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Supportive psychotherapy: definition, techniques, and process

Reading time: 16 mins
Supportive psychotherapy: definition, techniques, and process

Supportive psychotherapy is a form of therapy that focuses on reducing emotional distress and managing psychiatric symptoms in patients instead of delving into their deep-seated traumas or conflicts or trying to change their personalities.

The approach aims to address relatively minor here-and-now issues like workplace stress, interpersonal conflicts, and dysfunctional relationships by focusing on empathy, acceptance, praise, psychoeducation, rationalizing, remotivation, reframing of negative thoughts, and encouragement of desirable behavioral responses. It is similar to a counseling approach continued over an extended period.

The techniques of supportive psychotherapy include forming a therapeutic alliance, active listening, exhibiting empathy, emotion regulation, managing transference, cognitive reframing, esteem-building, behavior modeling, positive reinforcement, and psychoeducation.

The process of supportive psychotherapy includes these stages: case formulation; setting realistic goals agreed to by both the therapist and the patient; counseling intervention; and evaluation and termination. Each stage is completed reasonably before advancing to the next. However, case formulation and setting goals often occur throughout the therapy to address evolving patient needs.

What is supportive psychotherapy?

Supportive psychotherapy is a form of therapy that focuses on easing emotional distress and managing psychiatric symptoms instead of delving into the sources of deep-seated traumas or conflicts or attempting to alter the personality of the patient, per the APA Dictionary of Psychology published by the American Psychological Association and updated on 19 April 2018.

The approach aims to address relatively minor here-and-now issues like workplace stress, interpersonal conflicts, and dysfunctional relationships by emphasizing empathy, acceptance, reassurance, praise, psychoeducation, rationalizing, remotivation, reframing of negative thoughts, and encouragement of desirable behavioral responses.

Supportive psychotherapy aims to preserve, restore, or boost self-esteem, maximize adaptive mechanisms, and build a healthy ego in patients, according to a 2017 article by Eugenio M. Rothe published in the journal Psychiatric Times, titled “Supportive Psychotherapy in Everyday Clinical Practice: It’s Like Riding a Bicycle.” According to a chapter in the book Companion to Psychiatric Studies published in 2010, titled “Psychological Therapies,” and authored by Murphy et al., supportive psychotherapy has similarities with the counseling approach continued over an extended period.

According to a 2000 article by Donald A. Misch published in The Journal of Psychotherapy Practice and Research, titled “Basic Strategies of Dynamic Supportive Therapy,” supportive psychotherapy is used for the majority of patients with mental illnesses because the treatment approach focuses on improving the mental and emotional well-being and preserving or improving the functional capabilities of the patient. By doing so, supportive psychotherapy is able to address the needs of patients who do not want to or are not deemed fit to go through a more rigorous form of therapy, such as psychoanalysis.

The treatment approach of supportive psychotherapy draws from techniques used in a large number of psychotherapy schools. Whatever the technique employed, the goal is to create a safe, non-judgmental, and friendly setting where patients are able to open up about their thoughts, feelings, and personal struggles. Creating a strong therapeutic alliance is central to supportive psychotherapy.

What are the techniques used in supportive psychotherapy?

The techniques used in supportive psychotherapy are listed below.

  • Therapeutic alliance:  Good therapeutic alliance is at the core of supportive psychotherapy, as mentioned in this 2020 article by Grover et al., published in the Indian Journal of Psychiatry, titled “Clinical Practice Guidelines for Practice of Supportive Psychotherapy.” According to Dorothy E. Stubbe in her 2018 article titled “The Therapeutic Alliance: The Fundamental Element of Psychotherapy” published in Focus, a journal of the American Psychiatric Association, there is consistent evidence that the higher the quality of therapeutic alliance in psychotherapy, the more positive are the outcomes. This is true irrespective of the type of patients, presenting problems, and treatment modalities. The core themes of the therapeutic alliance are collaboration, the creation of an emotional bond between the therapist and the patient, and mutual agreement on treatment outcomes and tasks. The therapist must establish a positive alliance with the patient at the start of the therapy process. The therapist strives to create a positive working relationship with the patient by listening actively, displaying empathy, employing positive reinforcement, and setting clear goals.

