Doing Supportive Psychotherapy 2020 PDF

“A
concise, readable, and very experience-near guide to

supportive psychotherapy. Full of clinical examples
DOING SUPPORTIVE PSYCHOTHERAPY

and discussion questions, this book could be used by
trainees in any mental health field.”
Deborah L. Cabaniss, M.D., Associate Director, Residency

Training, Professor of Clinical Psychiatry, Columbia University,
Department of Psychiatry
“T
his book is an essential tool for any learners and profes-
sionals looking to forge meaningful, impactful therapeu-
tic relationships with their patients—even for clinicians
not intending to ‘do psychotherapy.’ Through engaging case ex-
amples, this book will teach the reader how to make relatively
quick sense of the complex life histories that our patients bring
to us, and how to truly allow patients to feel heard using spe-
cific techniques. The high-yield, practical pearls that Dr. Batta-
glia provides promise to form the basis for effective interactions
with your patients on a daily basis. In a nutshell, this book will
optimize the likelihood that your patients would answer ‘yes’ to
DOING
the question ‘Does your provider understand you?’ If you have
time for one quick, enjoyable read in the next month that will
immediately benefit your patients, it should be this.”
Claudia L. Reardon, M.D., Associate Professor, University

Health Services, University of Wisconsin School of Medicine and SUPPORTIVE
PSYCHOTHERAPY
Public Health, Department of Psychiatry
ABOUT THE AUTHOR

John Battaglia, M.D., is Clinical Adjunct Associate
Professor of Psychiatry at the University of Wisconsin
School of Medicine and Public Health, and Medical Direc-
tor of the Program of Assertive Community Treatment in
Madison, Wisconsin.
Battaglia
John Battaglia, M.D.
Cover design: Tammy J. Cordova

Cover image: © lolloj
Used under license from Shutterstock
DOING
SUPPORTIVE
PSYCHOTHERAPY
DOING
SUPPORTIVE
PSYCHOTHERAPY

Clinical Adjunct Associate Professor of Psychiatry,
University of Wisconsin School of Medicine and Public Health
Medical Director, Program of Assertive Community Treatment
Madison, Wisconsin
Note: The authors have worked to ensure that all information in this book is accu
rate at the time of publication and consistent with general psychiatric and medical
standards, and that information concerning drug dosages, schedules, and routes of
administration is accurate at the time of publication and consistent with standards
set by the U.S. Food and Drug Administration and the general medical community.
As medical research and practice continue to advance, however, therapeutic stan
dards may change. Moreover, specific situations may require a specific therapeutic
response not included in this book. For these reasons and because human and me
chanical errors sometimes occur, we recommend that readers follow the advice of phy
sicians directly involved in their care or the care of a member of their family.
Books published by American Psychiatric Association Publishing represent the
findings, conclusions, and views of the individual authors and do not necessarily
represent the policies and opinions of American Psychiatric Association Publishing
or the American Psychiatric Association.
If you wish to buy 50 or more copies of the same title, please go to www.appi.org/spe
cialdiscounts for more information.
Copyright © 2020 American Psychiatric Association Publishing
ALL RIGHTS RESERVED
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Library of Congress Cataloging-in-Publication Data
Names: Battaglia, John, M.D., author. | American Psychiatric Association
Publishing, issuing body.
Title: Doing supportive psychotherapy / by John Battaglia.
Description: First edition. | Washington, D.C. : American Psychiatric Association
Publishing, [2020] | Includes bibliographical references and index. |
Identifiers: LCCN 2019016962 (print) | LCCN 2019018260 (ebook) | ISBN
9781615372683 (ebook) | ISBN 9781615372621 (pbk. : alk. paper)
Subjects: | MESH: Psychotherapy—methods | Professional-Patient Relations
Classification: LCC RC480.5 (ebook) | LCC RC480.5 (print) | NLM WM 420 |
DDC 616.89/14—dc23
LC record available at https://lccn.loc.gov/2019016962
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
To Mary Kay, truly supportive, strong and beautiful, my Texas flower
Contents
Preface: Why This Book? . . . . . . . . . . . . . . . . . . ix
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . xiii
1 A Brief History and Evolution of
Supportive Psychotherapy . . . . . . . . . . . . . . . . . . 1
2 Psychodynamics and
the Therapeutic Alliance . . . . . . . . . . . . . . . . . . .13
3 Getting Started and
the Behavior of the Therapist. . . . . . . . . . . . . . 27
4 Transference and Countertransference. . . . . . 47
5 Strategies and Techniques . . . . . . . . . . . . . . . . 69
6 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91
7 Special Populations: Borderline Personality
Disorder, Substance Use Disorders, and

Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . 105
8 Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . .123
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133
Preface
Why This Book?
Over my 30 years of teaching psychotherapy,

