Monday, May 26, 2025

Supportive Psychotherapy - The Clinical Language of Psychiatry

 


 

An interesting topic came up a few days ago – how do you decide if what the patient is describing is just reality-based anxiety as opposed to a more global psychodynamic issue?  It sounds like a basic problem but it is not. A common example is the scenario where one person in a couple (married or not) decides to leave the other precipitating an emotional crisis in the remaining person.  In daily living there are a large array of acute and subacute stressors related to losses, conflicts, accidents, illnesses, moral injury, and other life transitions.  In psychiatric practice they occur across settings including emergency departments, acute care units, and even in patients who are considered stable and being seen on a long-term basis.  These situations are generally context dependent and require psychotherapy skills as the primary intervention.

In all the debate about the role of psychotherapy in psychiatry over the years – the obvious problem of emotional crisis gets left out.  It is as if psychiatrists are calmly assessing people for medical treatment – like an internist would assess somebody for hypertension and then advise them about the treatment.  The reality of psychiatry is that people are in a highly emotional and at times agitated state.  It is impossible to proceed with any kind of evaluation unless you can help them calm down, organize their thoughts, see the psychiatrist as a relative ally, and proceed with the interview.  There is no guarantee that will happen, but being trained in crisis situations and evaluations greatly increases the likelihood that a positive working relationship with the distressed person can be developed and used to help them. 

How do I know that to be true?  I have been in that situation thousands of times and rarely found myself in a non-productive interview. I have successfully done crisis intervention with psychotherapy alone and no medication prescriptions. No prescriptions is not a definitive marker for success – but I have seen the other end of the spectrum.  People in acute distress from being fired, separated from their spouse, or acute bereavement who were suddenly started on antidepressants or anxiolytics after a few days of anxiety or depression and a very brief assessment. I have stopped many of those medications by the time the patient was done seeing me.

What exactly is a crisis and how does talking help?  I go back to the very first book I read on supportive psychotherapy (1).  Werman defines a crisis as an acute deficiency of mental functions that allow people to tolerate the demands of the external world and the inner psychological world.  More specifically:

“The acute deficiency which we call a crisis, occurs when a patient whose life may previously have been in a state of reasonable equilibrium has more or less suddenly become deeply disturbed by a stressful event that may be real, symbolic, or fantasized, and that has precipitated a condition of psychological insufficiency.” (p. 5).

It would follow that the stressful event could be a combination of reality, symbolism, and fantasy.   

Most of these crises resolve without psychiatric or mental health intervention with varying durations.  They also happen commonly across all aspects of psychiatric practice including inadequately resolved crises that can present years later after transitioning to a more permanent psychiatric disorder.  A common example is sudden unemployment. That crisis is most commonly resolved by getting support during the period of unemployment and transitioning back into the work force. But some people have a difficult time with that transition and develop mood or anxiety disorders.  In some cases, it can result in permanent disability.

The correct approach when seeing someone in a crisis is knowing what can be done to restore their psychological equilibrium.  There are suggestions about how to approach that problem in supportive psychotherapy from various schools.  From a technical perspective, supportive psychotherapy originating from psychodynamic schools of thought requires an understanding of those dynamics from the patient but in the short time horizon of the crisis does not usually involve interpretation of the underlying unconscious conflicts.  It also tends to focus on affect rather than cognition or behavior.  It may involve reinforcing defenses or suggesting defenses and generally clarifying some restricted thinking that is an artifact of the effect of the crisis.  People in crisis often exhibit catastrophic or similar forms of restricted thinking that can be reviewed and discussed during an empathy-based interview.  Alternate interpretations can be discussed with the patient and the effect on their affect noted.  Listening and empathic responses are very useful interventions in decreasing patient distress.