  • Active listening: Active listening is crucial to building a strong therapeutic alliance. During a session, the therapist pays attention to what is being said verbally and non-verbally to understand a patient’s thoughts, ideas, emotions, and life circumstances. The patient is allowed to speak what’s on their mind. The therapist asks questions to learn more about their patients without being intrusive. They ask open-ended questions to elicit more expansive answers from the patients. For instance, the therapist asks, “How did you feel after that incident?” instead of asking, “Did that incident make you sad?” The latter is a closed question that the patient is most likely to answer with a one-word “yes” or “no” whereas the former, an open-ended question, encourages them to reflect on their feelings and ventilate their thoughts. According to a 2014 article by Weger Jr. et al., published in the International Journal of Listening, titled “The Relative Effectiveness of Active Listening in Initial Interactions,” the components of active listening include stating a summarized version of what the speaker had said and maintaining a moderate to high degree of non-verbal conversational engagement. People struggling with mental health issues feel they are not seen or heard, so these actions by the therapist assure the patient that they have been heard and understood.

  • Empathy: In a 2016 article titled “The Role of Empathy in Psychotherapy: Theory, research, and Practice.” published in Humanistic Psychotherapies: Handbook of Research and Practice, a publication by the American Psychological Association, author Jeanne C. Watson states that therapist empathy is a consistently powerful predictor of positive outcome in psychotherapy, irrespective of the treatment modality employed. Empathy means trying to understand the reality of another person—their past that is now shaping their present, their lived experiences, the motivations behind their actions and responses, and the reason why they feel the way they do. According to this 2017 article by Arnstein Finset and Knut Ørnes published in the Journal of Patient Experience, titled “Empathy in the Clinician–Patient Relationship,” empathy in a patient-healthcare professional relationship means that the clinician perceives their patient’s story, experiences their thoughts and feelings vicariously, and responds to express solidarity, understanding, and compassion. Empathy on the part of the therapist is manifest as being non-judgmental, refraining from arguing with and criticizing the patient, and expressing sincere positive regard for them. It is the basis for the creation of an emotional bond between the therapist and the patient.

  • Affect regulation: Difficulty in managing powerful emotions results in a person being unable to create or sustain a mental state where they are able to think objectively and rationally. The individual who has poor affect regulation strategies becomes a victim to powerful emotions and is thus, unable to filter out the most critical pieces of information about a situation in their lives or make rational and informed decisions. In a stressful situation, they are hyperaroused, which is an emotional state akin to the “fight, flight, freeze” response, or they enter a hyperarousal state where they “shut down” or collapse completely. In between these two states is the “window of tolerance,” which is the optimal zone of arousal where an individual manages their emotions effectively enough to function and cope with daily stressors the way they prefer to. According to a 2017 article by Eugenio M. Rothe published in the journal Psychiatric Times, titled “Supportive Psychotherapy in Everyday Clinical Practice: It’s Like Riding a Bicycle,” affect regulation is one of the most important goals of supportive psychotherapy. The goal of the therapist is to broaden the window of tolerance of their patients to enable them to ignore distressful thoughts, unwarranted fears, uncomfortable sensations, and unhealthy behavioral impulses so that they can access the mental resources required to tackle a challenging situation in their reality.

  • Management of transference: The emotional bond that the patient shares with the therapist distorts the way they perceive the latter. According to a 2000 article by Donald A. Misch published in The Journal of Psychotherapy Practice and Research, titled “Basic Strategies of Dynamic Supportive Therapy,” this distortion is due to “transference.” Patients form strong feelings about their therapists. They also have powerful feelings about important figures in their childhood, such as their parents, and during therapy, they project these feelings onto their therapist. A “transference” of feelings—positive or negative—takes place. Management of transference during supportive psychotherapy involves utilizing positive feelings toward fulfilling the aims of the therapy and correcting negative feelings by confronting the patient. For instance, the patient feels that the therapist is more kind, loving, or influential than they are in reality. So, they will be more likely to accept their therapist’s suggestions for change. The therapist realizes this and does not attempt to alter this perception. On the other hand, negative feelings are corrected as soon as they arise and/or are expressed by the patient to prevent them from terminating therapy.

