapist and patient are examining coping strategies or if the therapist is
seeking opportunities to expand his or her empathic understanding. 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
evaluate more. Therapeutic dialogue often involves both feelings and
thoughts; jumping to adaptive solutions without understanding the patient’s
emotional 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
discussion 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
important 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 response)
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).
PATIENT: I didn’t feel anything.
THERAPIST: You describe a situation in which most people would
feel disappointment or anger. That reaction won’t control the
other person, 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. Cognitive-behavioral
therapy focuses on the assumptions associated with patterns of thought and
provides tactics for overcoming these assumptions. Although cognitive and
psychodynamic approaches are usually taught separately, tactics of both
approaches are integrated in everyday treatment.
 The search for patterns that may explain symptoms or maladaptive
behavior is the expressive component of supportive-expressive
psychotherapy. 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
patient is insecure because he was afraid of his overbearing father, the
therapist 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 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 important
in the development of the individual and his or her problems. Creating 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
endlessly about their terrible childhoods, emphasizing how they suffered
various 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
manner 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
patient’s life. Retelling can be especially maladaptive in individuals with a
significant trauma history for whom the retelling is accompanied by
tremendous distress.

Mode of Action
Attempts to achieve the supportive psychotherapy objectives of improved
ego function and adaptive skills involve teaching, encouragement,
exhortation, modeling, and anticipatory guidance. People in general, not
only patients, 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
cooperate with the teacher to please him or her. Such cooperation has been
described 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).
Sometimes, 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
therapeutic relationship or therapeutic alliance is perhaps the most
important (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
accomplished. Therefore, the therapist must make deliberate efforts to
encourage a good relationship and avoid actions that are inimical to a good
relationship (for further discussion, see Chapter 6). The patient’s experience
of “an atmosphere of warmth, hope, caring, and authenticity” is important
in the therapeutic interaction (Brenner 2012, p. 262).
 The patient’s transference may cause him or her to unconsciously
perceive the therapist as having attributes associated with unpleasant
interactions 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 patient 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
corrective 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 current 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
psychotherapy” (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
interest 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 occur
even if neither patient nor therapist understood the historical origins of the
problem. Education and instruction have been accepted throughout history
as strategies for changing behavior and thought, although such changes
cannot be guaranteed or predicted—when a patient mentions a 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, although focused
on formal education, has led to observations that new information is linked
to what is already known, that retrieving information repeatedly enhances
subsequent recall, and that elaborating on the material contributes to
learning (deWinstanley and Bjork 2002). Although the field of learning
theory has contributed potentially useful ways of explaining 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
continuum 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 receive
no reassuring or normalizing response. Identification with the therapist 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
psychotherapy. 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 medications, 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 possible 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 useful advice, he or she must be familiar with the
psychological and emotional 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 happened?” 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 (normalizing, 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 constructive efforts).

These dialogues illustrate how even in work with the most impaired
individuals, the therapist must explore feelings and ideas of which the
patient 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
recovery 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
responding. 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 example 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 inevitable. 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 psychotherapy, may be the principal
approach once the patient sees that the behavior that is causing distress is
the outcome of a plausible story. Misch (2000) advises the supportive
therapist to be like a good parent. The supportive 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. Although
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 patient’s self-mastery
by helping him or her to become aware of thoughts and feelings that had
been outside awareness and to provide specific suggestions for more
adaptive living.
Assessment, Case Formulation, 3
and Goal Setting
Assessment
The process of evaluation and case formulation is essential for all
psychotherapeutic 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 positive 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
feedback 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 patient’s
illness and describe the patient’s problems so that the individual can be
treated appropriately. A thorough evaluation should help the clinician 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,
“Evolution 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 continuum
(healthier patients).

Figure 3–1. Impairment-psychotherapy continuum.

When a therapist meets a patient for the first time, the therapist
generally does not know the extent of the patient’s impairment,
psychopathology, 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 problems
and past history of each patient. The technical approach will vary, from the
use of a more supportive approach for patients with higher levels of
psychopathology to a more expressive approach for healthier patients. 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
psychotherapy is better suited for healthier patients. We have found in our
clinical 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
disorders across the psychopathology continuum (for a full discussion of
inclusion 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
enhanced when expressive and cognitive-behavioral techniques are
integrated 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 minutes. At the
end of the evaluation, the therapist should understand the patient’s
problems, interpersonal relationships, everyday functioning, and
psychological structure. The evaluation interview should not be a series of
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
patient for treatment and promote the therapeutic alliance. In a supportive
approach, a therapist may make an evaluation therapeutic by using
appropriate interventions, such as empathic clarifications and
confrontations.
The evaluation should begin with an exploration of the patient’s
presenting problems or areas of disturbance. Presenting problems may
include 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. Information about
symptoms will enable the clinician to adjust the evaluation interview 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 therapist
should explore the patient’s history. We want to emphasize that therapists
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 explored.
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 obtained.
Important issues to inquire about include trauma; separation and loss;
medical problems, psychiatric illness, and substance abuse (in the patient
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 response 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
triangles 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 triangle.
As is often the case, the patient may respond defensively to the exploration
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.

Figure 3–2. Triangle of conflict.

 In the triangle of person (Malan 1979; Menninger 1958) (Figure 3–3),
the three points all relate to people and include individuals in the patient’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 feelings
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 relationship and
its exploration are emphasized.

Figure 3–3. Triangle of person.

In supportive psychotherapy, the triangles of conflict and person are

used differently. In the triangle of conflict, feelings generally are not
pursued, 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
patient’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 supportive
therapy in an initial evaluation (see Video Vignette 1).

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].

The therapist recognizes that Mary may be depressed and asks a series of questions to
determine whether this is so and, if so, the extent 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 pleasure in your life? Do you
go out? Are you working or having difficulty 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 consistently downhearted,
tearful, fatigued, and pessimistic about the future and has had difficulty concentrating. She
has trouble falling asleep, consistently awakens during early morning hours, and is unable
to get back to sleep. Her appetite is poor, and she has lost approximately 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 episode, 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 depressive 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 been depressed several
times in the past. These things you’re describing—tearfulness, fatigue, difficulty
concentrating, trouble 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 patient 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 begun 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
understanding, 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 . . .
THERAPIST: Can you give me a specific example of this? (The therapist 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 contributed to making you feel
incompetent? (summarizes patient’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 instance, 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 therapist 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 therapist, a psychiatrist, concluded that Mary
would benefit from medication and a supportive psychotherapy approach employing some
cognitive-behavioral techniques. The therapist explained how both approaches—medication
and psychotherapy—would be helpful in 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 effects 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
issues emerging from the assessment and case formulation. The case
formulation 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
selected for attention. Case formulation depends on an accurate and
thorough 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
therapy 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)
diagnosis 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
individual. The DSM diagnosis alone does not fully explain the patient or
the problem.
The following case formulation approaches are derived from
psychoanalytic theory, including interpersonal and relational approaches, as
well as cognitive-behavioral approaches. In the following subsections, we
discuss 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
understood and formulated by the therapist but never or only partially
explored in psychotherapy. Although these approaches have always been
described separately, a great deal of overlap exists, so some repetition
occurs in the descriptions.

Table 3–1. Types and foci of case formulations

Type Focus
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

Structural Approach
A structural case formulation (Table 3–2) attempts to capture the relatively
fixed characteristics of an individual’s personality, which is understood
within a functional context (in contrast with genetic and dynamic
approaches, which are more content based). Assessment of an individual’s
strengths and weaknesses and overall level of psychopathology helps
determine the clinician’s technical approach. A thorough structural
assessment enables the clinician to determine with some degree of accuracy
where to place the patient on the impairment-psychotherapy continuum (see
Figure 3–1).

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

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 reality
as major components of relation to reality. The term reality testing describes
an individual’s ability to assess reality. Reality testing is impaired in the
presence of faulty judgment and is grossly disturbed in the presence of
hallucinations or delusions. Sense of reality relates to a person’s ability to
distinguish self from other; presence of this ability indicates 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 continuum (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 ability
to form intimate relationships, tolerate separation and loss, and maintain
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
psychological functions constituting the structural approach. In all forms of
psychotherapy, evaluation of object relations is central in determining a
patient’s placement on the impairment-psychotherapy continuum. Patients
who are withdrawn and not interested in others or who have narcissistic,
highly dependent, or chaotic relationships generally require a more
supportive approach and therefore are on the left side of the continuum.
Individuals who have had at least one meaningful give-and-take
relationship 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,
sweating, posture, facial expression, and tone of voice. The range of affects
includes excitement, joy, surprise, fear, anger, rage, irritation, anguish,
shame, humiliation, sadness, and depression. The individual’s ability to
experience 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, sadness, 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
behavior, such as physically or verbally lashing out at others or making
inappropriate 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
mature. Examples of immature defenses are projection, hypochondriasis,
acting out, sarcasm, and avoidance. Intermediate defenses include
forgetting, 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
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
psychopathology.
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
individual can function in a harmonious and integrated way. Synthetic
function 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 example, 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 instance, 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 concern 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 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 demonstrated by his inability to work or
to complete school. Relationships are conducted on a need-satisfying basis, without concern
 for others. Bert is often sadistic but then becomes self-defeating and self-punishing. He
exhibits impaired frustration tolerance and poorly controlled impulses, and his displays of
rage may indicate a limited repertoire of affective responses. He uses immature 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 current
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, depending on the
severity of the event, the developmental stage of the child experiencing 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 development 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 characterological 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
experience 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,
demanding 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 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 individual’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
individual’s relatively fixed characteristics and functioning, dynamic case
formulation 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
traumas 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
patterns. 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 “narratives,
called relationship episodes, that patients typically tell and sometimes 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 patient responds to others.
Understanding and using the CCRT method provides the clinician with a
central organizing focus. The CCRT method can be used differentially with
patients according to their position on the continuum.
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 debilitated 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, combined with positive feelings based on
earlier experiences. He becomes anxious and defends against these feelings or wishes by
displacing the anger 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 figure 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 mistake 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 father,
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 individual’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 addressed later in the course of therapy. The
cognitive-behavioral case formulation 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
Formulation” in the previous subsection) will be used to illustrate these six
components of cognitive-behavioral case formulations. The problem list is a
complete list of the patient’s difficulties and presenting complaints. It
includes 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
mistakes 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
cannot do anything right. This belief makes him especially vulnerable to the
opinions of others. The origins of core beliefs are early experiences,
generally involving parents or parental figures. Tim’s core belief appears to
have derived from his relationship with his overly critical father. Core
beliefs are generally activated by situations or events that are stressful or
problematic 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 patient
passivity in the treatment situation. Tim may be reluctant to complete
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 decreasing 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 beliefs
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 often
relate to the therapeutic relationship, and thus the concept of obstacles 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
assessments of Mary, the patient evaluated in Video Vignette 1 in the
“Assessment” section earlier in this chapter.

