PSYCHOANALYTIC PSYCHOTHERAPY

Freud had used the terms “psychoanalysis” and “psychotherapy”

interchangeably at various times throughout his writings, as mentioned,
and many of his so-called “analytic” cases would be considered
psychoanalytic psychotherapy by virtue of their length by today’s standards
and their failure to meet the standards of “classical analysis” as defined by
generations after Freud. Nevertheless, Freud had a very clear idea of
differentiating psychoanalysis from all other techniques that incorporated
suggestion. In fact, he wrote, “There was the greatest possible antithesis
between suggestive and analytic technique.” In 1919, he had written his
famous dictum, “It is very probable . . . that the large-scale application of
our therapy will compel us to alloy the pure gold of analysis freely with the
copper of direct suggestion.”
Yet, although psychoanalytic psychotherapy does go beyond the
boundaries of classic practice by permitting analytic techniques to be
modified and combined with nonanalytic techniques, it is no longer
necessarily considered an uncontrolled or contaminated treatment based
solely on suggestion. Rather, modifications offer acceptable and
appropriate applications of the analytic armamentarium in keeping with
the socio-cultural climate and temper of the times. The early-20th-century
Victorian Weltanschauung expressed in an age of sexual repression that
made hysterical neurosis the consummate disorder of its day has been
superseded by the current culture of narcissism, with its more modern
manifestations of mental illness, such as the narcissistic and borderline
personality disorders and other ego disturbances. At the same time, current
economic constraints and the effect of public policy on the nature of
psychiatric treatment have enforced practical considerations in the design
of revised analytic techniques to meet a broader spectrum of patients and
problems. The result has been an array of shorter-term psychodynamic
strategies in addition to long-term psychoanalysis.
Psychoanalytic, also called “dynamic,” “exploratory,” or “expressive”
psychotherapy, however, was always grounded in the principles of
psychoanalysis. The psychoanalyst Robert Wallerstein reported that
dynamic psychotherapy, as it developed in the post-World War II period,
was the “one distinctly American contribution” to modern-day psychiatry.

Distinguishing Psychoanalysis from Psychoanalytic Psychotherapy

As derivatives of classic psychoanalysis, the techniques of psychoanalytic
psychotherapy represent modifications that both resemble and depart from
it. As broadly practiced today, psychoanalytic treatment encompasses a
wide range of uncovering strategies used in varied degrees and blends.
Despite the inevitable blurring of boundaries in actual application, the
original modality of classic psychoanalysis and major modes of
psychoanalytic psychotherapy (i.e., expressive or exploratory or dynamic,
and supportive) are delineated separately here (Table 33.1–2). Analytic
practice in all of its complexity resides on a continuum. Individual
technique is always a matter of emphasis as the therapist titrates the
treatment according to the needs and capacities of the patient at every
moment. Psychoanalytic psychotherapy is based on fundamental dynamic
formulations and techniques that derive from psychoanalysis and is
designed to broaden its scope. Arnold Cooper notes that one of the major
distinguishing features of psychoanalysis from other analytically-oriented
therapies is the degree of internalization of the therapist and the process of
therapy after a patient has terminated. For example, he finds that after
therapy, a patient will remember it vividly as a powerful and important
experience, whereas after an analysis, a patient tends to remember it
poorly, reflecting the analytic experience has become an integrated part of
the patient, rather than sequestered as a separate internal representation.
Gabbard notes that the strategies of psychoanalytic dynamic
psychotherapy range from exploratory or expressive (e.g., insight-oriented
clarification, confrontation, and interpretation) techniques to supportive
(e.g., relationship-oriented suggestion, empathic validation, advice and
praise, and affirmation) techniques. Although those two types of methods
are sometimes regarded as antithetical, their precise definitions and the
distinctions between them are by no means absolute.
The primary distinction between psychoanalysis and other forms of
therapy, though, is in the handling of the transference. It follows that the
pivotal clinical issue for psychoanalytic psychotherapy is how the
transference is used or managed, to what extent it is interpreted or left
uninterpreted, and to what extent it is fostered by the therapist. In
psychoanalysis, all transference manifestations are analyzed. Robert
Michels has noted that in psychotherapy, as distinct from psychoanalysis,
the transference is analyzed primarily when it becomes a source of
resistance, that is, when it interferes with the progress of the therapy.
Psychoanalyst Lawrence Friedman, whose classic work, The Anatomy
of Psychotherapy, believes that the defining role of the therapist is his
“commitment to ambiguity.” But he adds, “If there were no theory behind
it, the psychotherapy session would be a very strange meeting.” At least one
source noted that all the controversies among analysts about what
constitutes analysis (e.g., how many times a week, whether to use the
couch, what theory to use) is analogous to being concerned about
reshuffling the deck chairs on the Titanic when the ship is going under. In
other words, maybe the focus has been misdirected. Cooper maintained
that there is often not a clear boundary between psychoanalytic
psychotherapy and psychoanalysis and said, “I had the not infrequent
experience that some of my sitting up so-called psychotherapy patients
were experiencing an analytic process and that some of my lying down five
times a week psychoanalytic patients were at best having a psychotherapy.”
He added, “The heart of analysis cannot be a matter of how many times a
week we see the patient and the patient’s posture.”
In support of that idea, Robert Wallerstein had demonstrated, years ago
in the Psychotherapy Research Project of the Menninger Foundation, that
even in psychoanalytic treatment, much of what is called structural change
came from supportive, noninterpretative means. His conclusion was that
the psychotherapies accomplished much more than initially expected and
“real treatments in actual practice are inextricably intermingled blends of
more or less expressive and more or less supportive elements.” Despite the
potential for intermingling blends, says T. Byram Karasu,
“Psychotherapeutic communication begins only when ordinary
communication ends.”
Thirty years after delineating four intrinsic criteria of psychoanalysis
(centrality of transference, neutral analyst, regression to transference
neurosis, and interpretation as sole instrument), Merton Gill revised them
in 1984 to provide the backbone of modern psychoanalytic psychotherapy:
(1) The centrality of transference is broadened to encompass
nontransference manifestations; (2) the guiding principle of neutrality is
loosened to acknowledge the real personality and attitudes of the analyst;
(3) the regressive transference neurosis is supplanted or replaced by less
frustration, fantasy, and focus on the past (and greater gratification, reality,
and focus on the present); and (4) interpretation is extended to include
more nonexploratory methods (with genetic interpretations expanded by
here-and-now interpretations). Those intrinsic changes accompanied three
major extrinsic changes: reduced session frequency, reduced or more
flexible treatment duration, and abandonment of the couch.
The duration of psychoanalytic psychotherapy is generally shorter and
more variable than in psychoanalysis. Treatment may range from brief,
even with an initially agreed-on or fixed time limit (e.g., Mann’s time-
limited psychotherapy), to a less definite number of months or years. Brief
treatment is chiefly used for selected problems or highly focused conflict,
whereas longer treatment may be applied in more chronic conditions or for
intermittent episodes that require ongoing attention to deal with pervasive
conflict or recurrent decompensation. In either event, when a time frame is
established at the beginning, it can often be altered in the course of therapy
as patient needs and goals change. Unlike psychoanalysis, psychoanalytic
psychotherapy rarely uses the couch; instead, patient and therapist sit face-
to-face. That posture helps to prevent regression because it encourages the
patient to look on the therapist as a real person from whom to receive
direct cues, even though transference and fantasy will continue. The couch
is considered unnecessary because the free association method is rarely
used except when the therapist wishes to gain access to fantasy material or
dreams to enlighten a particular issue. In current practice the use of the
couch may not even be advisable in many instances (especially in the
supportive type) because extensive unconscious data are not sought or
because the primitive thinking or behavior that may accompany severe
illness makes further regression undesirable.