  • Reframing: Cognitive reframing is a technique to shift the mindset of an individual. In supportive psychotherapy, this technique is used to help a patient perceive a situation or relationship from a different perspective to modify the thoughts associated with it and replace a negative thought with a positive idea. According to this 2014 article by Barnett et al., published in the Psychology of Addictive Behaviors, a journal by the American Psychological Association, titled “Bi-directional relationships between client and counselor speech: The importance of reframing,” when a therapist responds to a patient’s negative comments by steering its meaning in a positive direction, the latter is motivated to make positive behavioral changes. A reframed thought must be relatable to the patient, help them override their negative thoughts, and be memorable. According to a 2000 article by Donald A. Misch published in The Journal of Psychotherapy Practice and Research, titled “Basic Strategies of Dynamic Supportive Therapy,” reframing helps a patient overcome their sense of hopelessness and rationalize and normalize their behaviors and/or thought patterns. Just helping a patient overcome their sense of hopelessness often improves symptoms of depression and anxiety and motivates the individual to make positive changes. Being able to rationalize and normalize their behaviors and/or thinking patterns helps a patient with mental health issues feel less alienated and more in control of their lives. Knowing that they are not the only ones struggling with their mental health issues and that there is a name to what they are experiencing or how they are behaving and/or thinking makes them more hopeful about therapy outcomes.

  • Behavior modeling: Behavior modeling is a direct measure to improve adaptive skills in patients. The therapist acts as a “role model” who demonstrates a desired behavior or response and the patient learns by watching. For instance, the therapist role-plays to help a patient learn the most appropriate and healthy way to respond to or behave in a particular situation. According to the chapter in the June 2023 edition of the book Tasman’s Psychiatry by Arnold Winston and Adelle Schaefer, titled “Supportive Psychotherapy,” behavior modeling is an important strategy in supportive psychotherapy. According to psychologist Albert Bandura’s social learning theory, learning takes place by watching others and then imitating what they do or say. This is known as observational learning. It is natural for human beings to imitate people they perceive to be superior to them. Patients are motivated to emulate their therapists when both share a bond of trust and the former has confidence in the abilities of the latter.

  • Positive reinforcement: According to this 2023 StatPearls publication by Scott et al., titled “Behavior Modification,” positive reinforcement shapes behavior and is a powerful tool to bring about behavior modification. In supportive psychotherapy, positive reinforcement is in the form of praise from the therapist after the patient has displayed a desirable behavioral response. Praise from the therapist who is a “role model” is a pleasant or desirable consequence of a specific behavioral response, so the patient is motivated to repeat the behavior. The praise should align with therapy goals and must be offered only for behavioral responses that the patient deems worthy of praise.

  • Esteem building: People struggling with mental health issues often find it difficult to function in their real lives, make rational decisions, and cope with the daily stressors of life. The less they are able to live life according to their preferences, the more their self-esteem suffers. Self-esteem is linked to mental health, according to this 2017 article by Henriksen et al., published in the journal Child and Adolescent Psychiatry and Mental Health, titled “The role of self-esteem in the development of psychiatric problems: a three-year prospective study in a clinical sample of adolescents.” The authors cite several studies and mention that low self-esteem is implicated in negative emotions and the tendency to internalize problems in persons displaying symptoms of depression and anxiety. In supportive psychotherapy, cognitive reframing and praise from the therapist help in rebuilding self-esteem in patients. According to a 2000 article by Donald A. Misch published in The Journal of Psychotherapy Practice and Research, titled “Basic Strategies of Dynamic Supportive Therapy,” one of the most effective ways to raise self-esteem is by supporting a patient to improve competency in real-life skills. For instance, the therapist helps a patient struggling to find employment practice and prepare for interviews. Patients with psychiatric disorders benefit from being employed. Even if they work in an unpaid position or as volunteers and do not earn an income, being employed in any way increases their sense of self-worth and provides a sense of identity. Employment gives them a chance to connect with others, which decreases their feelings of alienation.