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
difficulty 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
experiences with her husband. Her depression has intensified her feelings of
inadequacy. 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
patient’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 abandon
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
functioning. 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
cannot function. The origins of her core beliefs are her mother’s and sisters’
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
therapeutic 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 clarity.
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
development of insight into previously unrecognized feelings, thoughts,
needs, and conflicts.
In the past, it was assumed that long-term changes in conflicts and
personality could not occur in supportive psychotherapy. Results of studies
by Rosenthal et al. (1999) and Winston et al. (2001) have suggested,
however, that supportive psychotherapy can produce personality changes in
patients 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 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 discontinuing, 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
expectation 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
interpersonal relationships.

Conclusion
Assessment of the patient’s problems, symptoms, and character structure is
critical for arriving at a complete diagnosis, case formulation, and treatment
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 setting 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
relationship 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
action 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 therapist).
These techniques are employed to maintain the therapeutic alliance—
without which nothing can be accomplished—and to achieve the objectives
of supportive psychotherapy (described in Chapter 1, “Evolution of the
Concept of Supportive Psychotherapy”): maintaining or improving self-
esteem, ego function, and adaptive skills.

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.

Alliance Building
The term therapeutic alliance implies that the work of forming and
maintaining 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; Westerman et al. 1995). Thus, the therapist using
supportive psychotherapy 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 unrealistic 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,
misalliance, 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 patient.
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 important in the
therapist’s experience. For example, when the patient has recently 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 physician 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 medication.
Possible issues include not wanting to feel overpowered by medication 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 adaptive
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
related to it. The patient may have fears about the future that are not
expressed. 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 relationships for
discussion. Lower-functioning patients (and some elderly patients) 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, acquaintances, and coworkers
and, in the case of an isolated patient, persons with whom the patient has
even brief contact, such as caseworkers, probation 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

unproductively 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
accomplished something. Praise can be interspersed throughout a
conversation, 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.
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 considerate 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
relationship.

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 present 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 cannot
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 specifics.)
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.)
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 understand the patient before expressing an opinion.
None of the therapists 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 patient (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 socially
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 episode (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 engagement.)
Reassurance
Reassurance is a familiar tactic in general medicine. Like praise,
reassurance 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 expert, 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. Therapists can say,
when true, that no side effects have been reported. It is correct 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 disease 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 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 demands reassurance and this
reassurance is outside the therapist’s expertise, 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
modified. 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 normalizes 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 educated person and the patient’s peer.)

Adages and maxims are a form of normalizing.

 THERAPIST 1: You can’t make your [adult] children like each other
(reassurance given as an authority).
THERAPIST 2: I don’t know of studies, but we know from
newspapers, literature, 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” (normalizing 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

nonadaptive behavior or to opportunistic, hostile interactions with others.
The objectives of supportive psychotherapy are most effectively advanced
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 useful 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 reinforcement of adaptive behavior).
THERAPIST 3: People with social phobia always fear losing control,
but actually 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
encourage 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
patients who have disabilities calls for ingenuity in identifying tasks and
activities 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.
THERAPIST 1: Occupational therapy isn’t intended to be job training
for flowerpot painting. The idea is to allow people to have the
experience 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 diversionary 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
assignments, and feel comfortable with other people. (Enrolling
in a degree 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
childhood; 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 eating and sleeping normally, is to begin doing things. Any
kind of work, even beneath your level, can help you to change
your perception 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
something 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?

Skills Building: Adaptive Behavior

Guiding the patient to better adaptive behavior by employing the techniques
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, featured at
the end of this chapter and available at www.appi.org/Winston, illustrate
this element of therapy.
Advice and Teaching
Advice and teaching are appropriate in areas where the therapist is
professionally expert, such as adjustment, mental illness, normal human
behavior, 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
instead 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 infer 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 patient 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.
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 connections, 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
possible 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 decision 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.

PATIENT: My boyfriend humiliated me in public again yesterday. I

screamed at him when we got home, and he said I was too
sensitive. I can’t take it anymore.
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
knowledge 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
supportive psychotherapy as it is in cognitive-behavioral therapy. The
objective 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
programs 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 apprehensive
in new situations, unsure of their ability to grasp social cues, unsure of
appropriate responses, fearful of rejection, and unable to maintain
prolonged 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 problem 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 nonaddicted

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
intended to accomplish these objectives include reassurance and
encouragement, which were discussed earlier in the section “Esteem
Building,” because anxiety invariably has an adverse effect on esteem.
Supporting or strengthening 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 common 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 adaptive, 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
concentration.
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
intervention that the patient may find difficult or uncomfortable. The
supportive 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

someone 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 connection 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 torture. On the other hand, a person can be
involved in a lot of violence 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.

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
minimized, 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 example 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
responsibility 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 affects 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.
 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 (rationalization 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 rationalization 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 happens before they feel better (disagreement, but the
therapist is conveying expert information that may be useful to
the patient).
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 clinical 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 therapist
is attentive and is processing what he or she hears. Clarification is an
awareness-expanding intervention. Both in and outside of psychotherapy,
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 harassing 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 account? 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
defended against. In the following dialogue, which is a continuation of the
comments presented in the preceding section, “Clarification,” the therapist
uses confrontation.

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 universally 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 often 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 directed 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 always 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
antipsychotics, these individuals may finally be able to grieve for the years
they have lost or for any suffering they may have caused others. Some
individuals 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 assumptions,
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 ultimately
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
patient’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, links between
patient and therapist are generally made only when necessary 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
narrative 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
enactments illustrating the spectrum of psychopathology and the associated
spectrum 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
illness. 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 mother. He was referred to the clinic for
continuing care. Since completing high school 3 years ago, he has spent most of his
time watching 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 idiosyncratic connections and assumptions, and
that he is negativistic. An important supportive measure is honest praise for the patient’s
efforts. When Jerry is negativistic and rejecting, he may perceive a therapist 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
therapeutic 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 impression 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 difficult? (looking for
opportunity to attempt anticipatory guidance)
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 perceive 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”).

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 suggests 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
maintain 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 argumentative—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 internal 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 environment 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 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 helping. 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
concept; 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, introducing 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 situation, but the patient’s
negative attitude prevailed. He said that his mother was a negative person and because of
this had trouble getting 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) interferes 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 always 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 correctly. 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)
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.
THERAPIST: 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 clarification). If you
could do something really positive that you really 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 hospital—
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, empathic).
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 maladaptive 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 isolation 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 itself. 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 education
(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 patients 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 sensitive 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 manifestation 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 processes, interpersonal relationships, and the
patient-therapist relationship. In this video, the therapist responds empathically, praises
Ann’s efforts, explains her reasons for questions, involves Ann in setting 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.

THERAPIST: How have things been going since our last meeting? (the initial question
involves reference to therapeutic relationship.)
ANN: I wasn’t so down this week. I got to shop a little bit. But sometimes 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 psychological 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 anything 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? (clarification, 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 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, empathic).
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 situation (reinforcing
acceptable social behavior). How do you feel that you handled yourself? (not
revisiting childhood, 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 going 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 anymore,
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 because 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 together 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 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 advice). 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. Sometimes 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 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 annoying.

The therapist suggested that Ann could alter her tendency toward 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
unconscious anxiety that might play a part in causing this behavior. Whenever the therapist
becomes aware of it, she will point it out to Ann and then structure the conversation so that
topics are finished before 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 problem, intending to enhance her self-esteem. The
therapist did not become 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 tentative confrontation that
Ann’s symptoms served a defensive function. The therapist also tentatively confronts Ann
about the possible underlying provocative intent behind what Ann describes as a simple
question. In each instance, the therapist is tentative to avoid increasing Ann’s anxiety or
appearing overbearing because such behavior would be inimical to her self-esteem.

THERAPIST: 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 economics class, and I swear he
has it in for me. He asks me questions 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 being put down
(empathic). And I think this is an important worry—perhaps we can stay with
this? (The therapist wants to maintain focus and also to involve the patient
in setting 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 bothering 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 something you have to maybe be careful
about is almost overintrospecting when you’re depressed (education; tentative,
to avoid a challenging approach). It’s almost like having a pimple 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 educational 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 relational 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 something 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 important 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 understand. And thanks for the explanation. I
really didn’t mean to be disrespectful before.
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 happened 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 sensible 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 economics are
emphasizing the social and psychological aspects of it (indicates source of
information that is outside professional 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 behavior). And even though you did put
 it as a question, it doesn’t mean that you weren’t really making a statement
(indirect 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 realistic 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 (personalizes
question). What was your professor’s response to this, ah, question? (uses
extra words to maintain conversational [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?
ANN: It was obviously the word novel. You know—“novel”—it sounded very sardonic
and sarcastic to me. I don’t know.
THERAPIST: I understand that, but I think it’s also important to be realistic 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?
(education 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
continued 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
optimistic, and raises the possibility of anticipatory guidance when Ann speaks of an
upcoming date. The therapist supports defensive positions 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
depressed 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 remarks and to start feeling very bad about yourself and very critical of
yourself when you looked at his remarks in a certain 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? (establishing 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 discussing. 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. Everything 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 important to remember that sometimes it
can take months to really 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 wrong
choice. But it’s hard and it’s normal for it to be hard (exhortation). And as far as
not making stupid mistakes, do you have any ideas about what you can do—now
that you recognize the problem? (reinforces progress; avoids trap of
proposing 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 solution)
ANN: I know that in the guidance office, I had seen some material before 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 before? 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 medications. 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 depressed 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 perhaps we should talk about?
(exploring possibility that anticipatory 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 beginning
is that your depression started at the end of a relationship 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 relationships. 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 accident. 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 account for that? (considers exploring
what may be the defense 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 angry and quite hurt. They may even take pleasure in that
person’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 excess
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 solution on her own. If Ann had said she
wanted to talk about the upcoming date with a new man, the therapist would have
attempted to present several common scenarios to consider how Ann might respond and to
explore her fears or likely automatic critical thoughts. Because Ann did not want to talk
about the date, the therapist accepted her choice. The therapist suspected that Ann’s
concern for the well-being of her ex-boyfriend might be reaction formation to 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 feeling, the therapy continued to be supportive-expressive.
General Framework of 5
Supportive Psychotherapy
Indications and Contraindications
For years, supportive psychotherapy was described as the treatment for
individuals 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,
supportive psychotherapy was said to be indicated for people with 1) a
predominance 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
expected gains (compared with patients who received psychoanalytic
treatments) 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),
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
psychotherapy is valuable in the context of moderate depression (Driessen
et al. 2016), but studies do not consistently demonstrate superiority of
supportive 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, individuals 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 psychosocial functioning (Harder et al.
2014; Lysaker et al. 2015). Studies suggest 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 improved
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
expressive elements. Luborsky (1984) and others have developed various
forms of supportive-expressive psychotherapy that have produced positive
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 supportive
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”).