I’ve been perplexed by a conundrum. Doing psychotherapy is one of the
most intimate and exciting things a mental health professional can do, yet
so many textbooks on psychotherapy don’t capture this immediacy. This in
cludes books that have accompanying videos with actors playing the roles
of patient and therapist. Such portrayals are even less engaging, because
somehow the actors demonstrating the process cannot draw the observer into
the intimacy or passion of the process, and it can end up looking like a bad
movie. During my psychotherapy training, I had the unique opportunity to
watch serial videos of a psychiatrist during actual psychotherapy with a pa
tient (not actors). The psychiatrist was a wise, nice, experienced therapist,
yet even under these circumstances, watching the psychotherapy was stale.
Even though it was “real” psychotherapy, the process seemed staged, maybe
because the patient knew his therapy would be viewed by psychiatric resi
dents. In similar regard, sometimes when I read the dialogue between patient
and therapist in psychotherapy textbooks, I think, Does anyone really talk
like that? because the conversation seems too formal or stilted. Bottom line:
most psychotherapy textbooks seem contrived, and I’m a person who loves
doing and teaching psychotherapy.
Doing psychotherapy is one of the most intimate professional activities
on earth. I decided that my textbook on doing psychotherapy would mirror,
as much as possible, this intimacy. I would share my experiences, failures,
and ideas along with the standard fare of the evidence-based psychotherapy
literature to provide a personal journey for the mental health professional
reading this text. In a parallel process way, I want the reader of this text to
feel what it’s like to do psychotherapy while learning it. I wanted this text
book to be supportive of the reader. Sometimes students of psychotherapy get
ix
x Doing Supportive Psychotherapy
the impression that older, wiser, experienced therapists don’t stumble, don’t
feel lost, don’t feel inadequate, or don’t get burned out while doing psycho
therapy. I wouldn’t trust a psychotherapist who didn’t experience these things
at times. I want the reader of this book to feel that they’re not alone as they
venture into the overwhelmingly complex, perplexing, and yet totally won
derful endeavor of the “talking cure.”
In my academic career, I’ve also noticed a shift in both the attention span
and the willingness to invest time in learning psychotherapy among psychi
atric residents. Sadly, many psychiatric residents do not read the assignments
for their seminars, or they read them only in abbreviated fashion. With
such a growing emphasis on neuroscience, I hear repeatedly that there “just
isn’t time” to sink into a textbook on psychotherapy. This isn’t just a training
phenomenon among psychiatry residents; it’s part of the larger culture as
well. With such a focus on production, there seems to be a shortage of time
spent to understand. I decided that if I wrote a textbook on psychotherapy,
I would make it relatively short and sweet, to reach people in an economical
manner. My goal would be to create a work that would teach essentials and
include “just enough” to get clinicians started in supportive psychotherapy.
I see this book as a “primer”—that is, a solid first step for clinicians of any
type (e.g., peer counselors, social workers, family counselors, psychologists,
psychiatrists) toward becoming a psychotherapist. For psychiatrists who do
not intend to do psychotherapy, I believe this book remains an essential tool
for learning how to understand patients as well as for learning strategies and
techniques for keeping a good therapeutic alliance (which inevitably trans
lates into good medication compliance).
Teaching supportive psychotherapy for all these years, I’ve had my own
evolution in thinking about what a textbook should bring to those learn
ing it. In the beginning, I absolutely adored The Practice of Supportive Psy
chotherapy by David Werman and used this landmark text with success for
psychiatric residents and other mental health professionals.1 Over time,
however, the book became dated, because it’s based from a psychoanalytic
perspective, and psychiatric residents began to eschew psychoanalytic prin
ciples. The field of supportive psychotherapy also grew, and newer text
books in supportive psychotherapy that reflected the greater scope and
techniques had evolved. I’ve pretty much used them all in teaching support
ive psychotherapy and find them lacking. Mostly they lack intimacy or
practicality. They also don’t do enough to coordinate the “why” people think
and behave as they do with the supportive therapy techniques indicated for
addressing this “why.” Cognitive-behavioral techniques have become the
gold standard for therapy with many mental health disciplines, psychiatry
Preface xi
notwithstanding. I find that patients and therapists alike, however, struggle

with things that aren’t directly addressed with cognitive-behavioral tech
niques. Motivation, purpose, meaning, and unconscious processes play a
major role in what people struggle with in their lives, and these things are
addressed directly in supportive psychotherapy in ways that are more direct
and gratifying. Understanding the “why” remains an essential element for
those seeking to become a psychotherapist. In my point of view, a therapist
needs to have a relatively decent answer to the question: “Why is the patient
having these symptoms at this time?” in order to provide good therapy, re
gardless of his or her theoretical orientation. I am hoping this textbook of
supportive psychotherapy does just that—provides one framework for un
derstanding “why” people suffer from what they do, in conjunction with the
supportive therapy techniques. This book is about doing psychodynamic sup
portive psychotherapy. I believe the approach in this book is universal and
can complement other forms of psychotherapy, such as cognitive-behavioral
and interpersonal psychotherapy. For psychiatrists seeing patients for med
ication management, the knowledge and techniques learned will improve
the therapeutic alliance with their patients, and this will translate into en
hanced medication compliance.
This is a textbook aimed for students in mental health disciplines, and
I purposefully use a conversational style of writing as well as intermittently
indulge in first-person commentary. I want the reader to get to know me,
to mirror somewhat the sharing of intimacy that’s required to do good psy
chotherapy. Every example used in this book is drawn from cases I’ve either
worked with myself or supervised. Of course, I’ve camouflaged important
details so that no patient or trainee can be identified. I’ve tried to keep di
alogue “real,” even if it sometimes appears awkward or goofy; but hey, that’s
how people talk.
I hope the readers of this book will experience a journey that not only
allows them to gain some knowledge but also helps them feel secure enough
in psychotherapy to let their creativity shine. The goal is not to be like any
other therapist, but rather to “be yourself”—and from the unique perspec
tive that only you have—to let the good things flow.
Reference
1. Werman DA: The Practice of Supportive Psychotherapy. London, Psychology
Press, 1984
Acknowledgments
I’ve been blessed with many who have shaped