  • Psychoeducation: Psychoeducation is employed by the therapist to educate the patient and their family members about the psychiatric disorder being treated; the patient’s personality traits that determine their coping mechanisms; their innate abilities and limitations; and the challenges inherent in their life circumstances that determine the extent to which they are able to cope with stressors. This knowledge allows the patient and their loved ones to form realistic expectations from the therapy. Psychoeducation also helps family members and loved ones support the patient by adjusting their expectations about how the latter should behave in real life.

What is the difference between supportive psychotherapy and CBT?

The difference between supportive psychotherapy and CBT is in their primary goals and the treatment approaches employed by each modality. Supportive psychotherapy focuses on helping patients deal with the problems stemming from their conscious and current thoughts, feelings, and symptoms and does not try to identify and change the maladaptive thoughts and behaviors that are contributing to their present struggles, which is the focus of treatment in cognitive behavioral therapy (CBT).

According to a 2000 article by Donald A. Misch published in The Journal of Psychotherapy Practice and Research, titled “Basic Strategies of Dynamic Supportive Therapy,” the focus of supportive psychotherapy is symptom reduction and enhancing the well-being and functional abilities of the patients by addressing here-and-now issues like the relationship problems the patient is experiencing, their problems at the workplace, and how they are coping with daily stressors. CBT, on the other hand, is organized on the premise that a patient’s reasoning biases, irrational beliefs, and misconstruction of reality are at the root of their psychotic problems and thus attempts to correct these.

According to a 2010 article by Klingberg et al., published in the journal Trials, titled “Cognitive Behavioral Therapy versus Supportive Therapy for Persistent Positive Symptoms in psychotic disorders: The POSITIVE Study, a multicenter, prospective, single-blind, Randomized Controlled Clinical Trial,” supportive psychotherapy relies only on non-specific factors like empathic listening, forming a therapeutic alliance, providing emotional support and validation, improving self-esteem, and enhancing adaptive skills to deliver therapy and achieve the intended therapy goals.

CBT, on the other hand, relies on both non-specific effects and specific factors, such as trying to attribute the cause of the psychotic disorder under consideration to a particular theory or assumption, to deliver treatment and attain therapy goals.

Where is supportive psychotherapy used?

Supportive psychotherapy is used for patients going through stressful life circumstances or suffering from mental health disorders who are unable to cope with the stressors in their lives.

According to a 2017 article by Eugenio M. Rothe published in the journal Psychiatric Times, titled “Supportive Psychotherapy in Everyday Clinical Practice: It’s Like Riding a Bicycle,” supportive psychotherapy is the preferred mode of treating patients who are struggling to cope with extra-psychic problems like poverty, imbalanced power dynamics or abuse of power in interpersonal relationships, and social and political exploitation. These people do not suffer from severe or debilitating psychological disorders.

Instead, their struggles stem from the fact that they lack the skills and/or mindset to cope with the extra-psychic problems that are adversely affecting their mental well-being and ability to lead functional and productive lives. Supportive psychotherapy helps them cope with and thrive despite these problems by teaching them adaptive mechanisms and social and functional skills and building their self-esteem.

Supportive psychotherapy is also used for patients unsuitable for other forms of psychotherapy. For example, it is used to prepare patients before they undergo more structured and intensive therapy, such as psychoanalysis or psychodynamic therapy.

Psychoanalysis seeks to bring about deep personal transformation by bringing to consciousness suppressed fears, traumas, and conflicts. Patients with poor emotional defense mechanisms are not suited to such intense self-reflection because they cannot cope with the powerful negative emotions that such therapies dredge up. So, they undergo supportive psychotherapy before they go through psychoanalysis.

Supportive psychotherapy is used to manage the symptoms of mental health conditions like anxiety disorders, depression, grief, addiction, personality disorders, post-traumatic stress disorder (PTSD), bipolar disorders, and schizophrenia.