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 concomitant 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 symptomatic in
the context of acute, overwhelming, or unusual stress. Under other
circumstances, persons in this group might be referred for expressive
treatment because these individuals have good reality testing, a capacity 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 social
relationships. The patient benefited from an empathic therapist’s
psychological 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
gradually 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
description for patients whose customary coping skills and defensive
structures have been overwhelmed by an (often unexpected) event, resulting
in intense 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
Intervention.”) Supportive techniques may even be implemented in the
middle of expressive therapies when there is a crisis for which support is
clinically indicated.

Adjustment disorders in relatively well-compensated people. People

in crisis may meet criteria for an adjustment disorder. Adjustment disorders
are time limited, lasting no more than 6 months (American Psychiatric
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 adjusting 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 resolution of the
episode of illness. In addition, the treatment may help prevent the condition
from becoming chronic.

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

psychotherapy is the only treatment recommended. An understanding of the
individual’s innate defensive, cognitive, and interpersonal styles (i.e., core
character 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 depression (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

dependence, 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
appropriate) 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 substance
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 poor
ego strength. These patients generally experience such symptoms as self-
reproach, social withdrawal, and an inability to maintain job or
interpersonal functioning and anxiety and depressive symptoms such as
insomnia 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
direction 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 feeling
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 psychotherapy can
specifically address alexithymia by working directly on somatic
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.
Patients 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
illness can be damaging to adaptive and psychological functioning and may
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
functioning for as long as practicable in patients with chronic illness (e.g.,
cancer; 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 psychotherapy and that
supportive psychotherapy can be applied over a wide range of
psychopathology and situations.
Supportive psychotherapy is contraindicated when psychotherapy itself
is contraindicated. This list of contraindications is short. Novalis et al.
(1993) suggested that supportive psychotherapy is unlikely to be effective
in delirium states, other organic mental disorders, drug intoxication, and
later stages of dementia; these are conditions in which any psychotherapy
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 advice are not
useful. Individuals who lie or malinger as a matter of course do as poorly in
this treatment as in other treatments. Psychopathic individuals who
establish a pattern of pseudomutuality in the therapeutic relationship 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 effect
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 bulimia
nervosa (le Grange et al. 2007; Walsh et al. 1997). The integration of
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
session with a patient, during which the therapist determines whether or not
supportive psychotherapy is the treatment of choice (see Chapter 3,
“Assessment, Case Formulation, and Goal Setting”). Supportive
psychotherapy is conversational in style and serves as the context for all
patient-therapist interactions. 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 explicit.
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 supportive
psychotherapy is to reduce anxiety by setting clear limits. For example, 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 treatment
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, facial
expression, and body language, which are important because supportive
psychotherapy relies on a dynamic understanding of the patient. The
therapist is sensitive to unconscious communication, even if the therapist
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
example, respecting the patient’s need for distance, the therapist may sit a
little farther away from a patient who expresses paranoid ideation. The
therapist should not be too far away or the patient’s anxiety may increase
because 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 therapist 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 tissues 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 accommodating, and
although it provides a supportive relationship, it is typically reserved 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 alliance. 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 entirely 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 temporal
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 processes.
The therapist encourages the patient’s verbalization, with the objective of
exploring the resistance and enabling the patient to express his or her wish
or feeling, which is generally related to the therapist or therapy. In
supportive psychotherapy, the therapist is free to discuss matters of lateness
from a practical point of view. Keeping appointments is an adaptive
behavior; arriving late to a meeting that is genuinely in the patient’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 approach
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 everything! 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, projection).
 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 unconscious
motivations, all amenable to discussion in the context of supporting ego
function and adaptive skills. With some patients and in certain cases, the
therapist might determine that extending a session is therapeutically
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 exiting the
session—if they are clinically provocative and raise the therapist’s acute
concern. Concerns about not gratifying the patient’s infantile wishes should
be entertained but should take second place to reasonableness, which the
therapist should always be modeling.
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 models
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 crisis
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 appropriate and
based on when the therapist can accommodate the patient. Fixed frequency
and length bring stability to the framework of the therapeutic 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 therapeutic
alliance increases the likelihood that the patient will remain in treatment
and will have a good outcome (Gunderson et al. 1984; Hartley and Strupp
1983). Over the first few sessions, the therapist should attempt to come to a
reasonable understanding of the 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 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 intensity of
supportive and expressive interventions accordingly. The therapist may
require an extended amount of time to develop a clear understanding of the
issues of patients who are cognitively impaired because of psychosis, severe
obsessive thinking, or mood disorder or of patients 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 psychiatric 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 structured environment in which to live so that he can
plan his near-term future appropriately. Without that stability, the patient
runs the risk of increased stress, disorganization, and decompensation.
However, the patient 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
interaction. Such explanation is also consistent with motivational
interviewing 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 patient
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 experience
of being understood and supported by the therapist. In the middle phase of
therapy, if therapy is proceeding well, the patient begins to accept that the
therapist is truly capable of understanding and supporting him or her, and
this acceptance can serve as a corrective emotional experience. 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
indefinitely, 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 support for self-esteem regarding goals that have not been
accomplished.
In supportive psychotherapy, the therapist can use well-structured
psychoeducational and skills-building interventions and can encourage the
patient 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 informed. The supportive psychotherapist uses these kinds of
educational interventions 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 interpersonal conflict or an inner need, the supportive therapist
can shift the balance 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
decision 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 regard
to termination. In supportive psychotherapy, the patient and therapist 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 therapist 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 return 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
psychotherapy 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 external 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 defenses and he or she becomes symptomatic. In supportive
psychotherapy, the model of treatment does not focus on character change
through emotional insight, so treatment is complete not when core conflicts
have been resolved 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 failing 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 silences.
The therapist’s empathic relatedness allows him or her to know when
silence will make the patient withdraw and feel overwhelmed and 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 nonstop 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,
collaborating, 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 therapist
may judiciously disclose personal information to the patient in a purposeful
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 listeners
seeking support for their recovery efforts. Many reports on individual
behavioral, cognitive, and cognitive-behavioral therapies suggest that
deliberate 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 appropriate 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, bragging,
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
facilitating 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)
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 uncomfortable. People who are able to master their fears
tend to get more accomplished (praise with modeling of
adaptive behavior).

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

inappropriate or extremely personal in nature in order to annoy or provoke
anxiety 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
sexual 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

differentiating the friendly but professional relationship from friendship.
The therapist clarifies and reinforces the boundaries in a respectful,
nondemeaning 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 therapeutic 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
opportunity 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 losing 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 therapist to use the
therapy to gratify his or her own needs and violate the patient’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 advice based on nonpublic
information) (AMA Council on Ethical and Judicial 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
specifically 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 ambivalent
feelings about the therapist. Treatment is focused on real relationships,
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
psychotherapy 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
patient-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
supportive 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
relationship.
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
impasses, more explicit discussion about the relationship may be
warranted.
6. The therapist uses only the amount of expressive technique necessary to
address negative transference.
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 criticism,
the therapist at times might have to frame the statement in a palatable or
supportive manner or first offer anticipatory guidance.

Transference: Supportive and Expressive

Approaches
Transference refers to the feelings, fantasies, beliefs, assumptions, and
experiences 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
assigned 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).

Figure 6–1. Roles of transference and the real relationship in

expressive and supportive psychotherapy.
Source. Adapted from Pinsker et al. 1991.
 When working at the supportive end of the supportive-expressive
psychotherapy continuum, the dynamically aware therapist recognizes
transferences 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 material
occurs. Supportive and expressive techniques can emerge at appropriate
times in treatment (Gorton 2000), but both the rationale for and content of
transference interventions by the therapist are different in supportive 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?
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 patients (accepts the positive statement but
modulates it slightly with reality testing).

Negative transference is more typically a focus in supportive

psychotherapy because such transference can be a threat to the integrity of
the treatment and normally adds to the patient’s suffering when acted on
outside the treatment setting. In supportive and supportive-expressive
psychotherapy, the therapist clarifies often and confronts at intervals but
interprets infrequently, if at all. The therapist’s interventions assist the
patient 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
functioning. 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 characterological
and core neurotic defenses are often expressed through positive and
negative transference phenomena. The therapist’s transference
interpretations and clarifications assist the patient in gaining insight and
working 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
relationship.
The content of the therapist’s transference interpretations also differs in
expressive versus supportive modes. The precision and comprehensiveness
of an interpretation may vary depending on the level of the patient’s object
relations and defensive functioning, the patient’s progress in treatment, and
the strength of the therapeutic alliance. Interpretations often 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 damaging 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 genetic references and generalizing
[Pinsker et al. 1991]) or inexact interpretations (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, as compared with how it is at work, where
everything must be annoyingly in its place and on time. Is there
a downside? (supports self-esteem, makes a connection to
angry feeling, contrasts patient’s style with real-world
expectation, opens a dialogue on adaptive skills)

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

interpretation.
 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 dependency 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
psychotherapy (Luborsky 1984)—an early and strong therapeutic alliance
(which is reflective of the real relationship) is predictive of positive
outcome 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
transference included a personal relationship with the patient, which he
called rapport or unobjectionable positive transference. He considered this
relationship necessary to maintain the motivation needed to collaborate
effectively 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
collaborative elements within the therapeutic relationship. Current
conceptions 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
affective 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
expressive 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
therapeutic 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 further support the therapeutic alliance, which has a basis in the real
relationship. 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 alliance,
supportive psychotherapy does not emphasize exploration of conflict. 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 communicate 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 provoking, 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 moving to symbolic or transference
issues (Pinsker 1997). The following vignette demonstrates how a therapist
addressed a misalliance (see Video Vignette 4, available at
www.appi.org/Winston).

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 computer 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 getting 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 struggling 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 clarification and confrontation, to
get the patient to become more specific).
RACHEL: What good is this? I talk and talk here, and now another relationship 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?
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 differently, 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 relationship, “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 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 position, 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 transferential statement about
her experience of the therapy and the therapist. 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
differently, 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 signify
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
outcomes. 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 therapies (e.g., supportive-expressive psychotherapies) than with
structured cognitive or behavioral treatments (Beutler et al. 2002b).