To perform this kind of intervention it assumes certain requirements on the part of the therapist.  An empathic interview style is required.  In medical schools - empathy and an associated non-directive interview style is typically taught in the second year before the clinical years start.  Since this is a psychiatry blog, I want to add a psychiatric definition of empathy and that is:

“Empathy is achieved by precise, insightful, persistent, and knowledgeable questioning until the doctor is able to give an account of the patients subjective experience that the patient recognizes as his own.” (2)

Subsequent editions (3) are more specific in how this is achieved but also describe the concept as controversial.  This is how I would understand it.  The basic problem is communication between two people with unique but also similar conscious states.  The person in crisis understands at some level that the psychiatrist can understand them based on that shared humanity. They want to say what happened and be understood. That requires the psychiatrist to be genuinely interested in the mental life of the other person and to avoid any potential obstructions to the flow of information. Therapeutic neutrality is a goal as well as the psychiatrist being aware of any personality characteristics that may get in the way – like impatience or getting bored or annoyed.  The psychiatrist experiences some of the detailed descriptions of what happened to the patient and can resonate with them based on life experience.  Based on that recreation of patient experience the psychiatrist can comment on the associated affect and confirm with the patient that it is their subjective experience.  The controversy about this approach involves the fact that not every experience the patient has (eg. psychosis) has been experienced by the psychiatrist – there are therefore limits to this method.

The concept of phenomenology is also relevant here. It refers to an examination of the patient’s conscious processes – specifically the events that brought them in for consultation- and the associated behavior.  It is a detailed description without any attention paid to theories about how the state occurred or evolved.  It is based on an empathic understating of the patient’s internal state.  Both concepts – empathy and phenomenology are tools for developing an understanding of the patient and communicating that understanding to them. 

In a crisis, there is a time constraint that is also a factor. To use empathic and phenomenological methods typically requires a significant amount of time for the initial descriptions of the patient’s mental state and additional clarifications. In many settings there is an emphasis on a diagnosis and more specifically – a diagnosis as an explanation rather than an initial understanding of the problem.  A supportive psychotherapy approach will be focused on the former rather than the latter. 

An additional part of any crisis assessment includes an evaluation for safety and whether the patient is at risk for self-injury, injury to others, or not being able to provide basic self-care. There are many considerations for the safety assessment that cannot be covered in this post.  For this post - assume there are no significant safety concerns following that assessment.  

There are a wide variety of interventions available.  A few are listed in the box below referenced by some of the authors I have listed. 

 

An important concept in supportive psychotherapy is that many of the current manualized or structured therapy approaches were taught as supportive psychotherapy before they became what appear to be separate schools of thought. For example, when I first read about interpersonal therapy for depression (4) and cognitive behavioral therapy for depression and anxiety (5) – I realized that I had been using these approaches in what I called supportive psychotherapy.  During the period I was trained my psychotherapy supervisors had varied theoretical backgrounds and had Rogerian, psychoanalytical, psychodynamic, existential, and behavioral orientations.  They worked in practice environments where people presented with severe problems. Some had experience in shifting from one paradigm to another based on whether the patient was making progress or tolerating the current interventions.  The best example in that case is this diagram from Kroll (6) on treating patient with borderline personality disorder. 

 

Modalities of Psychotherapy

 

Supportive

Exploratory

Content

WINDOW A

Openly supportive

Behavioral-didactic focus

Problem-solving

Competency based

WINDOW B

Explores patterns in life-events

Process

WINDOW C

Identifies process occurring in therapy

Provides support for changing the process toward competency

WINDOW D

Explores process occurring in therapy

Explores relationship of therapy to life patterns

    

Kroll begins his discussion of the diagram by this disclaimer that anticipates philosophical criticisms of psychiatry for the next 40 years: “The reader and the author must keep in mind that a schematic model is an artificial device having heuristic value and ought not to be mistaken as transmitted truth or a piece of reality. It is a way of organizing our observations and thoughts; too literal an adherence to any schema, especially a simplified one, will result in greater problems than benefits.” (p. 103).