According to a 2022 article by Jiang et al., published in the journal Frontiers in Neuroscience, titled “Supportive psychological therapy can effectively treat post-stroke post-traumatic stress disorder at the early stage,” a six-month regimen of supportive psychotherapy lessened the severity of PTSD symptoms in people who had developed the condition after recently suffering a stroke and was more effective than routine health counseling. The authors of the article clarify that supportive psychotherapy has not yet been proven to prevent PTSD.

Supportive psychotherapy is used in psychiatric and medical outpatient and inpatient settings, emergency setups, and consultation-liaison psychiatric settings, according to this 2020 article by Grover et al., published in the Indian Journal of Psychiatry, titled “Clinical Practice Guidelines for Practice of Supportive Psychotherapy.

What is the process of supportive psychotherapy?

The process of supportive psychotherapy comprises the following stages: formulating or conceptualizing the case, setting goals, counseling intervention, and evaluation and termination.

According to a 1992 article by Luis de Rivera published in The European Journal of Psychiatry, titled “The Stages of Psychotherapy,” each stage in a psychotherapy process must be completed reasonably before moving on to the next. Each stage comprises different challenges that must be resolved using specific and appropriate interventional techniques.

According to a 2020 article by Grover et al., published in the Indian Journal of Psychiatry, titled “Clinical Practice Guidelines for Practice of Supportive Psychotherapy,” comprehensive patient assessment is critical for the success of any form of psychotherapy.

Formulating or conceptualizing a case refers to the exercise of assessing the patient’s current problems; their level of physical, cognitive, and psychological functionality; the quality of their interpersonal relationships and the issues involved; the stressors in their lives; and the distressful and/or traumatic events they have experienced in the past.

During the assessment, the therapist gauges the patient’s coping abilities and adaptive techniques they employ to deal with the challenges in their lives.

Formulating or conceptualizing a case involves inquiring if the patient has undergone psychotherapeutic intervention in the past and if so, for what reason, the type of therapy received, and the outcome of the process. Formulating or conceptualizing a case allows the therapist to establish therapy goals, devise a treatment plan, and decide which therapeutic techniques to employ to help the patient overcome their struggles. It is critical to note that the information obtained and interpreted during the case conceptualization phase is subject to change based on future inputs from the patient and further insights gleaned by the therapist.

Goal setting is a collaborative exercise between the therapist and the patient. A positive and robust therapeutic alliance is established if the therapist and the patient are able to work toward shared goals. The goals are based on the patient’s challenges and priorities. The goals must be concrete, realistic, and achievable, and in this respect, the therapist must play an integral part in managing the expectations of the patient. Therapy goals are set for the “initial few sessions” or formulated as the “ultimate outcome” of therapy (Grover et al., 2020).

According to this 2020 article by Geurtzen et al. published in the journal Clinical Psychology & Psychotherapy, titled “Patients’ perceived lack of goal clarity in psychological treatments: Scale development and negative correlates,” patients gain clarity about their treatment outcomes if the goals are established at the start of the therapy in collaboration with the therapist and are discussed and evaluated regularly during the duration of the therapy. The authors cite several studies that mention that goal setting has a positive effect on the motivation levels of patients and treatment outcomes. However, goals are modified during the course of the therapy depending on the progress of the patient and their specific needs (Grover et al., 2020).

The goals set for a specific patient and their unique mental health issues determine the tactics employed during the counseling intervention stage. The overarching goal of the counseling intervention stage is to help the patient develop into a mature individual who is able to control the trajectory of their life, is more effective in dealing with stressors while displaying healthy adaptive mechanisms, and is satisfied with how their life is taking shape.

The objective of a supportive psychotherapist is to help the patient achieve their goals in life. Throughout the counseling intervention period, the therapist strives to foster and bolster the therapeutic alliance that they have created with the patient.

Supportive psychotherapy is not as structured as other forms of psychotherapy where a date of termination is fixed at the start of therapy. There is no formal termination of therapy in supportive psychotherapy. The objective is to sustain the relationship between the therapist and the patient indefinitely. A termination is an abrupt action that jars the sense of continuity, so supportive psychotherapy only considers interruption of therapeutic interactions (Grover et al., 2020).

