Learning Objectives

After reading this article, you should be able to 

1. Define the core elements and goals of supportive psychotherapy.

2. Understand the historical evidence supporting the effectiveness of supportive psychotherapy.

3. Recognize the importance of supportive and empathetic patient-therapist relationships in modern mental health treatment.

Although some may dismiss providing “support” as too simplistic an approach to helping patients navigate serious problems, most professional therapists spend a majority of their time using supportive interventions. Supportive psychotherapy is a treatment modality generally indicated for individuals with chronic mental illness—but it is also valuable for higher functioning persons experiencing an acute crisis. In this article, I will explore what supportive psychotherapy actually means, examine the evidence for its effectiveness, and discuss its application in clinical practice.

What is supportive psychotherapy?

Supportive psychotherapy focuses on the here and now, with goals that include: 

• Strengthening coping skills for greater adaptation and improved functioning
• Decreasing symptom severity
• Increasing self-esteem
• Improving quality of life 

Its techniques, many of which can be found from the earliest forms of psychodynamic therapy (eg, therapeutic alliance, empathic and active listening, goal consensus, collaboration) include a focus on reinforcement of strengths/defenses, consideration of pros/cons in problem solving, reassurance, and instillation of hope in a relationship context of unconditional acceptance of the individual as a person. 

The evidence for supportive psychotherapy

Many early career psychiatrists may equate supportive techniques with simply “being kind,” and question their legitimacy or potency as a therapy. Similarly, some research studies may set up supportive psychotherapy as “straw man” therapy in clinical trials, which can make it look ineffective. However, the solid evidence base for supportive psychotherapy goes back many decades.

The Menninger Psychotherapy Research Project

The Menninger Psychotherapy Research Project was a classic 30-year study that followed 42 patients in either psychoanalysis or psychoanalytic psychotherapy over the entire natural course of treatment, with 100% follow-up 2-3 years post-termination. Predicted clinical outcomes were compared to actual outcomes, and patients’ conditions were rated both pre- and post-treatment using the Health Sickness Rating Scale.

At the end of the study, the researchers found that while patients in both forms of treatment improved significantly, the main predictor of improvement in both groups was the use of supportive therapy techniques (Wallerstein R, J Consult Clin Psychol 1989;57(2):195-205). The study also found that there was no fundamental demarcation between expressive (insight-oriented) and supportive psychotherapies, and that almost all treatments including psychoanalysis incorporate more supportive components than is usually credited. In sum, “pure” forms of psychotherapy rarely exist in the real world, and there is significant overlap between therapy modalities in their use of supportive techniques. These techniques appear to drive therapeutic change.

Patients Find Supportive Psychotherapy Techniques Most Helpful

In a 2020 research study conducted by Olarte and team, 58 patients undergoing treatment with psychodynamic psychiatrists shared their experiences regarding the efficacy of different therapy interventions. This was done via a web-based questionnaire (Olarte S et al, Psychodyn Psychiatry 2020;48(3):314-336). Investigators found that patients endorsed the following aspects of treatment as most helpful:

• Feeling supported by the therapist
• Ability of the therapist to listen empathically
• Ability to relate to the therapist
• Understanding how the present experience stems from past experiences
• Discussing thinking patterns and their effect on behaviors and feelings. 

The researchers identified several "common factors" beneficial across various therapies. These encompassed elements like empathic attunement, emotional expression, mentalization, affirmation, validation, aligned therapeutic goals, collaboration, and establishing a solid therapeutic bond. Significantly, these elements are central to supportive psychotherapy.

Are psychiatrists providing supportive therapy?

A recent study reported that about half of US psychiatrists no longer practice psychotherapy (Tadmon D and Olfson M, Am J Psychiatry 2022;179(2):110-121). However, the study narrowly defined psychotherapy as only applying to treatment visits lasting longer than 30 minutes. Many would argue that meaningful psychotherapeutic interventions—like supportive therapy, motivational interviewing, etc.—can occur in sessions of 30 minutes or less, frequently in combination with pharmacotherapy. In fact, even a short 15-minute “med check” can incorporate key psychotherapeutic skills, according to Glen Gabbard: “When residents tell me they don't really need psychotherapy training to be a psychiatrist, I tell them, ‘Lot's of luck.’ The way I see it, there is no area of psychiatry that can be divorced from the use of psychotherapeutic skills” (Moran M, Psychiatric News Update 2010).

Utilizing supportive psychotherapy techniques

Even if one practices intensive psychodynamic psychotherapy, supportive therapy techniques can be useful and at times necessary. A purer form of supportive psychotherapy combined with pharmacotherapy is often indicated for patients with severe chronic mental illness. These 30-minute sessions may begin with a medication review and then focus on problem-solving in the context of working toward the patient’s short and long-term goals. For example, a psychiatrist working with a patient with chronic schizophrenia who is struggling to find employment may spend the first ten minutes of the session reviewing medication effects and the next 20 helping the patient consider alternatives to preferred employment or new methods of job-searching.

Studies of psychotherapy suggest the therapeutic alliance may be the most important determinant of success regardless of the specific modality used (Horvath A and Luborsky L, J Consult Clin Psychol 1993;61(4):561-573). Indeed, all psychotherapy seems to work primarily by providing a new hope/approach to problems within the context of a safe, positive therapeutic relationship.

For many patients, the most helpful aspect of treatment tends to be the overall supportive and collaborative tone of the working relationship, and when a specific helpful vignette from treatment is recalled, it more likely involves a supportive intervention than an insightful interpretation. A pregnant woman with schizophrenia, for instance, may not recall a sophisticated interpretation of her paranoia but may remember for many years the therapist’s warm encouragement: “You’re going to make a wonderful mother.”

This is not surprising given that surveys show that what patients value the most from their physicians are being respected, listened to, and treated with dignity (Schnelle C and Jones M, Heliyon 2023;9(2):e13115). The therapeutic power of simply “being with” the patient should not be underestimated. Sometimes a patient’s problems (eg, an acute loss) cannot be “fixed,” but the therapist’s abiding presence, deep listening, and compassionate support can promote healing.

CARLAT VERDICT

In this era of managed care and pressure for less frequent, briefer visits with patients, it is heartening to know that one of our best therapeutic tools, supportive psychotherapy, remains readily available in our toolkit. It is an evidence-based treatment, and when practiced skillfully can be effective even in the most severe mental health conditions.

References (in order of appearance in this article)

Wallerstein R, The Psychotherapy Research Project of the Menninger Foundation: an overview. J Consult Clin Psychol 1989;57(2):195-205. doi: 10.1037//0022-006x.57.2.195.

Olarte S., Teo D., Alfonso C. Intermittent Treatment with the Psychodynamic Psychiatrist: A Patient-Centered Approach. Psychodynamic Psychiatry 2020;48(3):314-336. 

Tadmon D. and Olfson M. Trends in Outpatient Psychotherapy Provision by U.S. Psychiatrists: 1996–2016 Am J Psychiatry 2022;179(2):110-121. 

Moran, M. (2010, July 2). Gabbard: To Teach Is to 'Witness Something Transcendent'. Psychiatric News Update. https://doi.org/10.1176/pn.45.13.psychnews_45_13_012

Horvath AO, Luborsky L. The role of the therapeutic alliance in psychotherapy. J Consult Clin Psychol. 1993;61(4):561-573. doi:10.1037//0022-006x.61.4.561 

Schnelle C, Jones MA. Characteristics of exceptionally good Doctors-A survey of public adults. Heliyon. 2023;9(2):e13115. Published 2023 Jan 21. doi:10.1016/j.heliyon.2023.e13115