Supportive Psychotherapy: How Good is “Treatment as Usual”?
Synopsis: Supportive psychotherapy is commonly used as a comparison intervention or “treatment as usual” in mental health research studies. While it is often expected by the scientific elite to be less effective than newer, manualized therapies, it has been proven to be an effective intervention for many conditions. This article covers basic approaches in supportive psychotherapy and who might benefit from the treatment.
BY LEN LANTZ, MD / 11.29.20; No. 41 / 9 min read
Disclaimer: Yes, I am a physician, but I’m not your doctor, and this article does not create a doctor-patient relationship. This article is for educational purposes and should not be seen as medical advice. You should consult with your physician before you rely on this information. This post might also contain affiliate links. Please click this LINK for the full disclaimer.
What is supportive psychotherapy?
Defining supportive psychotherapy is tricky. It eludes efforts to pigeonhole it as it is understood more by what it is not than what it is. Most authorities on supportive psychiatry would agree that it is a form of psychotherapy that is not psychoanalysis. There is evidence to suggest that supportive psychotherapy is as effective (or even more effective) than psychoanalysis (Grover, et al. Indian J Psychiatry. 2020; Wallerstein, RS. Inter J Psychoanalysis. 1989).
In 1984, Dr. David Werman’s groundbreaking book, The Practice of Supportive Psychotherapy, set the standard by which other supportive psychotherapy approaches are understood and measured. More recently, supportive psychotherapy has been viewed as a therapy that draws strategies and approaches from many different psychotherapy disciplines. The therapist may be proactive or reactive depending on the needs of the patient in the moment or across sessions. Common approaches or principles in supportive psychotherapy are:
Reducing symptoms (often focused on anxiety reduction)
Encouraging the use of adaptive coping strategies
Developing mutual positive regard between therapist and patient, which may result in a corrective life experience
Improving self-esteem, in part by helping patients be less self-critical
Working primarily with current awareness of thoughts and emotions (conscious material)
Creating a “safe space” or place to deal with difficult thoughts, emotions and life experiences
Supportive psychotherapy has been referred to as “treatment as usual” in research
It is often expected by scientists that new approaches are better than old ones, especially if the new approaches are more easily measured. However, a new therapy is not necessarily more effective or better just because it is easily measured. While it is hard to study interventions like supportive psychotherapy that are difficult to define, that does not make supportive psychotherapy any less important or effective. As Albert Einstein once said, “Not everything that counts can be counted, and not everything that can be counted counts.”
There are many useful forms of psychotherapy and it is certainly the case that different styles of psychotherapy are a good fit for different people. However, the ultimate benefit of any form of psychotherapy can be distilled down to the skill and responsiveness of the therapist. Whether or not psychotherapy - any style of psychotherapy - is effective for any person boils down to 2 critical areas (Miller, et al. Psychotherapy. 2013):
The therapeutic alliance: Many studies have shown that the strength of the therapeutic alliance - the strength of the connection/fit between patient and therapist - is one of the best predictors of success in therapy. (Horvath, et al. Journal of Counseling Psychology. 1991; Krupnick, et al. Journal of Consulting and Clinical Psychology. 1996).
Frequent feedback on therapeutic outcomes: Improved performance in psychotherapy has been clearly tied to the progress of the patient and the ability of the patient to provide (and the therapist listen to) feedback on their progress (Lambert, et al. Psychotherapy Research. 2001; Reese, et al. Psychotherapy: Theory, Research, Practice, Training. 2009).
So, any therapy, supportive psychotherapy included, is likely to be more successful if these 2 critical elements are present in treatment. The renowned psychiatrist Dr. Franz Alexander asserted, “It is widely but erroneously held that supportive psychotherapy methods require less technical and theoretical preparation than psychoanalysis” (“Current Views on Psychotherapy.” Psychiatry. (16), 1953).
In considering different forms of psychotherapy, I would conclude that most forms of psychotherapy can be effective, though there are ineffective therapists.
Supportive psychotherapy is different from low-quality talk therapy
Not all eclectic therapy is supportive psychotherapy. Also, being supportive alone is not the same as supportive psychotherapy and is not sufficient to qualify as therapy. “Crisis of the week” (COW) therapy is a label often applied to low-quality talk therapy. This type of therapy tends to be reactive and to have no clear goals. No skills are taught or practiced. There may be excessive self-disclosure by the therapist.