“Joining the Resistance”

Supportive treatment aims to support defenses unless they are maladaptive.
Again, a primary principle in supportive psychotherapy is to support the
therapeutic alliance. When a patient is resistant to looking at dysfunctional
patterns, the fact that the therapist reflects the patient’s despair and
hopelessness or empathizes with his or her tough life or work situation
might give the patient a strong sense of being understood and thus increase
his or her willingness to work in therapy (Messer 2002). Supportive
psychotherapy can provide, without coercion, an active empathic
environment and can reinforce the patient’s stated goals.
In supportive-expressive treatment, when a patient is struggling to
recognize his or her own feelings or impulses, the therapist can follow the
patient’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 really 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
anxious, 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 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 patient’s lateness is
related to the therapist.)
 PATIENT: Sure, but I just had stuff to do, and I lost track of the time
(rationalizes, deflects, and plays the lateness off as a result of
making more important choices).
THERAPIST: In psychotherapy, when someone creates a pattern of
somehow 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 uncomfortable emotions. I’m happy to explore it with
you if you are interested. It might be helpful (clarifies,
confronts, normalizes, offers guidance about the cost of
exploring this issue).
PATIENT: It’s not just here, doc. I’m late for everything [sheepish
grin] (generalizes 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 motivation, 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
authentic (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
definitive 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 withdrawal
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
patient’s lack of verbal engagement, which the therapist might choose to
address 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 getting in your way. (The therapist picks
up the patient’s topic from before 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 negative 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 emergencies, it’s not the same as coming for therapy.
PATIENT: That’s right [looks at the therapist less blankly] (engages a
bit, reinforces 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 themselves in that situation when their therapists come back
after a vacation (clarifies the situation but generalizes away
from the specifics of the patient and the therapist before
confronting the patient’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).

Defining Countertransference
In considering countertransference, the therapist must make a distinction
between 1) emotional reactions to a patient’s behavior that are due to the
therapist’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
described as the narrow or classical view of countertransference—
essentially, the therapist’s transference to the patient (Gabbard 2001). A
broader definition of countertransference includes the real relationship,
consisting of reactions 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 identify his or her bad feelings about the patient
and treatment as countertransference, or the therapist might misperceive the
problem as the patient’s resistance. The therapist makes an attribution that
the patient is being resistant, but actually, the therapist or treatment is not
effective.
Because we describe supportive psychotherapy as a dynamically
informed 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
information 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
transactional construct, affected by what the therapist brings to the situation
as well as by what the patient projects (Gabbard 2001; Kiesler 2001). A
discussion 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
countertransference elicitations in the therapy session. When the therapist
recognizes 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
adaptation. 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 awareness
is more important in supportive psychotherapy, in which the flow of
dialogue is conversational, than in expressive treatment, in which the
therapist may at times abstain from responding. Gelso et al. (1995, 2002)
demonstrated that better countertransference management correlated
positively with better outcome in brief therapy (consisting of 12 sessions).
 The therapist in the following dialogue recognizes the patient’s
maladaptive 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
(empathic).
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 finding 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. (Modulated confrontation and drawing of
parallels. The therapist restates 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 patient’s treatment
goal).

From the vantage point of interpersonal communication theory, Kiesler

(2001) described effective feedback of countertransference feelings as
applying 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
expression 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
being 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 borderline
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 patient’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 unreasonable 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 response; 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

understand feelings of irritation, frustration, and helplessness generated in
response to a patient’s chronic criticism and devaluation. Without adequate
peer support or professional supervision, the therapist may become
clinically 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
supportive 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 Psychotherapy”), will maintain a transference
position that is impermeable to therapist intervention and disclosure. These
patients’ pathogenic beliefs regarding 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 promotes
and maintains the therapeutic alliance. In supportive psychotherapy, 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 impact of negative
transference is likely to interrupt treatment. The therapist typically uses
clarification and confrontation in supportive treatment, but when
interpretations are made, they tend to be incomplete or inexact. Because
defenses are not confronted in supportive psychotherapy unless they are
maladaptive, the clinician can learn to manage resistance with supportive
techniques. The clinician must always be alert to the potential 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, soldiers with combat fatigue or “shell shock” were
quickly evacuated from the front lines, without treatment, despite observations that early
intervention might reduce psychiatric morbidity (Salmon 1919). These soldiers 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 survivors 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) described 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 colleagues, Gerald Caplan
(1961), began to work in the field of preventive psychiatry 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 turning 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 when an individual encounters a situation that leads
to a collapse in his or her usual pattern of functioning, entering a state of psychological
disequilibrium. 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 relationship 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 occurrence, 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, generally 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 psychological
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 treatment. Davanloo (1980) incorporated production of a
crisis into his short-term dynamic psychotherapy approach, viewing crisis as a means of
disrupting 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 homeostatic balance and
diminishing vulnerability to the stressor. The therapist helps the individual to accomplish
homeostasis by mobilizing the individual’s abilities and social network and promoting
adaptive coping mechanisms 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, including age, health,
personality issues, prior experience with stressful events, emotional support, resources, belief
systems, and underlying biological or genetic strengths or vulnerabilities. Traumatic events
are common 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 attacks, 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 produce 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.
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 sessions. This more
inclusive form of crisis therapy is based on a number of different treatments, including
dynamic supportive, cognitive-behavioral, humanistic, family, and systems approaches, as
well as the use of medication when indicated. Systems approaches can be broad and can
encompass actions such as working with and referral to social service agencies, clergy, mobile
crisis units, suicide hotlines, and law enforcement agencies. In recent years, the focus of crisis
intervention has been on emergency management 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 equilibrium, and deal with reality, and 2) assessing
problem-solving and coping 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 immediately. Even the evaluation session itself should be therapeutic to assist 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 traumatic 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.

Video Vignette 5: Crisis Intervention

Session 1
William is a 44-year-old police officer with anxiety, depressive feelings, 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? (summarizes and attempts to find out when
the patient’s difficulties began)
WILLIAM: It’s been going on for about 6 months, but it’s gotten worse over the last couple of months, I’d say.
THERAPIST: 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 terrible. I still can’t believe what happened (begins to talk about the traumatic events that
occurred on September 11, 2001).
THERAPIST: Well, you know it is important that we try to go into as much detail as we can (attempts to get
details 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).
THERAPIST: I can see that this is very difficult for you (responds 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.
THERAPIST: Oh my God! That must have been so frightening (responds 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 ordeal. 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 sudden, 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 clarification, tracking, and admiration, and
continues exploring)
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 thinking about it. (Despite his heroic behavior and the therapist’s praise and admiration, the
patient indicates 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 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 examined, as well as his history. The following information emerges.

William has been extremely anxious and tearful following his traumatic 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 decorated on several occasions for heroism.
William grew up in a middle-class family and had a good relationship with his mother. When he was 15
years old, his father died. William’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 disorder (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
psychotherapy. 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 relationship at the onset of
treatment, followed by work on symptom reduction with the use of exposure therapy, along with cognitive
restructuring. Medication for anxiety and depression, such as a selective 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.

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 positive
therapeutic alliance through the use of supportive interventions. 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, doing anything . . . . I just don’t feel like talking (begins with a complaint from
his wife rather than continuing to discuss 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 something about your past life, and a bit concerning your relationship 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 implications 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, anxiety 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 saxophone. 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).
 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 summer, 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
distraction accompanied by annoyance with his wife; again employs the supportive technique
of asking for feedback so that the patient is not overwhelmed)

The therapist has asked for a specific example of William’s difficulty 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 concentrate on William’s current life and his difficulty with his wife, Cathy. In
supportive psychotherapy, the transference generally is not addressed 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 addition, the
therapist has been able to link William’s avoidance and annoyance 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 psychotherapy 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 relationship was established during the first three
sessions (session 3 is not shown). Therefore, exposure therapy within a supportive framework 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 together, 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 proceed. Let’s go back to that day when you
went to the World Trade Center. OK? (praises the patient and continues to involve 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 outside to keep people out, as I said before.
THERAPIST: What was it like for you, remaining outside while the others went in? (is aware of the patient’s
not wanting to remain 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 therapist 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.

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 exploration 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 holding 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 anxiety 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
patient 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 reassurance can also
be used.
The session continues with a detailed exploration of William’s experiences 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 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 amazing! (offers
praise and expresses admiration—both useful 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 include rescuing a man, going to the hospital to have lacerations sutured, 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
begins to become overly aroused, the therapist stops the exposure work and uses a number of supportive
techniques, such as praise, reassurance, 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 inside the World Trade Center with his fellow officers (cognitive restructuring). 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 tragedies 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 episodes 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
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, and a number of supportive and cognitive-behavioral
interventions; and, most importantly, establishment of a solid therapeutic alliance. A number
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 interventions, 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 therapeutic 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 resulting from the events of September 11, 2001. These sessions illustrate the
treatment process in a broad-based supportive psychotherapy crisis intervention approach.

Treatment Approaches for PTSD

In this chapter we have described the treatment of PTSD using supportive psychotherapy
combined with exposure therapy and cognitive restructuring, along with the anxiety-reducing
techniques of progressive muscular relaxation 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 repetition (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 approach 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 suicide 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 alcoholism and drug abuse, schizophrenia, borderline personality
disorder, 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, being 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 determine the diagnosis and the proper treatment approach. Crisis intervention
approaches, generally accompanied by the use of medication, often 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 attempts increases a person’s risk for
completing suicide. Individuals who have well-defined plans to kill themselves are at greater
risk than individuals 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 significant risk. The presence of strong family
support or a significant other can have a mitigating effect on suicidal risk. Hopelessness,
pessimism, aggression, impulsiveness, and psychic anxiety are poor prognostic signs. Another
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 denied suicidal thoughts or indicated
that they rarely occurred (Clark and Fawcett 1992). Often, these same patients communicated
directly or indirectly 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, agitation, 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 admission and the
month after discharge and during the early period of recovery 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).

Treatment
Suicidal thoughts represent a form of problem-solving by patients in tremendous and
unrelenting psychological pain. Acknowledging the patient’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 considerations: 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 reasons 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 experiences of their
patients and those who are early in their training or clinical practice, may feel overwhelmed
by the suffering felt and expressed by suicidal patients. To be effective in working in crisis
settings with suicidal patients, 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, hospitalization may be
indicated. If hospitalization is not feasible or not absolutely necessary, the therapist should
enlist the aid of significant others who can spend time with the patient and not leave the
patient alone. The therapist needs to be available for contact either by the patient or by the
patient’s family or friends and should provide them with information regarding 24-hour
hotlines and the nearest emergency department. Medication is often necessary in the short
term to relieve the patient’s anxiety, agitation, or depression. The frequency of treatment
sessions will vary depending 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. Important issues on which to focus are
patient hopelessness and pessimism. Supportive approaches involving praise, reassurance, and
cognitive restructuring are often useful to help enhance self-esteem by counteracting negative
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, including dynamic
supportive psychotherapy, cognitive-behavioral therapy, humanistic treatments, family
therapy, and systems approaches. Crisis intervention is time limited and is not focused on
psychological insight, personality issues, or psychiatric disorders. An individual receiving
crisis intervention is generally in transition or has lost his or her equilibrium because of a
traumatic experience that has disrupted his or her life. Patients vary in their resilience and
sources of support. The objective of crisis intervention is to help the individual deal with the
stressful period, achieve stability, 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 psychotherapy (as opposed to expressive psychotherapy), the focus is on the here
and now rather than on the past or on transference issues.