Table 33.1–2.
Scope of Psychoanalytic Practice: A Clinical Continuum
Expressive Mode
Features “Classic” Analytic (Exploratory) Supportive Mode
Frequency Regular 4–5 Regular 1–3 times/wk; 1/2 to Flexible 1 time/wk or less;
times/wk; “50- full hour or as needed 1/2 to full
minute hour” hour
Duration Long term; usually Short or long term; several Short or intermittent long
3–5+ years; sessions to months or term; single session to
maybe years lifetime
considerably
longer
Setting Patient primarily on Patient and therapist face to Patient and therapist face-
couch with face; occasional use of to-face; couch
analyst out of couch contraindicated
view
Modus operandi Systematic analysis Partial analysis of dynamics Formation of therapeutic
of all positive and and defenses; focus on alliance and real object
negative current interpersonal relationship; analysis of
transference and events and transference to transference
resistance; others outside of sessions; contraindicated with
primary focus on analysis of negative rare exceptions; focus
analyst and transference; positive on conscious external
intrasession transference left events; regression
events; unexplored unless it discouraged
transference impedes progress; limited
neurosis regression encouraged
facilitated;
regression
encouraged
Analyst/therapist Absolute neutrality; Modified neutrality; implicit Neutrality suspended;
role frustration of gratification of patient and limited explicit
patient; greater activity of gratification, direction,
reflector/mirror therapist and disclosure
role
Mutative change Insight Insight within more empathic Auxiliary or surrogate ego
agents predominates environment; as a temporary
within relatively identification with substitute; holding
deprived benevolent object environment; insight to
environment the degree possible

Patient population Neuroses; mild Neuroses; mild to moderate Severe character disorders,
character character latent or manifest
psychopathology psychopathology, psychoses, acute crises,
 especially narcissistic and physical illness
borderline disorders
Patient requisites High motivation, High moderate motivation Some degree of motivation
psychological and psychological- and ability to form
mindedness, mindedness, ability to therapeutic alliance
good previous form therapeutic alliance,
object some frustration tolerance
relationships,
ability to
maintain
transference
neuroses, good
frustration
tolerance
Basic goals Structural Partial reorganization of Reintegration of self and
reorganization of personality and defenses; ability to cope;
personality; resolution of preconscious stabilization or
resolution of and conscious derivatives restoration of pre-
unconscious of conflicts; insight into existing equilibrium;
conflicts; insight current interpersonal strengthening of
into intrapsychic events; improved object defenses; better
events; symptom relations; symptom relief a adjustment or
relief an indirect goal or prelude to further acceptance of
result exploration pathology; symptom
relief and environmental
restructuring as primary
goals
Major techniques Free association Limited free association; Free association method
method confrontation, contraindicated;
predominates; clarification, and partial suggestion (advice)
full dynamic interpretation predominates;
interpretation predominate, with abreaction useful;
(including emphasis on here-and- confrontation,
confrontation, now interpretation and clarification, and
clarification, and limited genetic interpretation in the
working through), interpretation here-and-now are
with emphasis on secondary; genetic
genetic interpretation is
reconstruction contraindicated
Adjunct treatment Primarily avoided; if May be necessary, e.g., Often necessary, e.g.,
applied, all psychotropic drugs as psychotropic drugs,
negative and temporary measure; if family rehabilitative
positive meanings applied, negative therapy, or
and implications implications are explored hospitalization; if
thoroughly and diffused applied, positive
analyzed more implications are
recently, emphasized
medication
adjunct
This division is not categorical; all practice resides on a clinical continuum.