According to a 2005 article by Ann H. Appelbaum published in the journal Focus, titled “Supportive Psychotherapy,” the decision to interrupt supportive psychotherapy or move on to exploratory therapy is made by the therapist and the patient after they have evaluated the latter’s progress based on the therapy goals.

What does a supportive psychotherapy session look like?

A supportive psychotherapy session looks like a relaxed conversation between the therapist and the patient, according to a 2020 article by Grover et al., published in the Indian Journal of Psychiatry, titled “Clinical Practice Guidelines for Practice of Supportive Psychotherapy.“The patient is allowed to take the lead and direct the session wherever they want to go.

The therapist interrupts or breaks the flow of speech only if the patient becomes disorganized or anxious or gets carried away with their fantasies. A supportive psychotherapy session, in reality, is a highly disciplined endeavor despite there being no rigid or structured regimen and no homework assignments for the patients.

During the session, the therapist maintains a reassuring stance, displays empathy, and is responsive to the patient without being intrusive. The patient is allowed to ventilate or speak their mind, and the therapist displays a keen interest in and understanding of what is being said by gesturing or uttering short and sincere phrases. The therapist refrains from asking questions that begin with “why” or “why don’t you” that tend to be perceived as accusations by individuals who had been made to feel guilty about their struggles. They avoid confrontations, criticisms, and arguments and offer advice only on issues related to the patient’s problems.

The goal is to build and foster a therapeutic alliance in the first few sessions. Creating a safe, non-judgmental space where patients can open up and make them feel seen, heard, and understood allows the therapeutic bond to form quickly.

According to a 2000 article by Donald A. Misch published in The Journal of Psychotherapy Practice and Research, titled “Basic Strategies of Dynamic Supportive Therapy,” during counseling intervention, the psychotherapist strives to be a role model whom the patient mirrors to learn and internalize critical psychological functions that they currently lack. They attempt to maximize the adaptive coping mechanisms of the patient; help them acknowledge, understand, and name their feelings to normalize emotions that otherwise tend to feel overwhelming if they remain unidentifiable; and help them form connections between their emotions and what is happening in the real world.

The therapist enlists the help of family members and/or an employer to create a supportive environment for the patient where the latter is not judged, belittled, or made to feel guilty for their struggles. This often takes the form of psychoeducation because the struggles of a person going through a mental health crisis are not always evident to or understood by others.

A supportive psychotherapy session is not always limited to the confines of the therapist’s office. As part of the therapy, the therapist accompanies the patient to the Social Security Office if the latter has appealed for a Social Security Disability Insurance claim or a current beneficiary has to furnish evidence that they are still eligible for benefits.

According to a publication by the Social Security Administration titled “Fact Sheet for Mental Health Care Professionals: Supporting Individuals’ Social Security Disability Claims,” last updated in 2008, a mental health professional, such as a psychotherapist, is allowed to release medical records, consistent with applicable privacy laws, to support their patient’s disability claims.

Who performs supportive psychotherapy?

Supportive psychotherapy is performed by several different mental healthcare professionals like psychiatrists, psychotherapists, psychologists, licensed social workers, licensed family and marriage counselors, and psychiatric nurses. Any individual who has specialized training in psychotherapy is able to perform supportive psychotherapy.

The professional credentials of mental healthcare providers who perform supportive psychotherapy are available on the websites of the National Alliance on Mental Illness and the Substance Abuse and Mental Health Services Administration.

Primary care physicians, community health clinics, workplace Employee Assistance Programs (EAP), local psychiatric associations, and online resources are common referrals of healthcare professionals who perform supportive psychotherapy.

According to a release by the National Institute of Mental Health titled “Psychotherapies,” last updated on February 2024, the websites of the following organizations feature directories for locating healthcare professionals who perform supportive psychotherapy: Academy of Cognitive and Behavioral Therapies; American Academy of Child and Adolescent Psychiatry; American Association for Geriatric Psychiatry; American Association for Marriage and Family Therapy; American Board of Clinical Social Work; American Board of Professional Psychology; American Psychiatric Association; American Psychological Association; Association for Behavioral and Cognitive Therapies; National Association of Social Workers; National Register of Health Service Psychologists; and Society of Clinical Psychology.