Table 7–1. Crisis intervention versus psychotherapy

Crisis intervention Psychotherapy

Context Prevention Reparation

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

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 Conscious and unconscious sources
stressors or factors of pathogenesis
Temporal focus Here and now Present and past
Patient Symptom reduction, reduction of Symptom reduction, reduction of
expectations impairment, directive support impairment, personal growth,
guidance, collaboration
Goals Stabilization, reduction of Symptom reduction, reduction of
impairment, a return to function impairment, correction of
or a shift to next level of care 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.

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

Intervention Timing Activation Goals Recipients

Precrisis Precrisis Driven by Setting of Individuals,

preparation crisis expectations, groups,
anticipation improved organizations
coping, stress
management
Demobilization Shift Event driven Presentation of Organizations,
and staff disengagement information, large groups
consultation consultation,
(rescuers) psychological
decompression,
stress
management
Intervention Timing Activation Goals Recipients

Crisis management Anytime Event driven Presentation of Organizations,

briefing postcrisis information, large groups
(civilians, consultation,
schools, psychological
businesses) decompression,
stress
management
Defusing Postcrisis (within Usually Symptom Small groups
12 hours) symptom mitigation,
driven possible
closure, triage
Critical incident Postcrisis (1–10 Usually Facilitation of Individuals, small
stress days; mass symptom psychological groups
debriefing disasters: 3–4 driven; closure,
weeks) sometimes symptom
event mitigation,
driven triage
Individual crisis Anytime, Symptom Symptom Individuals
intervention anywhere driven mitigation,
possible return
to function,
referral if
needed
Family crisis Anytime Symptom or Fostering of Families
intervention event support and
driven communication
Community and Anytime Symptom or Symptom Organizations
organizational event mitigation,
consultation driven possible
closure,
referral if
needed
Pastoral crisis Anytime Usually “Crisis of faith” Individuals,
intervention symptom mitigation, use families,
driven of spiritual groups
tools to assist
in recovery
Intervention Timing Activation Goals Recipients

Follow-up and Anytime Usually Mental status Individuals,

referral symptom assessment, a families
driven shift to higher
level of care 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.

Critical Incident Stress Management

Critical incident stress management (CISM) was originally developed for use with emergency
workers; however, its scope has been expanded to include 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 individuals 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 assessment and
triage and to mitigate symptoms; critical incident stress debriefing (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 referral 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 preventing 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 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 cognitive restructuring (Bryant
et al. 1999; Foa 1997; Foa et al. 1991).

Conclusion
In this chapter, we provided a brief history and the theoretical background 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 always necessary. Treatment approaches vary depending on the needs of the patient
but generally include supportive interventions, exposure therapy, cognitive restructuring, and
anxiety-reducing techniques. A patient’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 crisis. The terrorist attacks of September 11, 2001, in New York and Washington,
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 intervention services.
Applicability to Special 8
Populations
Severe Mental Illness
As originally conceived, supportive psychotherapy was indicated for
patients with severe mental illness, as well as for other patients for whom
expressive treatment was not indicated. The original indication for
supportive 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 social drift due to
loss of adaptive skills and increasing isolation. In addition to offering the
patient an understanding, supportive relationship, this approach contained
many of the following techniques: advice, reassurance, exhortation, praise,
encouragement, lending ego, and environmental manipulation. 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
supportive and expressive elements in supportive treatment. Depending on
several factors—including the degree of stabilization after acute
exacerbation of illness, the strength of the therapeutic alliance (see Chapter
6, “The Therapeutic Relationship”), and the patient’s treatment goals—
confrontation and, at times, interpretation can be useful techniques in
supportive psychotherapy. Cognitive learning strategies, such as teaching,
using slogans, modeling, 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 supportive 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
behavior with praise (Lamberti and Herz 1995). Gunderson et al. (1984)
demonstrated that patients with schizophrenia have better treatment
retention 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.
However, praise builds self-esteem only when the praised behavior is
considered 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. Determining what
the patient finds rewarding is especially important in schizophrenia and at
the left side of the psychopathology continuum, where positive
reinforcement is an important factor in maintaining the therapeutic alliance
and motivating engagement in treatment.
Positive reinforcement is helpful for patients with schizophrenia
because they commonly have neurocognitive impairments; negative
symptoms, such as apathy, anhedonia, and poor motivation; and poor
insight. A reinforcer can be a favorite food, activity, person, or social event
that increases the strength or frequency of the patient’s contingent behavior.
Properly assessed and delivered reinforcers increase patients’ skill
acquisition, achievement of goals, and self-esteem (Lecomte et al. 2000).
External rewards that patients value may be helpful in engaging and
maintaining these patients in treatment. Rewards can include subway
tokens, certificates of accomplishment, a celebratory event, and gift
certificates. Administration of accurate praise, as described throughout this
book, is an effective and inexpensive reward.

Psychoeducation
Typically, supportive psychotherapy for patients with severe mental illness
includes psychoeducation about the illness, its trajectory, and its treatment.
The literature suggests that educating patients about schizophrenia 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, psychoeducation offers the
patient a new cognitive structure on which to base more realistic decision
making. Psychoeducation also gives the patient 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 exacerbation 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 relapse 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 future events and will
strengthen the therapeutic alliance.

Supporting Adaptive Skills

To help patients who have impairments in interpersonal functioning
secondary to severe mental disorders such as schizophrenia, the therapist
can integrate behavioral skills training and other cognitive-behavioral
techniques into supportive psychotherapy. The model of change in
supportive 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 therapist
uses supportive techniques, such as behavioral goal setting, encouragement,
modeling, shaping, and praise (positive reinforcement), to teach
interpersonal skills (Glynn et al. 2002). This activity directly supports
adaptive skills and builds patients’ self-esteem. Studies have demonstrated
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
result 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,
medication 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
Prevention” later in this chapter.
At times, the clinician must balance his or her focus on anxiety
reduction 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 content
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 guidance 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 psychiatric treatment.
PATIENT: Uh, depression. I have depression.
THERAPIST: That’s what they told you?
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 experiencing 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 clarification 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, connecting 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.
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 response 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
disorder 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
vampires—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 reassures).
PATIENT: What’s going to happen to me? [tears up]
THERAPIST: We have better medicines and better therapies than ever
before, 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,
environmental manipulation generally is not employed. With more impaired
patients, however, the therapist can judiciously intervene in the patient’s
environment to support continued adaptation and reduce anxiety and stress.
A clear example of this approach is family psychoeducation, 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 exacerbation 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
impairment of ego functioning) but rather the patients who are highly angry,
demanding, suspicious, or dependent (Horowitz and Marmar 1985).
Patients with personality disorders use pervasive, maladaptive interpersonal
strategies, and their behaviors are sometimes dangerous or frightening.
Therefore, these patients can provoke strong negative emotions in people—
including psychiatrists, who may avoid treating patients with personality
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
countertransference 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 adaptive skills while developing and maintaining a strong therapeutic
alliance. 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
functioning, 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
behaviors. For example, in the treatment of patients with avoidant
personality disorder, a major focus is on getting the patient to develop skills
to overcome passivity and fears of rejection. In contrast, in the treatment of
patients 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
psychotherapy, within the supportive psychotherapy frame, clarification can
elucidate maladaptive constructs that contribute to the patient’s
interpersonal problems 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
patients with personality disorders. In contrast to earlier concerns that
medicating patients would deprive them of the motivation for engagement
in treatment, today it is recognized that judicious pharmacological treatment
of comorbid depression and anxiety disorders generally acts synergistically
with the patients’ attempts to learn and master new adaptive skills. In
depressed patients, pharmacotherapy reduces Cluster C personality
pathology—in particular, harm avoidance, which is associated with poor
social function (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
disorder, Perry et al. (1999) found that all studies of active psychotherapies
reported positive outcomes at termination and follow-up. In addition,
patients receiving treatment have an accelerated rate of recovery from
personality disorders compared with the natural course of the disorders.
Bateman and Fonagy (2000) conducted a systematic review of the evidence
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 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 psychotherapy
in combination with antidepressant treatment led to greater reduction in
personality pathology compared with antidepressant treatment alone (Kool
et al. 2003). Patients with problems of hostile dominance, 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 patients’ having some capacity
to form a therapeutic alliance.
In supportive psychotherapy, it has been posited that when transference
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 commitment,
concern, and attention to the supportive technique during psychoanalytic
treatment and suggested that the development of secure attachments
fostered more autonomous functioning. By discouraging destructive
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 intensity 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,
fostering 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 works to
create a sense of safety so as to reduce maladaptive defenses, which are
typically linked to fears of annihilation, abandonment, and humiliation.
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 anxiety.
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 regression,
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 focused
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 decidedly
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
patients’ 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 significant
positive changes in depression, anxiety, global functioning, and social
adjustment. Compared with the DBT group, the supportive psychotherapy
group had significant reductions in anger, but supportive psychotherapy 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
chapter). Generally, residents learned about withdrawal syndromes and
detoxification while working on inpatient psychiatric units that admitted
patients with psychiatric disorders or substance-induced mental disorders.
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
intervention for substance use disorders. Some medications approved for
use in substance use disorders are maintenance medications for opioid use
disorder, 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 intervention
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 treatments,
when offered as the sole ambulatory treatment, are not well suited to the
needs of patients with substance use disorders. In expressive treatments,
symptom control and development of coping skills are often not the primary
focus. Patients drop out frequently because of a lack of focus on the
patient’s presenting problem and because patients find the therapist’s
neutral, abstaining stance anxiety provoking. Today, it is understood 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. Therefore, 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
disorder focuses on helping patients to develop effective coping strategies
to control or reduce substance use and stay engaged in treatment. Other
important 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 includes
use of newer, more evidence-based strategies, such as motivational
interviewing, relapse prevention, and psychoeducation. General supportive
principles are maintained during the course of addiction treatment, even as
patient and therapist embark on particular cognitive and behavioral 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 therapy
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
substances 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
relationships, 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 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
directive, patient-centered intervention that helps patients to explore and
resolve 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 perception 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 actions about reducing or stopping substance use; the patient
might experience 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 motivational 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 cessation 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
alliance 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 directed 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
(restates the passive role expectation).
THERAPIST: Well, actually, we’re both going to try to better
understand your problems with substances, and then we’ll
collaborate on setting 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 actively 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
promoting 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 interviewing 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 remaining
drug-free is hard. The specific adaptive skills that must be learned in
addiction recovery are 1) identifying high-risk situations and cues, 2)
anticipating exposure to these situations and cues, and 3) developing
alternative strategies for coping when exposed to these situations.
 Relapse prevention involves a formal set of cognitive-behavioral
approaches 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
refusal skills for when the patient is offered the target substance (Marlatt
and Gordon 1985). However, identification of risky situations and
development 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 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 adaptive
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 increasingly
intense praise and positive feedback for each successive goal met.
Because a dysphoric mood is a frequently reported antecedent of
relapse, 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
difficult time differentiating mood states into specific affects, in part
perhaps 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 identify and
label feelings makes it easier to reflect on these feelings and communicate
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 appropriate adaptive skills to manage
painful affects. As patients begin to identify these feelings, they experience
—in spite of increased awareness of negative affect—an increase in self-
esteem that comes from mastery of the internal 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
to self-medicate, and a disease model of addiction. Most cultures implicitly
or explicitly operate out of a moral model of substance abuse and addiction,
which attributes the irresponsible or criminal behavior of the addicted
individual to his or her bad character. In contrast, the unitary disease
concept of addiction, variously attributed to Alcoholics Anonymous (1976)
or Jellinek (1952), stresses that addiction is a chronic, relapsing, and
progressive 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 reductionistic; he in
fact described several typologies, which differed regarding onset, severity,
pattern, and chronicity of use. Nonetheless, the psychotherapeutic 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, available
at www.appi.org/Winston).

