To the Editor: In the April 2008 issue of the Journal, Carolyn J. Douglas, M.D. (1) discussed many issues involved in the surprisingly complex enterprise of teaching supportive psychotherapy. Dr. Douglas stated that “supportive therapy has not been sufficiently well defined in a manual or tested in controlled clinical trials to be considered evidence based” (1, p. 450). This assertion deserves exploration.
Supportive psychotherapy may be the most prevalent psychotherapy (2). In the 1998 National Survey of Psychiatric Practice, 36% of patients treated by psychiatrists received supportive psychotherapy, a higher percentage than that for insight-oriented therapy (19%), cognitive behavioral therapy (CBT) (6%), or psychoanalysis (1%). The practice of supportive psychotherapy seems likely to increase since 1) residency training in the United States currently requires competency in the area of supportive psychotherapy; 2) several supportive psychotherapy texts have been recently published (3–5); and 3) supportive psychotherapy applies to a wide range of patients and clinical situations.
Psychotherapy research has usually examined supportive psychotherapy as a comparison treatment for more specific—putatively more “active”—approaches that may have received more rigorous therapist training, greater researcher allegiance (6), and even a larger allotment of therapeutic hours. Thus, existing data pertaining to supportive psychotherapy are often suspect. Nevertheless, increasing literature on supportive psychotherapy suggests that it is active, efficacious, and often achieves lasting, meaningful results (3–5, 7, 8). In a recent borderline personality disorder study (9), supportive psychotherapy demonstrated generally comparable outcomes with those of dialectical behavioral therapy and transference-focused psychotherapy. In treating depression, supportive psychotherapy matched CBT despite fewer therapy sessions (10).
Perhaps now is the time to complete the process of establishing supportive psychotherapy as an evidence-based treatment. As the most common psychotherapy, supportive psychotherapy should receive high research priority and be developed, applied, and evaluated as rigorously as CBT or interpersonal psychotherapy. It can then be taught to residents and other students as a treatment with demonstrated efficacy and refined through further research.
1.Douglas CJ: Teaching supportive psychotherapy to psychiatric residents. Am J Psychiatry 2008; 165:445–4522.Tanielian TL, Marcus SC, Suarez AP, Pincus HA: Trends in psychiatric practice, 1988–1998, II: caseload and treatment characteristics. Psych Services 2001; 52:8803.Novalis PN, Rojcewicz SJ, Peele R: Clinical Manual of Supportive Psychotherapy. Washington, DC, American Psychiatric Publishing, 19934.Pinsker H: A Primer of Supportive Therapy. Hillside, NJ, Analytic Press, 19975.Winston A, Rosenthal RN, Pinsker H: Introduction to Supportive Psychotherapy: Core Competencies in Psychotherapy. Arlington, Va, American Psychiatric Publishing, 20046.Luborsky L, Diguer L, Seligman DA, Rosenthal R, Krause ED, Johnson S, Halperin G, Bishop M, Berman JS, Schweizer E: The researcher’s own therapy allegiances: a “wild card” in comparisons of treatment efficacy. Clin Psychol Sci Pract 1999; 6:95–1067.Wallerstein RS: The psychotherapy research project of the Menninger Foundation: an overview. J Consult Clin Psychology 1989; 57:195–2058.Hellerstein DJ, Rosenthal RN, Pinsker H, Samstag LW, Muran JC, Winston A: A randomized prospective study comparing supportive and dynamic therapies: outcome and alliance. J Psychiatric Pract Research 1998; 7:261–2719.Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF: Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry 2007; 164:922–92810.Markowitz JC, Kocsis JH, Fishman B, Spielman LA, Jacobsberg LB, Frances AJ, Klerman GL, Perry SW: Treatment of HIV-positive patients with depressive symptoms. Arch Gen Psychiatry 1998; 55:452–457
Drs. Hellerstein and Markowitz have participated in studies of supportive psychotherapy funded by NIMH. Dr. Markowitz has received royalties from psychotherapy-themed books.
This letter (doi: 10.1176/appi.ajp.2008.08040565) was accepted for publication in May 2008.