TIFT #7 How Much Support

I am not comfortable with the concept of “supportive therapy” and here’s why:

“Insight psychotherapy is an expensive, prestigious treatment conducted by a relatively few highly trained professionals. Supportive psychotherapy, on the other hand, is conducted, in a skilled fashion or naively, by everyone who cares about the patient and is willing to care for him or her.” Frederick Neuman M.D. Psychology Today Blog, 6/2/2013.

As originally defined, the concept has a pejorative connotation, not only for patients, but for the therapist as well. It can lead to subtle disrespect, even discrimination. However, if we look more closely, it becomes clear that all therapy is supportive and that the original concept of supportive therapy might be traded for a dimension of therapy rather than a separate technique. First let's look at the supposedly unsupportive nature of "insight therapy," then let's look at just what support actually does.

The “blank screen” of therapy is a holdover from Victorian times, when the therapist was thought to be an objective observer. Now we know that we are actually participants as well as observers. Withholding is far from neutral and can even trigger a transference reaction in those who have been subjected to the trauma of an unresponsive other. For other patients, the blank face of the traditional analyst is an odd way of relating, where the good ones let their humanity slip through the mask. What these therapists get to observe is, hopefully, a patient with a strong enough ego to cope with the deprivation and still communicate what is going on inside. But is the “abstinence” actually helpful?

Here’s my own experience with two therapies: In one positive case, the deprivation didn’t matter because the analyst’s true feelings and emotional engagement were subtly communicated. While I don’t think the deprivation contributed positively, the humanness was helpful, even essential to progress. In a failed case, the deprivation, along with the prestigious aura of the analyst and setting, served to cover up the analyst’s destructive countertransference and to discourage the patient from even thinking of sharing critical thoughts about the analyst, which, if correctly processed, could have led to insight and cure.

Why does this technique persist? Perhaps it’s for the same reason that many CBT therapists may not wonder why people have the automatic thoughts they do. The answer is shame. New therapists, when they start training, are highly susceptible to internalizing the values of their older teachers and mentors. In the the psychodynamic and behavioral traditions respectively, the blank screen and the rejection of “subjective” material are passed from generation to generation. Deviating from these internalized values leads to potent feelings of shame. Moreover, such values are highly resistant to change.

More Concerns About Supportive Therapy

My next concern about the concept of supportive therapy is that the support is often seen as binary, all or nothing. Insight therapy is seen as including no support, which is a fiction, or, in supportive therapy, the patient’s defenses are given blanket support, including the entrenched maladaptive patterns, EMPs, which should be the targets of all therapy.

In the traditional view of supportive therapy, the aim is to leave defenses intact on the theory that letting go of them would lead the patient to decompensate. Both Otto Kernberg and Marsha Linehan have shown this to be incorrect. In a more nuanced version, when defenses are maladaptive, then the goal should be to trade them in for healthier ones, but to do so in a manner that maintains safety and avoids dysregulation.

The Positive Side of Support

Now let’s look at the positive side of support. First, as many have pointed out, 4-5 times a week psychoanalysis is very supportive, simply by the unusual availability of someone whose sole aim is to listen to whatever one might have to say. So what does support really accomplish in therapy?

Accurate Empathy**

First, the gold standard of support from parents and from therapists is “accurate empathy,” a term coined by Carl Rogers to say that empathy is not just a sympathetic attitude, but the critical skill of helping patients communicate the most important and subtle nuances of their emotions and their full context. Feeling truly understood is both supportive and positive. More technically, it represents the moment when the mechanism of Memory Reconsolidation can go to work to heal painful feelings. That is, the moment when deep emotions associated with danger are activated while juxtaposed with their antidote, the safe and empathic other’s larger perspective.

[**Note added 2024, An alternative and perhaps better term is "Complex Caring." The definition is the same, seeking an increasingly deep understanding of the individual, which naturally leads to caring.]

This mechanism is what allows the sense of direness associated with emotional pain to be softened. It is also the moment captured in Alexander and French’s “corrective emotional experience” and in the concepts of mindfulness and mentalization.

If there is one essence of successful psychotherapy, it is precisely the cultivation and benefits of accurate empathy. Is this kind of support only present in psychoanalysis? No, of course not. It is central to the work of every effective parent and every effective therapist, regardless of school or orientation.

Furthermore, accurate empathy is the perfect medicine. It has only benefits and no negative side effects (except in rare situations where being understood constitutes a threat) and no dosage limit. 

Other Kinds of Support

A good way of understanding the use of support for emotional growth is to observe good parents. They tie the child’s shoe until the child is able to do it and, occasionally, after long day when the child is tired out. In other words, support is given according to the level of need and the child’s ability to do for him or herself. Failure to be aware of nuances in the child’s readiness is harmful either as overindulgence or cold indifference.

The same standard should apply to therapists. If we give support to an extent that is not needed, then the message is against self-efficacy, and if we withhold support when it is needed, we are being cruel. Thus, other than the unlimited giving of accurate empathy, support needs to be dosed with sensitivity.

What Are the Effects of Support?

In other writings, I have suggested that in all therapies (in addition to three basic change mechanisms), four “Facilitative Factors,” are critical, whether explicitly or implicitly. These provide a framework for looking further at the effects of support.

1. Arousal Regulation: Work with trauma survivors has shed increased light on the simple fact that when patients are dysregulated, that is, in flight or fight mode, their capacity for change is impaired. This fact, detailed, for example, in polyvagal theory, has spawned a range of techniques, many taken from Eastern practices, for calming the nervous system. Notwithstanding, the therapeutic relationship has served this purpose from the beginning of the practice of professional psychotherapy. Thus, one of the functions of support is to help regulate a dysregulated nervous system as a prerequisite for change.
2. Support for Motivation: As I have pointed out elsewhere, therapy aimed at trading EMPs for healthier patterns is hard and requires facing uncomfortable feelings and taking emotional risks. Supporting motivation is one of the things every therapist does, whether overtly or implicitly. All kinds of support are helpful, but in particular, helping the patient find hope, or (to put it in more technical terms) the expectation of a positive outcome, is one of the most important enhancers of motivation. The motivational system (Panksepp’s SEEKING system) is highly sensitive to the presence or absence of hope.
3. Safety: The therapist’s ensuring safety and, where there is risk, supporting informed consent and refraining from giving false expectations, is an essential form of support in any brand of therapy.
4. Maintaining the Therapeutic Relationship: A strong therapeutic relationship is highly supportive and helps with each of the three change mechanisms and the three facilitative factors listed above.

Conclusion:

All therapies are supportive. The degree of support, beyond accurate empathy, which can almost always be given without restraint, should depend on the patient’s need at that moment and should be dosed to avoid the dual pitfalls of indulgence (being overly helpful or overly accepting of maladaptive patterns), or excessive withholding, to the point of diminishing the patient's ability to make positive changes.

Jeffery Smith MD