A 32-year-old woman had been in twice-weekly psychotherapy for about a year when her
therapist presented the possibility of her coming into analysis with him. It was just around the
time that the therapist had gotten a large ottoman for the chair his patients used. This patient,
who became quite frightened and confused by the idea of switching her therapy to analysis, felt
this new furniture represented a “neither here nor there”—that is, “neither a couch nor a chair.”
She chose not to enter analysis but did continue her therapy. She was never was able to use the
ottoman.

Mutative Change Agents

Insight. Insight has been defined as the process by which the meaning,
significance, pattern, or use of an experience becomes clear or as the
understanding that results from that process. Theoretically, it has been
portrayed as occurring in four successive stages, which can be applied to
the psychoanalytic process as follows: (1) preparation, characterized by
frustration, anxiety, feelings of ineptness, and despair, often accompanied
by trial-and-error activity and falling into habitual patterns (repetition
compulsion); (2) renunciation, in which one desires to escape from the
problem or is unmotivated to make insightful efforts (resistance, negative
transference); (3) inspiration or illumination, in which the problem is
grasped and solutions suggest themselves (beginning of discovery based on
interpretive process); and (4) elaboration and evaluation, in which the
validity of the insight is checked and confirmed against external reality
(working through).
Insight is not fully understood, and it is frequently misidentified as a
dramatic “eureka” phenomenon. Such sudden enlightenment rarely occurs
in analysis, and if it does, it is usually short lived but may mislead the
analyst or the patient into wishfully believing that profound understanding
has occurred. It is much more common for the patient to achieve insight in
a slow and subtle manner, in small ripples rather than in sudden tidal
waves. Insights also tend to be circumscribed and specific to certain
problem areas rather than whole-truth revelations that are associated with
mystical experiences or religious conversions.
Despite its presumed potency as a therapeutic agent, insight in
psychoanalysis is not definitive in its role or its function. There is no proof
of a necessary relation between the truth (or falseness) of insight and
therapeutic results, although that finding may be clinically obviated by the
role of mutual belief as a nonspecific healing agent. What is clinically
known, however, is that intellectual insight alone is of minimal value;
insight must be emotionally integrated (even though the distinction may be
difficult to make). Moreover, not all change in psychoanalysis is
attributable to insight, and not all insight leads to behavioral change.
Perhaps the major controversy that characterizes contemporary thinking
on the subject is the mutative role of insight versus the role of the
therapeutic atmosphere or the empathic relationship within which the
interpretation occurs. In his 1953 classic paper that introduced the term
“parameter,” Kurt Eissler wrote, “It is still a riddle why a human being
should refuse to make maximal use of insight which is conveyed to him.”

Identification and Empathy. Insight is still regarded as the sine qua non
of analytic cure, and the interpretation of transference remains the primary
vehicle through which mutative change occurs, but greater attention in
recent years has been paid to the role of the therapeutic atmosphere in
facilitating insight and to the therapeutic relationship itself. The traditional
concern has been more with recreating the original infantile neurosis than
with the ameliorating qualities of the analyst as an ideal or real person who
is different from desired past objects.
Identification is an automatic, unconscious process that occurs when an
individual takes on the qualities of a substitute object or model. This
phenomenon—an early expression of an emotional tie with another person
—is considered a consequence of the desire to believe in the benevolent
power of another, the tendency both consciously and unconsciously to want
to be like the loved or admired object. As the therapist’s values are
presumably more realistic and constructive than those of the patient,
repeated identification with the image of the therapist serves not only to
lessen the harsh quality of the patient’s superego, but it can also modify the
patient’s ego with the therapist as role model, increasing self-esteem
through identification with the therapist. The therapist’s role as an
identification model is facilitated, at least in part, by his or her elevated
transferential image as an idealized authority.
In recent years, there has been an emphasis on the important role of the
therapeutic atmosphere, as expressed in the concept of empathy, defined
by Auchincloss and Samberg as “a complex affective and cognitive process
of feeling, imagining, thinking, and somatically sensing one’s way into the
experience of another person.” Kohut had focused on the importance of
empathy in his theory of self-psychology and defined it as “vicarious
introspection.” For Kohut, major failures of empathy by parental figures
during childhood interfered with the crystalization of the self. As the
therapist communicates an understanding of the patient’s problems and
psychological pain (i.e., an empathic resonance), the patient is more likely
to gain insight. Current research suggests that even the most accurate and
well-timed interpretation will not be effective if the patient does not
experience such an empathic therapeutic atmosphere.
The complex question of mutative change agents in psychotherapy is
unresolved. Investigations by Jerome Frank, Hans Strupp, T. Byram
Karasu, and others suggest that the critical ingredients of
psychotherapeutic effectiveness may transcend specific strategies or types
of treatment and to a large extent reside in nonspecific ingredients that all
therapies share, such as the personality, commitment, and availability of
the therapist.
Adjunctive Therapy and Concomitant Use of Medication in Psychotherapy
Another issue is the use of adjunct treatment during psychoanalytic
psychotherapy. Patients may present with more severe pathology in
psychoanalytic psychotherapy and may require concurrent treatment with
psychotropic drugs to relieve acute symptoms of anxiety or depression
before any dynamic exploration can ensue. Just as in the concomitant use
of medication with psychoanalysis, there may be similar complex
transferential and countertransferential issues in the context of the
analytically-oriented psychotherapies. Because these treatments lack the
depth of psychoanalytic exploration, therapists need to be particularly
aware of their own, as well as their patients’ fantasies, regarding the use of
medication during the course of therapy. A 2014 article by Huhn et al.
conducted a systematic overview of the efficacy of pharmacotherapy and
psychotherapy, with 61 meta-analyses and over 137,000 participants.
Because patients often benefit from both modalities, the authors
recommended that future research should focus on how both modalities
can be combined “to maximize synergy” of the two rather than debate
which treatment is more efficacious. The authors found that direct
comparisons of medication and psychotherapy did not demonstrate
consistent differences but their combination was superior to either alone. A
survey of psychotherapists (61 psychiatrists, and over 1900 patients in
treatment) in the New York/New Jersey areas found that so-called “split
care”—care by two professionals, one of whom does the medication
management and the other does the psychotherapy—was common.
Regrettably, though, there was often poor, irregular, or infrequent
communication about the patient between the professionals involved.
With the analytically-oriented therapies, depending on the nature of the
patient’s pathology and support system, other treatments may also be
necessary, including hospitalization, rehabilitative therapies, couple or
family therapy.