COW therapy tends to be “tell me about your week,” which is then discussed throughout the session, and near the end, there is hopefully an insight or teachable moment imparted by the therapist to the client. This type of therapy often makes patients increasingly anxious as they feel they have to keep the conversation going even when their life is going relatively well, so therapy may feel like a burden that the patient has to carry. They start to cancel and avoid therapy for reasons such as, “I don’t have anything else to talk about. I don’t know what else to say.”
Why supportive psychotherapy doesn’t receive more support
There are several reasons why supportive psychotherapy doesn’t receive more support. Some of the lagging support for this form of therapy comes from researchers, who naturally gravitate toward studying approaches that are easier to measure. There is far less research available on supportive psychotherapy than many other therapies. Interestingly, the researchers who have dismissed supportive psychotherapy’s effectiveness and used it as a control in their studies have later become dismayed to see supportive psychotherapy perform as well (or nearly as well) as their favored psychotherapy approach.
Some of the negativity towards supportive psychotherapy comes from the limited availability of therapists trained in and willing to adhere to the principles of time-limited, skills-oriented therapy with an extensive evidence-base, such as Cognitive Behavioral Therapy (CBT). In my community, I can find 10 therapists who primarily provide supportive psychotherapy for every 1 therapist trained in and willing to provide CBT. Most community therapists, even if they are excellent at delivering CBT, Interpersonal Therapy (IPT) or Acceptance and Commitment Therapy (ACT), drift away from rigidly adhering to those models and end up performing a blended therapy. Some of these blended therapies would best be described as supportive psychotherapy, especially if no homework is given to the patient between sessions.
Another reason supportive psychotherapy does not receive more attention is that health insurance companies are not thrilled about paying for it, because the therapy can go on for months to years. An interesting aspect of supportive psychotherapy is that the therapy itself is usually never formally concluded, although it may be placed on pause for a while. Insurance companies love time-limited psychotherapy approaches, such as CBT, as they can limit their costs in an individual’s therapy by approving 16-20 sessions and fulfill their obligation. Insurance companies often state that they will only pay for “evidence-based” psychotherapy approaches. They suggest that CBT is evidence-based psychotherapy and that supportive psychotherapy is not. The assertion that supportive psychotherapy is not evidence-based is simply not true, as you will see in the research studies below.
What conditions supportive psychotherapy helps
The strength of the available research on supportive psychotherapy varies, however, this form of therapy has been shown to be effective in treating the following conditions alone or in combination with other treatments:
Suicidal ideation (Erlangsen, et al. The Lancet Psychiatry. 2015)
Phobias (Klein et al. Archives of General Psychiatry. 1983)
Alcohol dependence (O’Malley, et al. “Naltrexone and Coping Skills Therapy for Alcohol Dependence. A Controlled Study.” Archives of General Psychiatry. 1992)
Anorexia (McIntosh, et al. American Journal of Psychiatry. 2005)
Posttraumatic Stress Disorder (PTSD) (Bradley, et al. American Journal of Psychiatry. 2005)
Schizophrenia (Dickerson, et al. The Journal of Nervous and Mental Disease. 2011)
Personality disorders (Rosenthal, et al. The Journal of Psychotherapy Practice and Research. 1999)
Depression (Cuijpers, et al. Clinical Psychology Review. 2012)
Anxiety (Stanley, et al. Behavior Therapy. 1996)
Medical conditions (Conte, HR. American Journal of Psychotherapy. 1994)
This is only a partial list of conditions and a small fraction of the research showing supportive psychotherapy to be effective.
Who can benefit from supportive psychotherapy?