Video Vignette 6: Substance Use Disorder

Kevin Waters is a 28-year-old single man who studied structural engineering 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
connect cause and effect) to assist the patient in deciding that his substance dependence is
not worth what it costs in his life. In this session, the therapist instead uses psychoeducation
to address Kevin’s denial and uses a moral model to explain his addictive behavior.
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 inherent 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 behavior 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 results 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 predictable. 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 through demonstrating knowledge of patient’s personal 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 different 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 substance
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 efforts to cut down or
control substance use” (American Psychiatric 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 always spend
everything I have (recognizes own loss of control; becomes sad).
THERAPIST: So, maybe initially when you started, you made the mistake 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
alcoholism are things that run in families. They are inherited. The risk is inherited,
and drug problems are very similar (supports patient’s understanding with
clarification, normalizing, rationalizing, 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 problems 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 recognize the loss of
control, but this is a very common experience for people who are in the early
stages or in the beginnings of recovery. But those who stay with treatments tend
to have better outcomes than those who don’t stay with treatments (offers
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 illness, like many other chronic illnesses.
We don’t have a cure for diabetes. We don’t have a cure for hypertension. But
people are able to recover from the more severe forms of the illness. Even with
 the illness being out of control, they can go on to have better lives (expert
opinion, normalizing, and offering 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 psychiatric
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
Comorbidity Survey, Kessler et al. (1994) found that of the population who
had psychosis or mania or who needed hospitalization for a mental disorder
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
negative 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
psychotherapy, 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
integrates the techniques that are useful for each problem, as delineated in
the sections “Severe Mental Illness” and “Substance Use Disorders” earlier
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 situations likely
to trigger relapse to substance abuse are all generally needed to treat co-
occurring substance use disorders and other mental 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 addiction 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
(especially programs that are less likely to reduce self-esteem, such as
“double 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 alliance and
the engagement of patients in treatment (Rosenthal et al. 2000).

Psychoeducation
In the context of supportive treatment, patients with substance use disorders
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
capacity 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 illness
learns that he or she has another chronic illness such as substance
dependence, this knowledge can become a factor in his or her
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 discuss
their own symptoms and their own history of treatment responsiveness and
to attempt to understand what role their substance abuse may have played in
either relieving or exacerbating psychotic, mood, and anxiety 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 disorders and
other mental disorders is not linear, and exacerbation of both disorders 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
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 supportive 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 severe mental
disorders. If a patient remains in treatment, however, reduction 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
psychotherapeutic intervention; therefore, treatment strategies and
approaches such as motivational interviewing, psychoeducation, and relapse
prevention, 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
psychotherapy has beneficial impact and can serve as a natural platform for
integrating 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
motivational 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
competence. These methods include various types of written, oral, and
clinical examinations; a combined assessment approach of patient, family,
supervisors, and others; record reviews; portfolios and case logs;
simulations, models, and use of standardized patients; and evaluation of live
or recorded performance (Accreditation Council for Graduate Medical
Education 2015). The Residency Review Committee for Psychiatry chose
five types of psychotherapy in which residents in psychiatry must be
certified as competent by their training programs, but a few years later
decreased this requirement to three types: supportive, psychodynamic (or, in
our terminology, expressive), and cognitive-behavioral psychotherapies
(Accreditation Council for Graduate Medical Education 2014). In this
chapter, we outline our approach to evaluating competence of psychiatry
trainees in one of these three psychotherapies—namely, supportive
psychotherapy.
The definition of competence is a major issue that needs to be
addressed. An acceptable definition of competent is “having requisite or
adequate 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
competence, 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
psychotherapy. 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 methodologically
rigorous. They called for additional well-designed studies to evaluate 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
psychotherapy was the most widely practiced but received the least amount
of didactic time and supervision.
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
integrated 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
process 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
classroom approaches generally consist of reading courses, in which
psychotherapy 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 intensive 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
combination of these approaches
4. Discussion of the psychotherapy process, including resistance,
dysfunctional thinking, defenses, affect, and therapist interventions, as
well as 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 noting

how well the resident performs the tasks listed above, as well as assessing
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
evaluated within the broader context of general psychotherapy. The
assessment should encompass skills of, attitudes toward, and knowledge
about general psychotherapy and the more specific approach of supportive
psychotherapy. 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
included other skills, such as identifying patterns and implementing
strategies for change. The AADPRT Psychotherapy Task Force also
developed psychotherapy competencies for the five psychotherapies
originally mandated by the Residency Review Committee for Psychiatry,
including supportive psychotherapy. Table 9–1 includes the complete list of
AADPRT competencies for supportive psychotherapy (Pinsker et al. 2001).

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.
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.

The supportive psychotherapy competencies are divided into knowledge

about, skills of, and attitudes toward supportive psychotherapy. The
knowledge category encompasses knowledge about objectives, the patient-
therapist relationship, and indications and contraindications for supportive
psychotherapy. The skills section contains 15 items, including the ability to
maintain a therapeutic alliance, the ability to use appropriate interventions,
and the ability to establish treatment goals. The attitudes section includes an
empathic, respectful, nonjudgmental approach and sensitivity 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 performing
supportive psychotherapy. A formal written evaluation of the resident by
the supervisor should be completed at least twice a year. This evaluation
should be educative and be based on the supervisory work preceding 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
evaluator to observe the conduct of psychotherapy directly. The more
traditional method of summarizing a session or working from process notes
is less likely to convey what actually occurred in a psychotherapy session,
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 viewing 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
include the cost and maintenance of the equipment and the ability of
residents 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 operate,
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 generally do not provide
each resident with textbooks. The main purpose of recording is not to have
a high-quality picture but rather an understandable 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 subsection
can be used to evaluate a trainee reporting on psychotherapy sessions from
process notes. Another approach would be to present a video recording 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 psychotherapy
approach.

Assessment Instrument
The AADPRT supportive psychotherapy competencies provided the basis
for our development of a rating form to be used as a measure of a resident’s
competence in supportive psychotherapy. Our form (Figure 9–1) does not
include all the items on the AADPRT list of competencies because 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 supportive
psychotherapy and general psychotherapy competencies.
Figure 9–1. Beth Israel resident evaluation form for competence in
supportive psychotherapy.

The evaluation form covers three areas: knowledge (general

psychotherapy 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 supportive
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 supervision, 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 supervisors 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 research to measure
therapist adherence to manual-based forms of psychotherapy (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
psychotherapy evaluation guide for both residents and supervisors, and the
supervisors found the form to be useful and easy to use.

Outcome Research
In this section we report on a number of clinical trials of supportive
psychotherapy in the treatment of various psychiatric disorders. We discuss
some early uncontrolled studies and more recent controlled trials that
address 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 psychotherapy
with psychoanalysis. Wallerstein (1986, 1989) studied the treatment,
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; and
supportive interventions accounted for more of the change in outcome. 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
psychotherapy 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 maintained 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
psychotherapy 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 compared 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
psychoeducation, skills training, or role therapy. Defining supportive
psychotherapy 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 supportive
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 significantly more
than the treatment as usual group in social function and general
psychopathology.
In another study of first-episode psychosis using supportive
psychodynamic psychotherapy, Harder et al. (2014) found significant
improvement 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 therapy
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
Collaborative Research Program, two psychotherapies (cognitive-
behavioral therapy and interpersonal therapy) were compared with an
antidepressant (imipramine)–clinical management condition and a control
condition consisting of drug placebo and clinical management (Elkin 1994;
Elkin et al. 1989; Imber et al. 1990). The clinical management was a low-
level supportive 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
treatment with cognitive therapy, behavior treatment, or supportive
psychotherapy. 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 supportive 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 psychotherapies 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 psychotherapy or short trials of more specialized types of
psychotherapy.
Maina et al. (2005) completed a randomized controlled trial comparing
brief dynamic therapy with supportive psychotherapy in treating patients
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.
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
therapy is more efficacious than pharmacotherapy alone and that
psychotherapy 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
efficacious 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 various
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 attacks
received either imipramine plus behavior therapy or imipramine plus
supportive psychotherapy (Zitrin et al. 1978). The majority of patients
showed moderate to marked improvement, and there was no difference
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
therapy elements in treating patients with social anxiety disorder. They
found that all three treatments produced significant reductions in symptoms
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
significant improvement from pretreatment to posttreatment, with neither
therapy being superior to the other. However, Shear et al. (2001) reported
that emotion-focused psychotherapy, a form of supportive psychotherapy,
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 treatment
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.
Patients 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 symptomatology, 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 psychotherapy (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 generally
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
psychotherapy and found significant positive changes in both treatment
groups on general functioning, depression, and social functioning.

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
supportive psychotherapy was associated with a more rapid response than
interpersonal therapy.