Exploratory (Expressive) Psychotherapy

Indications and Contraindications. Exploratory psychotherapy has
become a desirable and widely applicable form of treatment under the
following circumstances: (1) Psychoanalysis is diagnostically or clinically
contraindicated because the patient lacks sufficient ego strength to tolerate
the extent of regression, frustration, or suspension of reality that is
required; the patient is deficient in the cognitive resources necessary for
the achievement of deep insight; the patient is not sufficiently motivated
because of competing family, social, or cultural influences; or the problem
is so pressing that lengthy treatment is unsuitable. (2) Practical or logistical
considerations prevail whereby patients otherwise suited for a more
lengthy psychoanalysis are unavailable for long-term treatment for reasons
of time, money, or geography. For that group the techniques used are closer
to those of psychoanalysis proper because extrinsic rather than intrinsic
factors are largely responsible for the change of approach. Nonetheless, the
category of healthier patients constitutes a sizable population of recipients
of current psychoanalytic psychotherapy. (The inclusion of both categories
here in part accounts for the blurred boundaries and confusion in the
application of expressive psychotherapy.)
Diagnostically, psychoanalytic psychotherapy in its mode is suited to a
range of psychopathology with mild to moderate ego weakening, including
neurotic conflicts, symptom complexes, reactive conditions, and the whole
realm of nonpsychotic character disorders. The last includes those
disorders of the self that are among the more transient and less profound
on the severity-of-illness spectrum, such as narcissistic personality
disorders. It is also the treatment controversially recommended for
patients with borderline personality disorders, although special variations
may be required to deal with the associated turbulent personality
characteristics, primitive defense mechanisms, tendencies toward
regressive episodes, and irrational attachments to the analyst. Depending
on the level of pathology, however, narcissistic and borderline personalities
may be amenable, as mentioned, for psychoanalysis. Sometimes a trial of
therapy is indicated to assess a patient’s suitability. There was considerable
discussion among many psychoanalysts and psychotherapists about one of
the very last episodes of the popular television program, The Sopranos. In
this particular episode, Dr. Melfi, the long-time therapist of mobster Tony
Soprano, summarily dismisses him from his psychoanalytic psychotherapy
after hearing about a study that indicated sociopaths did not benefit from
psychotherapy. Glen Gabbard, who has used the program to teach
psychotherapy, has written extensively on The Sopranos and discussed the
complex issues involved in treating “a man who is beyond redemption” in
his book, The Psychology of the Sopranos.
The persons best suited for the exploratory psychotherapy approach
have fairly well integrated egos and the capacity both to sustain and to
detach from a bond of dependency and trust. They are, to some degree,
psychologically minded and self-motivated, and they are generally able, at
least temporarily, to tolerate doses of frustration without decompensating.
Patients must have some capacity for introspection and impulse control,
and they should be able to recognize the cognitive distinction between
fantasy and reality. Often, they may appear similar to those suitable for
psychoanalysis. Sometimes, logistical issues, such as time constraints and
ability to commit to a lengthy, intense process, determine the method of
treatment.