It is important to note that not all modalities of therapy work well for all people. Finding the right approach and the right therapist to deliver it is key. People who are a better fit for supportive psychotherapy are those who have:
Severe emotional, cognitive or interpersonal impairment (people who would not tolerate delving into their unconscious mind or practicing cognitive reframing exercises)
Current stressful circumstances that they are dealing with (divorce, job loss)
Previously been easily overwhelmed in therapy
Difficulty committing to regular therapy sessions or who show low initiative for behavioral change
A story about giving therapy another try
“Adam” was 28 years old and he was not interested in therapy. He had experienced some depression and anxiety in high school around the time his parents divorced, and his parents had made him meet with a therapist. He hated it. Adam felt that others judged him for not liking or cooperating with therapy but he couldn’t help it. He was angry a lot of the time in high school and he frequently would explode in therapy and get up and leave in the middle of the session. He recently rediscovered an old David Letterman-style list that he had written and shared with his parents when he was trying to convince them not to send him back to therapy. It was titled, “The Top 10 Reasons NOT to Send Me Back to Therapy!!!” and the reasons on the list were:
10. Homework sucks! I shouldn’t have to do therapy homework when I have enough at school already.
9. I’m not your project or my therapist’s project! People need to stop trying to FIX me!
8. Sometimes I actually like feeling angry! It’s better than feeling sad.
7. Ever since you guys got divorced, you never seem to have any money. You need to stop wasting money on therapy and then you might have some left over for me!
6. I think my therapist hates me, and the feeling is mutual!
5. I would be happier gaming than spending that time each week in therapy.
4. None of my friends are in therapy. It makes me feel like a freak!
3. My therapist does not accept that my thoughts are my thoughts and my feelings are my feelings! She’s the cognitive distortion - not me!
2. My therapist uses a creepy “soothing” tone of voice when she talks to me! She doesn’t use that tone of voice with you guys! I’m not a confused animal or toddler!
1. And the NUMBER ONE reason why I shouldn’t have to keep doing therapy is that it DOESN’T WORK!!!
Adam had to smile when he read that old list. It was pretty funny. “Man, was I angry,” he chuckled to himself. His smile faded when he reflected and thought, “Wow…I still am.” He hadn’t been smiling much lately. His depression had come back after he had lost a series of jobs. He had 3 different jobs in the last 3 months and he was fired from each job after losing his temper. He knew that he needed to do something about it but hated the idea of going back to therapy. He wanted some help, but on his terms, and he didn’t want to commit to doing therapy forever, which is what it felt like in high school.
He liked his family doctor and asked if she knew any therapists in town that might be a bit more flexible in therapy. His doctor replied, “Sure, I know of several great therapists in town. It depends on what you want to work on.” Adam said, “I just want someone to talk to about my anger and give me a few ideas. I’m not interested in doing therapy forever and I don’t want to have to work on anything between sessions. I just need some help for what I’m going through right now.”
The doctor thought for a minute and said, “Here are the names and phone numbers of a male therapist, Julian, and a female therapist, Kathy, who are both exceptional. They are both trained in modes of therapy like CBT but they are both very good at and willing to do supportive psychotherapy. In fact, some businesses will cover the full cost of up to 5 sessions per year as part of their Employee Assistance Program when you are going through a difficulty.”
Adam thought about what his doctor said and he decided to give therapy a try again. He liked being able to choose a therapist for himself and not being forced to do therapy in a certain way. He chose to work with Julian and found that he could share his thoughts and emotions exactly how he felt them. He liked Julian, who seemed like a really nice guy and who made him feel better about himself. Over time, he took some of Julian’s advice and found that it usually worked. Eventually, he and Julian reached an agreement that he could call and schedule appointments only when he felt like he really needed it.
Supportive psychotherapy may be helpful for you or a loved one
Supportive psychotherapy has helped many people feel better and lead more productive and healthy lives. The evidence supporting its effectiveness is greater than many people would predict. It can be an effective treatment for people who have avoided other forms of psychotherapy and it requires less commitment from the patient. For people who are needing support but find that some of the newer styles of therapy are overwhelming or not the right fit for them, supportive psychotherapy might be best for them.
For further reading, check out:
Len’s article, “Finding Quality Psychotherapy – Moving Beyond Talk Therapy”
Len’s article, “Cognitive Behavioral Therapy (CBT) – the Most Effective Therapy?”
Doing Supportive Psychotherapy by Dr. John Battaglia (See Len’s Book Review)
The Practice of Supportive Psychotherapy by Dr. David Werman (See Len’s Book Review)
Feeling Good by Dr. David Burns (See Len’s Book Review)
A Guide to Rational Living by Drs. Albert Ellis and Robert Harper (See Len’s Book Review)
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