Medical Disorder Studies

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

Conclusion
In this chapter, we have provided an overview of current efforts to evaluate
the competence of residents engaged in various clinical tasks, and in
particular supportive psychotherapy, as well as a summary of outcome
research in supportive psychotherapy. We have presented a preliminary
approach 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 treatment 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.

___ 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

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
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
impression 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
demands 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 difficulty
sleeping, and feels worried about her future and the impact of their
father’s death on her teenage children. Which of the following 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)

___ 28. Which of the following patients is most likely to benefit from
supportive 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 context
of supportive psychotherapy, according to the American
 Psychiatric 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
psychotherapy?

A. Always permitted
B. Never permitted
C. Permitted when it serves to strengthen the therapeutic
relationship 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
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 facing 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 statement 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 anger
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
patient’s feelings of anger and estrangement
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
estrangement with feelings of joy and emotional connection

___ 45. An 18-year-old high school graduate feels unsettled by the

prospect of attending college across the country in just a few
months. Which of the following is the most accurate statement
about psychotherapy 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
separation and adaptation to the new college environment may be
helpful
D. Engaging in expressive psychotherapy with the goal of
personality 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
situation

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
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
symptoms 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
psychotherapy 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

___ 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
intervention 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
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
approach 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
patient’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

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
psychotherapy

___ 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 Medical Education (ACGME), 163–164, 166

Activities of daily living, 63
Acute bereavement, 92–93
Acute crisis, 91
Adaptive behavior
advice and, 62–63
definition of supportive psychotherapy and, 9
supportive psychotherapy for severe mental illness and, 143–147
supportive treatment for substance use disorders and, 154–155
techniques of supportive psychotherapy and, 54, 60, 62–64
Adjustment disorders, 92
Adolescents, and depression, 94
Affects, and structural approach to case formulation, 44. See also Emotion(s)
Alcoholics Anonymous, 102, 154, 156
Alexithymia, 25, 93, 155
American Association of Directors of Psychiatric Residency Training (AADPRT), 165, 166, 167–
168, 170
Anger
awareness-expanding interventions and, 70
unrecognized forms of, 25
Anorexia nervosa, 177
Anticipatory guidance, 64–65, 154
Antidepressants
chronic depression and, 175
personality disorders and, 149
Antisocial personality disorder, 149
Anxiety
reduction and prevention of, 65–69
resistance in therapeutic relationship and, 114–115
schizophrenia and, 144
Anxiety disorders, outcome research on supportive psychotherapy for, 175–176
Assessment. See also Evaluation
of competence in supportive psychotherapy, 166, 170
diagnosis and, 33–34
evaluation interview and, 34–35
patient history and, 35–36
 personality disorders and, 148
of suicidal patient, 134
supportive-expressive continuum and, 34, 35
therapeutic alliance and, 33
triangle of conflict and triangle of person, 36, 37
video vignette of, 36–41
Attacking questions, and self-esteem, 21
Automatic thoughts, and depression, 40
Autonomous functions, and case formulation, 45
Awareness, expansion of, 69–71

Beginning phase of treatment, 98–99. See also Initiation

Behavior. See Adaptive behavior; Maladaptive behavior; Passive-aggressive behavior
Beth Israel Medical Center Psychotherapy Training Program, 170, 171–172
Bipolar disorder, 143
Borderline personality disorder, 149–150, 176
Boundaries, professional, 101–104
Brief dynamic therapy, for depression, 174
Brief psychotherapy
crisis intervention and, 123
indications for, 101
Bulimia nervosa, 94. See also Eating disorders
Buprenorphine, 151

Cancer, and depression, 90

Case formulation
cognitive-behavioral approach to, 42, 48–49, 50–51
definition of, 41
DSM-5 and, 41
dynamic approach to, 42, 46–48, 50
genetic approach to, 42, 46, 50
personality disorders and, 148
structural approach to, 42–46, 49–50
Case illustrations. See also Video vignettes
of dynamic case formulation, 47–48
of psychodynamic formulations, 24
of structural case formulation, 45–46
of supportive-expressive continuum, 9–10
Change, concept of in literature on psychotherapy, 29–30. See also Personality change
Chronic pain, 92
Clarification
as awareness-expanding intervention, 69
transference and, 14
Cognition, supportive psychotherapy and faulty forms of, 29
Cognitive-behavioral approach, to case formulation, 42, 48–49, 50–51
Cognitive-behavioral therapy
depression following traumatic brain injury and, 175
eating disorders and, 177
 patterns of thought and maladaptive behaviors, 26
relapse prevention for substance use disorders and, 154
supportive interventions and, 7
Cognitive therapy, for PTSD, 133
Communication. See Conversational style; Interpersonal communication theory
Community mental health movement, and crisis intervention, 121
Competence, in supportive psychotherapy
assessment of, 163, 166, 170
definition of, 164
methods of measuring, 163–164
psychotherapy supervision and, 165–166, 168, 170
Conflict, triangle of, 36, 37
Confrontation
as awareness-expanding technique, 69–70
transference and, 15
Conscience, and case formulation, 45
Contextual techniques, 53
Contraindications for supportive psychotherapy, 94–95
Conversational style, in supportive psychotherapy, 16–19
Co-occurring mental disorders
indications for supportive psychotherapy and, 90
substance use disorders and, 159–161
Coping skills
anxiety reduction in schizophrenia patients and, 144
substance use disorders and, 152
Core beliefs, and case formulation, 48–49
Core conflictual relationship theme (CCRT), 47
Core psychotherapy skills, 166
Corrective emotional experience, and transference, 28
Counseling, and supportive-expressive continuum, 6, 8
Countertransference, and therapeutic relationship, 116–120
Crisis intervention
critical incident stress management and, 136, 140
definition of crisis, 121
evaluation and, 123–126
history and theory of psychiatric care for, 121
indications for supportive psychotherapy and, 91–93
psychotherapy as distinct from, 123, 135–136, 137–139
suicide and, 133–135
therapeutic approaches to, 126–133
Critical incident stress management (CISM), 136, 140
Cultural context
models of substance abuse and addiction, 156
provision of food or small gifts in office setting, 96

Debriefing, and crisis intervention, 123, 136, 138, 140

Defenses
approach to in supportive psychotherapy, 22–23
 case formulation and, 44
denial, 22
expressive approach to transference and, 108
personality disorders and, 148
Delayed grief, and schizophrenia, 70
Delirium, 94
Dementia, 94
Depression. See also Major depression
adaptive behavior and, 55
indications for supportive psychotherapy for, 90
outcome research on supportive psychotherapy for, 174–175
video vignette illustrating assessment of, 37–41
video vignette illustrating supportive-expressive treatment of, 77–88
Desensitization, and behavioral techniques in supportive psychotherapy, 29
Devaluation, and countertransference, 119–120
Diagnosis, and assessment process, 33. See also Assessment; Case formulation
Dialectical behavior therapy, for personality disorders, 150, 176
Disease model, of addiction, 156
Disulfiram, 151
“Doorknob issues,” and conduct of sessions, 97
DSM-5, and case formulation, 41
Dynamic approach, to case formulation, 42, 46–48, 50
Dysphoric mood, and substance use disorders, 155

Early life experiences, and psychodynamic theory, 26–27

Eating disorders, 177. See also Bulimia nervosa
Education. See also Psychoeducation
modes of action in supportive psychotherapy and, 28
psychotherapy supervision and, 165–166, 168
teaching of supportive psychotherapy, 10–12, 164–165
Ego functions
definition of supportive psychotherapy and, 8–9
structural approach to case formulation and, 43
techniques of supportive psychotherapy and, 54
Emotion(s). See also Anger; Corrective emotional experience
awareness-expanding interventions and, 70
countertransference and, 117
psychodynamic therapy and unrecognized, 24–26
substance use disorders and, 155
Emotion-focused psychotherapy, for panic disorder, 176
Encouragement, as technique, 60–61, 154
Evaluation, and crisis intervention, 123–126. See also Assessment
Exhortation, as form of encouragement, 61
Exposure therapy
PTSD and, 133
social anxiety disorder and, 175
Expressive psychotherapy, 2, 5
substance use disorders and, 151–152
 supportive-expressive continuum and, 6, 7, 9, 34
termination phase of treatment and, 100–101
transference in, 106–109
Expressive stance, in supportive psychotherapy, 23
Eye movement desensitization and reprocessing, 133

Family. See also Interpersonal relationships

assessment of risk of suicide and, 134
psychoeducation on severe mental illness for, 147
Family-based treatment, for eating disorders, 177
Fearfulness, and reassurance, 59
Food, and office arrangements, 96
Freud, Sigmund, 13, 45, 109
Friends, and friendship. See also Interpersonal relationships
assessment of suicide risk and, 134
professional boundaries and, 103

Genetic approach, to case evaluation, 42, 46, 50

Gifts, and therapist-patient relationship, 96
Goals
of crisis intervention, 137
definition of supportive psychotherapy and, 3
setting of in supportive psychotherapy, 51–52
Grief. See also Acute bereavement
crisis intervention and grief work, 121
unrecognized emotions and, 25, 70
Ground rules of supportive psychotherapy, 95
Group therapy, for substance use disorders, 152

Harm avoidance, and personality disorders, 148

Help-rejecting, as contraindication for supportive psychotherapy, 94
HIV-positive patients, and depression, 92
Holding environment, and anxiety reduction, 66
Homeostasis, and crisis intervention, 122
Hospitalization, of suicidal patients, 135

Ideals, and case formulation, 45

Imipramine, 175, 176
Impulse control, and case formulation, 44
Initiation, of supportive psychotherapy, 95. See also Beginning phase
Integrated psychotherapy, for PTSD, 133
Interpersonal communication theory, and countertransference, 118–119
Interpersonal relationships. See also Family; Friends
professional boundaries and, 103
therapeutic alliance and, 55–56
Interpersonal therapy
for eating disorders, 177
for PTSD, 133
 for social anxiety disorder, 176
Interpretation
expressive approach to transference and, 108–109
techniques of supportive psychotherapy and, 70–71
Interpretive psychotherapy, for personality disorders, 176
Interventions. See also Crisis intervention; Techniques
specific techniques, 53
transferences as guides to, 106
Inventory of Interpersonal Problems, 176

Lateness, of patients for sessions, 96–97

Learning theory, 28–29
Lending ego, 64
Limit setting, and conduct of sessions, 98
Long-term psychotherapy, indications for, 101
Loss, and crisis intervention, 122