Goals. The overall goals of exploratory psychotherapy are to increase

the patient’s self-awareness and to improve relationships with people in the
patient’s life through exploration of current interpersonal events and
perceptions. In contrast to psychoanalysis, major structural changes in ego
function and defenses are modified in light of patient limitations. Instead
of systematically resolving the unconscious nuclear conflict, the therapist
may opt to resolve some conflict areas and undo specific resistances,
intentionally overlooking or reinforcing others. The aim is a more limited,
and thus select and focused, understanding of one’s problems. Rather than
uncovering deeply hidden and past motives and tracing them to their
origins in infancy, the major thrust is to deal with preconscious or
conscious derivatives of conflicts as they became manifest in present
interactions. Although insight is sought, it is less extensive; instead of
delving to a genetic level, there is a greater emphasis on clarifying recent
dynamic patterns and maladaptive behaviors in the present. Symptom
relief may be an acceptable aim rather than simply a concomitant of the
better resolution of conflicts. In more integrated patients who have the
capacity for greater insight, it may be a prelude to further analytic work.
Much like with analysis, though, both patient and analyst can divide goals,
as Ernst Ticho has noted, into life goals and treatment goals.

The Main Approach. Facilitating a full-blown, regressive transference

neurosis is neither necessary nor appropriate. Rather, the major modus
operandi involves establishment of a therapeutic alliance and early
recognition and interpretation of negative transference. Only limited or
controlled regression is encouraged, and positive transference
manifestations are generally left unexplored unless they are impeding
therapeutic progress; even here, the emphasis is on shedding light on
current dynamic patterns and defenses.
Although technical neutrality is largely maintained, the therapist is less
strictly anonymous and silent and is more active and responsive in his or
her overall stance and in the nature of specific interventions. The free
association method is no longer used as the major patient tool, and primary
process material is elicited only as a selective way of accessing specific
conflictual data. Clarification and interpretation are still used, but they are
altered both qualitatively and quantitatively. Partial interpretations address
some conflict areas as others are left untouched; the depth of interpretation
is less penetrating, with emphasis on the present.

Limitations. Some therapists fail to accept the limitations of a modified

insight-oriented approach and so apply it inappropriately to modulate the
techniques and goals of psychoanalysis. Overemphasis on dreams and
fantasies, zealous efforts to use the couch, indiscriminate deep
interpretations, and continual focus on the analysis of transference may
have less to do with the patient’s needs than with those of a therapist who is
unwilling or unable to be flexible.
Ms. S was an attractive 30-year-old, unmarried woman working as a secretary when she
presented for consultation. Her chief complaints at the time were feeling “only anger and
tension” and an inability to apply herself to studying voice, “which is one of the most important
things to me.”
In obtaining a history, the therapist noted that Ms. S had never completed anything: She
had dropped out of college; never pursued a music degree; and switched from job to job, and
even city to city. What initially seemed like a woman with diverse interests (e.g., jobs as a
research assistant, freelance copyeditor, part-time radio announcer; manager of data entry for
a software company; and, most recently, secretary) really reflected a woman with a chaotic
lifestyle and serious difficulties committing to anyone or anything. Although obviously
intelligent, Ms. S presented with unrealistic expectations regarding her consultation. For
example, after the first consultative session, Ms. S said she felt good afterward but felt there
were “no revelations yet.” Because of Ms. S’s inability to commit and her somewhat
disorganized life, the therapist recommended a course of psychotherapy, beginning twice a
week, rather than something more intense like psychoanalysis. The therapist also realized over
the course of the consultation that Ms. S would have difficulty with free association without
getting disorganized. The therapist thought that Ms. S might regress unproductively on the
couch without visual contact with the therapist.
Ms. S was the second oldest of four children—two brothers and a younger sister, with whom
she was most competitive and who clearly seemed the mother’s favorite. She described her
mother as a successful professor who was demanding and critical, as if she had a “raised
eyebrow” in disapproval. For example, much to her mother’s chagrin, Ms. S had once wanted a
sandwich “with everything on it.” Ms. S was also disappointed when she was given one piece of
luggage rather than a complete set for a Christmas gift. She was able to accept the therapist’s
interpretation that she felt “part of a set” by being one of four siblings. Ms. S initially idealized
her father, who was active in the family church, but eventually saw him as disappointing and
rejecting.
Ms. S’s ideal therapist would be “flexible,” by which she meant a therapist who might do
hypnosis one session, psychotherapy the next, and, maybe, analysis another session. In fact,
within the first week of beginning therapy, Ms. S had simultaneously consulted a
hypnotherapist, which she mentioned in passing only weeks later, for her neck pain and
tension. Although she did not pursue hypnosis, she did maintain a chiropractor for most of her
therapy, also something she mentioned in passing many months after beginning therapy. She
did speak of wanting to be “on best behavior” and “follow the rules.” Her tremendous sense of
entitlement, however, was evident: She had an expectation of getting “cut-rate prices” on
everything from haircuts and car repairs to doctors’ visits. Her initial fee was a much-reduced
one, which she paid late and begrudgingly throughout most of her therapy. During one session,
for example, she held up her hands admiringly, delightedly noting the bargain she had gotten
for her $7.00 manicure. She was oblivious to the transference connection, which the therapist
pointed out, that she was paying the same price for each therapy session.
Although she was seen only twice a week, Ms. S developed intense feelings for her therapist.
Mostly she experienced rage when she saw evidence of the therapist’s other patients, such as
footprints on the waiting room floor after a snowstorm or a coat hanger turned around. She
expressed the wish to keep some of her things, like bobby pins and hairspray, in the therapist’s
bathroom. She vacillated between feelings she wanted to move in and feelings that the
therapist did not exist. For example, before she took a plane flight, she wondered who would
tell her therapist if something happened to her. She had never given the therapist’s name to
anyone, nor did she have her name in her weekly appointment book. The therapist interpreted
that she had a wish to devalue her and not to share her with anyone else. Associations to a
dream with an image of a string of Baroque pearls led to thoughts that these pearls—irregular
and imperfect—defective and even lopsided, represented how she viewed herself.
Over the course of the next few years, Ms. S was able to commit to coming regularly to
therapy, although the course was somewhat tumultuous, with many threats of quitting and
much withholding of information. At one point, she even tried to provoke the therapist by
seeking a consultation with another therapist in order to “tattle” on her, just as she had tattled
on her siblings. Her therapist remained unprovoked and continued to provide a safe
environment for Ms. S to explore her ambivalence to the therapist and the therapeutic
situation. The therapist was also able to contain Ms. S’s tendency to regress, particularly with
separations, by providing her with the therapist’s telephone number.
She had actually entered therapy with a wish to become a world-famous musician who
would win her mother’s approval and praise. Her narcissism and sense of entitlement made it
difficult for her to give up on that fantasy despite repeated evidence that she did not have
sufficient talent. She was finally able to settle on a compromise: She began to work diligently
and closely as a research assistant to her mother, who was writing a book, and as Ms. S became
more focused and organized over time, she even thought she might write a book about the
Church.