He then goes on to illustrate by example how a young patient with parental conflict could be addressed in any of the 4 windows in his table.  He points out that are therapies have elements of supportive and exploratory therapy and that in a typical therapy session the therapist can move between windows based on their experience and judgment about timing.  I plan to illustrate this with an example from Viederman and his original psychodynamic life narrative in a subsequent post.  I also plan to illustrate additional supportive therapies based on the common factors model in psychotherapy and behavioral activation as a supportive psychotherapy for depression.    

It is not very common knowledge that supportive psychotherapy has historical roots in psychiatry and is both evidence and empirically based.   The first physician to use the term psychiatry was Johann Reil (1759-1813) a German physician described as a physiologist, anatomist, and psychiatrist. In 1803 he wrote Rhapsodien uber die Anwendung der psychischen Kurmethode auf Geisteszerrüttungen ('Rhapsodies about applying the psychological method of treatment to mental breakdowns') that included a method of supportive psychotherapy (11,12). Modern techniques of supportive psychotherapy have be used in clinical trials in some cases as placebo but in many of these trials the performance of supportive psychotherapy is equal to or superior to the psychotherapy intervention being studied (13).

Supportive psychotherapy has come a long way since the time I learned it nearly 40 years ago.  Like most things in psychiatry the issue of psychotherapy is always highly politicized due to several factors. When I learned it – polarization between the psychiatrists who considered themselves therapists as opposed to biological psychiatrists was at an all time high.  I can still recall walking into the room with those biological psychiatrists when I had to staff patients with them and listening to what they were saying to the patient.  I would end up thinking: “Wait a minute this biological psychiatrist is doing supportive psychotherapy!”  That is an oversimplification – I was taught by some of the best psychiatrists in the country if not the world and most of them were clear that both psychotherapy and biomedical psychiatry were skills that all psychiatrists needed to have. Supportive psychotherapy is a language for communicating with patients and it alway has been.

 

George Dawson, MD, DFAPA

 

References:

1:  Werman DS.  The Practice of Supportive Psychotherapy.  New York: Brunner/Mazel Publishers; 1984.

2:  Sims A.  Symptoms in the Mind: An Introduction to Descriptive Psychopathology. 3rd ed. London: Saunders; 1995.

3:  Oyebode F.  Sims’ Symptoms in the Mind: Textbook of Descriptive Psychopathology. 6th ed. London: Elsevier; 2018.

4:  Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES.  The Interpersonal Psychotherapy of Depression.  New York; Basic Books; 1984.

5:  Beck AT, Rush AJ, Shaw BF, Emery G.  Cognitive Therapy of Depression.  New York; Guilford Press; 1979.

6:  Kroll J.  The Challenge of the Borderline Patient. New York; WW Norton and Company.  1988:  p. 104.

7:  Viederman M. The psychodynamic life narrative: a psychotherapeutic intervention useful in crisis situations. Psychiatry. 1983 Aug;46(3):236-46. PMID: 6622599.

8:  Viederman M.  Clarification: A Powerful Therapeutic Strategy in Psychodynamic Psychotherapy. Psychodynamic Psychiatry.  2025; 53(2), 172–183.

9:  Dewald PA.  Psychotherapy: A Dynamic Approach.  2nd ed. New York: Basic Books; 1969.

10:  Battaglia J.  Doing supportive psychotherapy.  Washington, DC: American Psychiatric Press: 2020.

11:  Novalis PN, Rojcewicz SJ, Peele R.  Clinical Manual of Supportive Psychotherapy.  Washington, DC: American Psychiatric Press; 1993.

12:  Novalis PN, Singer V, Peele R.  Clinical Manual of Supportive Psychotherapy.  2nd ed.  Washington, DC: American Psychiatric Press; 2020.

13:  Markowitz JC. Supportive Evidence: Brief Supportive Psychotherapy as Active Control and Clinical Intervention. Am J Psychother. 2022 Sep 1;75(3):122-128. doi: 10.1176/appi.psychotherapy.2021.20210041. Epub 2022 Mar 2. PMID: 35232221.

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