Major depression
contraindications for supportive psychotherapy and, 94
outcome research on supportive psychotherapy for, 175
video vignette of misalliance and, 111–113
Maladaptive behavior
countertransference and patterns of, 117–118
psychodynamically oriented therapy and, 26
Malingering, 94
Mania, 143
Maxims, and normalizing, 60
Medical illness. See also Cancer
indications for supportive psychotherapy and, 92
outcome research on supportive psychotherapy for, 177
Medications. See also Self-medication
personality disorders and, 148
substance use disorders and, 151
suicidal patients and, 135
Menninger psychotherapy research project, 27, 89, 172–173
Mental illness. See also Anxiety disorders; Bipolar disorder; Co-occurring mental disorders;
Depression; Personality disorders; Posttraumatic stress disorder; Psychopathology; Psychotic
disorders
indications for supportive psychotherapy and chronic, 93–94
supportive psychotherapy for severe forms of, 141–142
Mentalization-based psychotherapy, for personality disorders, 176
Methadone, 151
Middle phase of treatment, 99–100
Mindfulness exercises, and dialectical behavior therapy, 150
Morals, and case formulation, 45
Motivation and goal setting in supportive psychotherapy, 51
Motivational interviewing
substance use disorders and, 152–154, 161
 supportive conversational style and, 17
Myocardial infarction, 177

Naltrexone, 151
Naming of problems, and reduction of anxiety, 67
Narcissistic personality disorder, 148
National Comorbidity Survey, 159
National Institute of Mental Health, 173, 174
Negative transference, 108
Neurosis, 1–2
Normalizing, and reassurance, 59–60

Objectives, and definition of supportive psychotherapy, 3

Object relations, and case formulation, 43–44
Observation, and transference, 14
Obsessive-compulsive disorder, 94
Obstacles to treatment, and case formulation, 49
Office arrangements, for supportive psychotherapy, 95–96
Open-ended questions, and conversational style, 18
Origins
of core beliefs, 49
personal story of patient and, 30–31
Outcome research, and clinical trials of supportive psychotherapy, 172–177
Overpowering statements, and patient’s self-esteem, 20–21

Panic disorder, and panic attacks, 94, 175, 176

Parents, as metaphor for supportive therapist, 31
Paroxetine, 38
Passive-aggressive behavior, 22
Patient. See also Safety; Therapeutic alliance; Therapeutic relationship
goal setting in supportive psychotherapy and, 51–52
pattern of lateness to sessions, 96–97
video vignette of uncooperative, 71–77
Patient history, and assessment process, 35–36
Person, triangle of, 36, 37
Personal growth, and crisis states, 122
Personality change, and objectives of supportive psychotherapy, 2, 51
Personality disorders, 147–150, 176–177
Pharmacotherapy. See Medications
Phobia, 175
Positive reinforcement, and schizophrenia, 142
POST (psychodynamically oriented supportive therapy), 3
Posttraumatic stress disorder (PTSD), and crisis intervention, 126, 133
Praise, as technique, 56–57, 142, 155
Prevalence, of co-occurring mental illness and substance use disorder, 159
Preventive psychiatry, and crisis intervention, 121
Problem list, and case formulation, 48
Prompts, and conversational style, 18
Psychoanalysis, and psychoanalytic theory
case formulation approaches and, 41
development of supportive psychotherapy and, 1–2
education of psychotherapists and, 11
supportive-expressive continuum and, 6
Psychodynamic psychotherapy, 2, 3–4
Psychodynamic theory
psychoanalysis and development of, 2
supportive-expressive continuum and, 5–10
supportive psychotherapy and assumptions based on, 23–27
Psychoeducation. See also Education
for family on severe mental illness, 147
substance use disorders and, 155–159, 160–161
supportive psychotherapy for severe mental illness and, 143
Psychogenetics, 26–27
Psychological functions, and ego functions, 9
Psychopathology, supportive psychotherapy and assessment of levels of, 34, 35
Psychopharmacology. See Medications
Psychotherapy. See also Expressive psychotherapy; Integrative psychotherapy; Interpretive
psychotherapy; Psychodynamic psychotherapy; Short-term dynamic psychotherapy; Supportive
psychotherapy; Transference-focused psychotherapy
as distinct from crisis intervention, 123, 135–136, 137–139
efficacy of for personality disorders, 148–149
research studies on teaching of, 164–165
Psychotic disorders, supportive psychotherapy as adjuvant treatment strategy for, 90. See also
Schizophrenia

Questions
conversational style and patient’s responses to, 17–18
self-esteem of patient and, 21
Rationalizing, and reduction of anxiety, 67–69
Reality and reality testing, and case formulation, 42–43
Reassurance, as technique, 58–60, 154
Reframing
reduction of anxiety and, 67–69
resistance in therapeutic relationship and, 115
Rehabilitation, and encouragement, 60–61
Rehearsal, and technique of anticipatory guidance, 64–65
Relapse
prevention of as objective of supportive psychotherapy, 65
substance use disorders and risk of, 152, 154–155, 160
Research
clinical trials on outcome of supportive psychotherapy, 172–177
studies on teaching of psychotherapy, 164–165
Resentment, and negative emotions, 70
Residency Review Committee for Psychiatry (ACGME), 163–164, 166
Resident Evaluation for Competence in Supportive Psychotherapy, 170, 171–172
Resistance
 elements of psychodynamic psychotherapy and, 4
therapeutic relationship and, 113–116
Respect, and patient’s self-esteem, 21–22
Retelling, by individuals with trauma history, 27
Rewards, and positive reinforcement, 142
Risk assessment, and crisis intervention, 134

Safety, of patient
borderline personality disorder and sense of, 150
crisis intervention and, 127
Schizoaffective disorder, 71–77
Schizophrenia
anticipatory guidance and, 65
delayed grief and, 70
outcome research on supportive psychotherapy and, 173–174
reassurance and, 58
substance use disorders and, 159
supportive psychotherapy for severe mental illness and, 90, 142–147
Seating, and office arrangement, 95–96
Self-assertion, reframing of resistance as, 115
Self-disclosure, of information by therapist, 16, 102
Self-esteem
adverse effects of anxiety on, 65
definition of supportive psychotherapy and, 8
development of as technique, 19–22, 54, 56–61, 142
substance use disorders and, 155
suicidal patients and, 135
Self-help groups, and models of self-disclosure of information, 102
Self-medication, and substance use disorders, 155, 156
Setting the agenda, as tactic in supportive psychotherapy, 22
Short-term dynamic psychotherapy
crisis intervention and, 122
for personality disorders, 176
Showing the map, as tactic, 22
Silence, and resistance in therapeutic relationship, 115
Skills building. See Adaptive behavior; Problem solving; Social skills training
Social anxiety disorder, 175–176
Social skills training, and schizophrenia, 144, 173. See also Interpersonal relationships
Somatization disorder, 92
Stances
supportive-expressive continuum and, 5, 7
transference and expressive form of, 14
Stress, factors in individual response to, 122
Structural approach, to case formulation, 42–46, 49–50
Substance use disorders, and supportive psychotherapy, 92, 150–161
Suicide, and suicidal ideation
crisis intervention and, 133–135
dialectical behavior therapy and, 150
 prediction of, 133
Superego functions, and case formulation, 43, 45
Supervision, and training in supportive psychotherapy, 165–166, 168, 170
Supportive-expressive continuum assessment process and, 34, 35
psychodynamic theory and, 5–10
Supportive-expressive treatment, video vignette of, 77–88
Supportive psychotherapy. See also Assessment; Competence; Crisis intervention; Education;
Techniques; Therapeutic relationship
contraindications for, 94–95
conversational style and, 16–19
defenses and, 22–23
definition of, 1, 2–3, 8–10
direct measures and, 13
history of development, 1–5
indications for, 89–94
initiation of treatment, 95
mode of action, 27–31
office arrangements for, 95–96
outcome research on, 172–177
personality disorders and, 147–150
professional boundaries and, 101–104
psychodynamic theory and assumptions in, 23–27
schizophrenia and, 142–147
self-esteem and, 19–22
session initiation and termination, 96–98
severe mental illness and, 141–142
substance use disorders and, 150–161
supportive-expressive continuum and, 5–10
therapist-patient relationship and, 13–14
timing and intensity of treatment sessions, 98–101
transference and, 14–16, 106–109
Supportive therapy, as distinct from supportive psychotherapy, 8
Synthetic function, and case formulation, 45
Systematic approaches, to crisis intervention, 123, 127
Systematic hierarchical desensitization, 175

Teaching, of adaptive behavior, 62. See also Education

Techniques, of supportive psychotherapy
anticipatory guidance, 64–65, 154
building of self-esteem, 54, 56–61
definition of, 3
expanding of awareness, 69–71
reduction and prevention of anxiety, 65–69
skills building and adaptive behavior, 54, 60, 62–64
therapeutic alliance and, 53, 54, 55–56
video vignettes of, 71–88
Temporal framing, and initiation or termination of sessions, 96–98
Termination phase of treatment, 100–101
Therapeutic alliance. See also Therapeutic relationship
assessment and establishment of, 33
beginning phase of treatment and, 98
crisis intervention and, 127
development of concept, 109–110
middle phase of treatment and, 99
mode of action in supportive psychotherapy and, 28
recognition and repair of misalliance, 110–113
substance use disorders and, 152
techniques of supportive psychotherapy and, 53, 54, 55–56
Therapeutic relationship. See also Therapeutic alliance; Transference
countertransference and, 116–120
general principles of, 105–106
resistance and, 113–116
underlying assumptions of supportive psychotherapy and, 13–16
Thoughts, and thinking. See also Automatic thoughts
cognitive-behavioral therapy and patterns of, 26
as focus of supportive psychotherapy, 25
structural approach to case formulation and, 44–45
Time limitation, of crisis intervention, 136, 137
Topiramate, 151
Tourette’s disorder, 94
Transference. See also Therapeutic relationship
advice and, 62
elements of psychodynamic psychotherapy, 4
expressive stance and, 14
idealizing form of, 120
mode of action in supportive psychotherapy and, 28
personality disorders and, 149
supportive and expressive approaches to, 106–109
underlying assumptions in supportive psychotherapy and, 14–16
Transference cure, 27
Transference-focused psychotherapy, for personality disorders, 176
Trauma, and crisis intervention, 122
Traumatic brain injury, 90, 175
Treatment plan, and case formulation, 49
12-step programs, and substance use disorders, 152, 160. See also Alcoholics Anonymous

Venting, 102, 177

as curative technique, 29
early life experiences and, 27
Video recording, of psychotherapy for supervision, 168–169
Video vignettes. See also Case illustrations
assessment and, 36–41
crisis intervention and, 124–126, 127–133
substance use disorders and, 156–159
techniques of supportive psychotherapy and, 71–88
therapeutic alliance and, 111–113
Virtual reality, and PTSD, 133

Withdrawal, and resistance in therapeutic relationship, 115–116

Working alliance, 109