Supportive Psychotherapy
Supportive psychotherapy aims at the creation of a therapeutic relationship
as a buttress or bridge for a patient. It has roots in virtually every therapy
that recognizes the ameliorative effects of emotional support and a stable,
caring atmosphere in the management of patients. As a nonspecific attitude
toward mental illness, it predates scientific psychiatry, with foundations in
18th-century moral treatment, when, for the first time, patients were
treated with understanding and kindness in a humane interpersonal
environment free from mechanical restraints.
That perspective underlies such diverse developments as milieu therapy
for rehabilitating chronic hospitalized patients; crisis intervention to assist
otherwise functioning persons through sudden periods of great turmoil or
stress; and guidance or counseling practices for children, former patients,
and nonpatients who need interim help in social, academic, or vocational
areas but do not warrant long-term or in-depth exploration. Supportive
psychotherapy has been the chief form used in the general practice of
medicine and rehabilitation, frequently to augment other therapeutic
measures such as prescriptions of medication to suppress symptoms or for
hospitalization to provide a structured therapeutic environment,
protection, and control of the patient. It may be applied as primary or
ancillary treatment. The global perspective of supportive psychotherapy
(often part of a combined-treatment approach) places major etiological
emphasis on external rather than intrapsychic events, particularly on
stressful environmental and interpersonal influences on a severely
damaged self.
As a viable modality within the psychoanalytic movement, supportive
psychotherapy has been described as the most ill-defined and nebulous of
all psychotherapies. It is the treatment to which very difficult,
characterologically or intellectually limited patients were referred when no
other modality, particularly insight-oriented psychotherapy, seemed
suitable. In the late 1940s, Alexander and French noted the persistent
tendency to differentiate between two main categories of treatment—
primarily supportive methods and primarily uncovering methods.

Relationship to Psychoanalysis. With the widening scope of

psychoanalysis, supportive psychotherapy has emerged as a specific body
of techniques. The contributions of modern ego psychology and object
relations theory, which have broadened the focus and goals of
psychoanalytic psychotherapy beyond classic psychoanalysis, have
generated renewed interest in defining the role of supportive
psychotherapy in analytic work. Supportive strategies include an emphasis
on suggestion, persuasion, encouragement, reassurance, advice-giving,
reality testing, or environmental manipulation, in contrast to or in addition
to insight-oriented strategies. Caretaking in the form of a positive
relationship provides the basic context or milieu for listening to and
understanding patients (no matter what specific strategies are used). Not
only the actual methods, but the entire atmosphere and nature of
communication are characterized by support and safety. This method
provides the patient a relationship where the therapist is an auxiliary or
substitute ego that offers the patient a secure and nurturing interpersonal
relationship, as well as specific control, direction, and counsel.
In the psychoanalytic spectrum, supportive psychotherapy represents
not so much a separate entity as an important emphasis within its
exploratory-supportive boundaries. Instead of being negatively viewed as a
compromised approach for patients unsuitable for analysis, it is positively
viewed as effective treatment for a broad clinical range of patients. Concern
and empathy are integral to all therapeutic endeavors, but the focus here is
on a stance or interpersonal bond that is affectively responsive (rather than
neutral) and oriented to present reality (rather than a focus on the past)
and in which limited interpretive work in the broadest sense can more
readily occur. Many therapists now explicitly recognize the
complementarity of exploratory and supportive modes of treatment, which
can be combined, modified, and individualized according to the needs of
the patient. The therapeutic focus is more directly on the caring and
nurturing aspect of the doctor–patient relationship (without analyzing it as
a past transference manifestation).

Indications and Contraindications. Supportive psychotherapy is

generally indicated for those patients for whom classic psychoanalysis or
insight-oriented psychoanalytic psychotherapy is typically contraindicated
—those who have poor ego strength and whose potential for
decompensation is high. Amenable patients fall into the following major
areas: (1) persons in acute crisis or a temporary state of disorganization and
inability to cope (including those who might otherwise be well-
functioning), whose intolerable life circumstances have produced extreme
anxiety or sudden turmoil (e.g., persons going through grief reactions,
illness, divorce, or job loss or who were victims of crime, abuse, natural
disaster, or accident); (2) patients with chronic severe pathology, with
fragile or deficient ego functioning (e.g., those with latent psychosis,
impulse disorder, or severe character disturbance); (3) patients whose
cognitive deficits and physical symptoms make them particularly
vulnerable and so unsuitable for an insight-oriented approach (e.g., certain
psychosomatic or medically ill persons); and (4) persons who are
psychologically unmotivated although not necessarily characterologically
resistant to a depth approach (e.g., patients who come to treatment in
response to family or agency pressure and are interested only in immediate
relief or those who need assistance in some very specific problem areas of
social adjustment as a possible prelude to more exploratory work).
Supportive psychotherapy is usually used when other complications
enter the clinical picture, such as when the primary diagnosis is physical
illness but the patient needs help in dealing with disability, or for long-term
mental illness, in which intermittent support and guidance in everyday
living augment the control of symptoms through pharmacotherapy and
provide out-of-hospital management. Regardless of the diagnosis, a
supportive approach may also be used in the early phases of virtually all
treatments as preparation for the establishment of a firm therapeutic
alliance (even when expressive treatment is the predominant mode) or
intermittently whenever the patient is in danger of excessive regression.
Because support forms a tacit part of every therapeutic modality, it is
rarely contraindicated as such. The typical attitude regards better-
functioning patients as unsuitable, not because they will be harmed by a
supportive approach, but because they will not be sufficiently benefited by
it. In aiming to maximize the patient’s potential for further growth and
change, supportive therapy tends to be regarded as relatively restricted and
superficial, and thus it is not recommended as the treatment of choice if the
patient is available for and capable of a more in-depth approach.

Goals. Supportive psychotherapy has more limited objectives than

does insight-oriented psychotherapy because the patient’s psychopathology
and diminished psychological resources restrict the potential for major
intrapsychic change or growth. Because the patient may begin supportive
therapy in a decompensated state, the therapist (at least initially) aims at
reconstituting and stabilizing the patient’s function. Although the
individual aims of supportive treatment vary, the general thrust is toward
the amelioration or relief of symptoms through behavioral or
environmental restructuring within the patient’s existing psychological
framework. That often means helping the patient to adapt better to
problems and to live more comfortably with his or her psychopathology. To
restore the disorganized, fragile, or decompensated patient to a state of
relative equilibrium, the therapist has the major treatment goal of
suppressing or controlling symptomatology and of stabilizing the patient in
a protective and reassuring benign atmosphere that militates against
overwhelming external and internal pressures. The ultimate treatment goal
is to maximize the integrative or adaptive capacities so that the patient
increases the ability to cope while decreasing vulnerability by reinforcing
assets and strengthening defenses.

The Main Approach. The techniques of supportive psychotherapy are

designed to restore or enhance the patient’s ego strength by helping the
patient to control impulses through direct limit-setting, to gain a more
accurate picture of reality through the clarification and testing of
perceptions, to sustain the adaptive structure by accepting (not analyzing
or confronting) defensive maneuvers, and to develop better coping skills
through direct teaching and practical advice and through the use of the
therapist as a role model and as a constantly reassuring figure on whom the
patient can rely. The active therapist serves as a substitute or auxiliary ego
until the patient is able to incorporate those assets in which he or she is
largely deficient, either acutely or characterologically. The safety and
security of a controlled and consistent therapeutic atmosphere also act as a
holding environment to contain the patient’s aggression and dangerous
impulses as he or she learns better to repress or sublimate the tendencies to
act out feelings rather than to verbalize them.
The traditional analytic techniques of clarification and interpretation
are also used to the extent that they focus on the here-and-now of the
patient’s problems, but genetic interpretations are contraindicated and may
cause decompensation in an already fragile patient.
Transference management also differs from that of classical
psychoanalysis and exploratory psychoanalytic psychotherapy. Supportive
psychotherapy focuses on the fostering and maintenance of a positive
transference at all times and on vitiating the effects of negative transference
should they arise. A complete or partially controlled transference
regression is contraindicated because intense transferences that are
allowed to develop in ego-impaired patients can produce sudden, turbulent
reactions that have disruptive effects on both the patient and treatment. A
positive transference is fostered and rarely analyzed as such. Exceptions
are those instances when positive transference may lead to acting out,
which can be forestalled by drawing attention to the patient’s distorted
perceptions and projections. The development of negative transference is
minimized by the use of highly structured interventions, with the therapist
assuming a much more direct and active approach than in expressive
psychotherapy. That includes discouraging free associations and fantasies
and continually bringing the patient back to reality and to the immediate
situation.
Techniques are thus designed to focus on conscious external events and
on the therapist as a largely nontransferential figure. To accomplish such
aims, the therapist suspends therapeutic neutrality, with much greater
direction, disclosure, and gratification offered than would be appropriate in
more uncovering approaches. The therapist as a real object serves to
validate the patient’s reality testing, diminishes the breakthrough of
regressive negative transference, and provides a reliable companion to
sustain the patient until he or she can function independently.

Limitations. To the extent that much supportive therapy is spent on

practical, everyday realities and on dealing with the external environment
of the patient, it may be viewed as more mundane and superficial than
depth approaches. These patients are seen intermittently and less
frequently, and the interpersonal commitment may not be as compelling on
either the patient’s or the therapist’s part. Greater severity of illness (and
possible psychoses) also makes such treatment potentially more erratic,
demanding, and frustrating. The need for the therapist to deal with other
family members, caretakers, or agencies (e.g., auxiliary treatment and
hospitalization) can become an additional complication as the therapist
comes to serve as an ombudsman to negotiate with the outside world of the
patient and with other professional peers. Finally, the supportive therapist
needs to be able to accept personal limitations and the patient’s limited
psychological resources.

Mr. W was a 42-year-old widowed businessman who was referred by his internist because of
the sudden death of his wife, who had had an intracranial hemorrhage, about 2 months earlier.
Mr. W had two children, a boy and a girl, ages 10 and 8 years, respectively.
Mr. W had never been to a psychiatrist before, and when he arrived he admitted he was not
certain what a psychiatrist could do for him. He just had to get over his wife’s death. He was
not sure how talking about anything could really help. He had been married for 15 years. He
admitted to having difficulty sleeping, particularly awakening in the middle of the night with
considerable anxiety about the future. One of his relatives had given him some of her own
Klonopin for his anxiety, which helped tremendously, but he feared getting dependent on it. He
was also drinking more than he thought he should. He was most concerned about raising his
children alone and felt somewhat overwhelmed by the responsibility. He was beginning to
appreciate just how wonderful a mother his wife had been and now saw how critical he had
been of her for spending so much time with the children. “It really does take a lot of effort,” he
said.
Mr. W did admit to feelings of guilt. For one thing, he admitted to some sense that he could
now start over. He had been somewhat restless in the marriage recently before his wife’s death
and had actually been unfaithful for a brief period early in the marriage. He also felt some guilt
that had he been awake the night of his wife’s hemorrhage—maybe he could have saved his
wife. In reality, there was nothing he could have done.
Mr. W agreed to come for a few sessions to talk about his wife. At this point, only 2 months
after her death, he seemed to have an uncomplicated mourning reaction. Although he talked
easily in session, he was clearly worried that he might like “being here too much.” The therapist
chose not to interpret his dependency conflicts. Mr. W seemed to have good coping skills and
used humor as a high-functioning defense. For example, in giving a eulogy for his wife (who
had been a very popular member of the congregation), he looked around at the enormous
crowd of people at the church service and said he had never seen so many people attending
church before, adding, “Sorry, Reverend.”
After about four sessions, Mr. W said he that felt better and no longer saw the need for
further sessions. He was sleeping better and had stopped drinking excessively. The therapist
suggested that he might want to continue to talk more about his guilt and his life as he went
forward without his wife. The therapist was reassuring that there seemed to be nothing else
Mr. W could have done to save his wife. He also encouraged the patient to begin dating when
he felt ready, something that Mr. W’s in-laws were clearly not encouraging. For now, however,
Mr. W was not interested in any further therapy. He was appreciative of the therapist and felt
that talking about his wife’s death had been helpful. The therapist accepted his wish to
discontinue their sessions but encouraged Mr. W to keep in touch to let him know how he was
doing.

Recent Developments/Variants on Psychoanalytically Oriented Psychotherapy

With the widened spectrum of more severely ill patients, therapists have
decreased the frequency of sessions to influence the nature of the
transference and control excessive regression and dependency. Otto
Kernberg and his colleagues have devised an analytically oriented
treatment for borderline and narcissistic patients who manifest severe
breakdown in their intimate, social, and work relationships and who have a
lack of a coherent self (i.e., identity diffusion). Their model, transference-
focused psychotherapy, is based on a psychoanalytic object relations
theory, originally derived from the work of British analyst Wilfred Bion, as
well as from their work done years before at the Menninger Foundation. In
transference-focused therapy, patients are seen sitting up at a frequency of
two-to-three times a week for many years and encouraged to free-associate.
The major techniques are interpretation, an emphasis on the transference
as it relates to the patient’s current problems in external reality, and
therapist neutrality. The therapeutic focus is on the here-and-now, rather
than an interpretation of the past. Though it is a manualized technique,
Kernberg emphasizes it cannot be learned from a book. He recommends
ongoing supervision, even for senior clinicians, for these particularly
challenging patients, who can treat their therapists with disdain, disregard,
and distrust. Some of these patients are even “serial killers,” as it were, of
therapists, in that they blame the therapist for their difficulties and fire one
therapist after another, with an “unconscious sense of triumph at having
killed off another therapist.” Limit setting and involvement of the family
become crucial when working with these patients as well.
Kernberg has found his approach works better than supportive therapy
for patients with severe character pathology such as borderline personality
disorders for several reasons: ignoring these patients’ impulses only
increases their fear of their impulses and encourages acting out, failing to
analyze their severe negative transferences and paranoid dispositions has
disruptive effects on the therapeutic relationship and pre-empts any efforts
to provide a stable, reliable, and empathic atmosphere, and gratifying their
transference needs significantly distorts those patients’ perception of the
therapeutic situation (i.e., they identify with an overly idealized version of
their analyst that they feel they are not capable of living up to). Kernberg’s
approach is controversial and many therapists still do advocate a
supportive approach for those patients.
Fonagy and colleagues have devised a form of psychodynamically-