my life in so many important ways; it’s hard to narrow down the “thanks.”
For these acknowledgments, I focus on those who had a direct impact on
my professional career. For my high school swim team coach, Bill Brash
witz, who urged me to go to college when I was adrift and had no direction
in my life: I had completed high school and had no plans, and was working
part time as a telemarketer and sometimes sleeping in my Volkswagen
Microbus. I went to visit Coach Bill at the high school, and he said, “Hey
Johnny, you’re a smart kid, why don’t you go to college?” From his little
closet of an office at the high school pool, he made a call to Admissions at
Cleveland State University and had me go straight there to enroll. I have
absolutely no idea where my life would have taken me if not for Coach Bill.
I love you always, Coach Bill (R.I.P.). For Dr. Karem Monsour, who was
my first psychiatrist and a perfect example of a supportive, caring, and inti
mate professional: He treated me when I was a student at Pomona College
and was a wonderful role model for what I would aspire to be someday. I love
you always Dr. Monsour (R.I.P.); I’m so grateful you were there for me. For
Dr. Carol Stark, who was my supervisor when I was undergoing psychiatry
residency training at the Baylor College of Medicine: Your support, creativ
ity, and encouragement were instrumental in helping me become a com
plete psychiatrist. You were also picture perfect in showing me what really
excellent psychotherapy supervision is. For Dr. Betsy Comstock, who took
me on as a patient for psychotherapy and psychoanalysis during my psychi
atry residency training: You were kind, generous and insightful and the per
fect person to guide me into the labyrinth of my unconscious mind. Your
attendance at my wedding remains a high point for me in one of the most
important events of my life. For Dr. Joseph Colletti, psychotherapist, for all
your guidance in helping me understand the effects of trauma on my life, as
well as helping me to have empathy for myself: I have come so far under
your sensitive and insightful care.
xiii
xiv Doing Supportive Psychotherapy
For those directly involved in providing me with helpful feedback on

drafts of this book, I would like to thank the following: my daughter Mary
Autumn Battaglia, B.S. (Sociology and Human Services); Katrina Radi,
M.S.W., C.S.W.; Dr. Colleen Considine, a psychiatry resident at the Uni
versity of Wisconsin; Dr. Sara Lindeke, a psychiatry resident at the Medi
cal College of Wisconsin; Alicia Benedetto, Ph.D., a lifelong friend and
psychologist extraordinaire; and Dr. Douglas Puryear, psychiatrist, author,
mentor, and friend.
CHAPTER 1
A Brief History and
Evolution of Supportive
Psychotherapy
I’m going to tell you a story about a man

who changed the world, how it led to the science of psychotherapy and its
transformations over the past 100 years, and eventually what led to you read
ing this book. We meander a bit as I tell this tale, so relax and enjoy this
foray into the history that steered you toward becoming a psychotherapist.
Let’s start at the beginning, the very beginning (a very good place to
start). How long have humans benefited from talking to other humans? Were
the cave paintings done by early humans just an illustration of a story painted
on a wall, or were they also therapeutic in some way for the people who
drew them? The paintings were often depicting hunting activities, which
were likely dangerous events for the people involved in the hunt. Was
painting them on the wall a method of decompression or catharsis, of cop
ing with feelings? Moving on to written history, there are many examples
to illustrate the value of talking about one’s troubles. In ancient Greece, pol
iticians and military leaders traveled to the Oracle at Delphi to seek guidance
on important decisions. They were seeking prophecies from the priestess
Pythia, although often her answers were ambiguous and left ample room
for interpretation. Perhaps the “answers” were less important than the relief
felt from talking about one’s problems. It seems inherently sound to con
clude that talking about one’s feelings to another person has held benefit for
people throughout our history.
1
2 Doing Supportive Psychotherapy
Freud
But when did the science of talking therapy begin? To discuss the scientific
origins of talking as a cure for psychological illness, we must begin with the
master psychiatrist himself, Sigmund Freud. I understand that some readers
might be groaning right now to hear about Freud, because he has become
somewhat of a “politically incorrect” figure over time. His ideas about the
mind, however, remain as critical for understanding human behavior as
they were more than 100 years ago, and they formed the basis for the science
of psychotherapy. So sit back and put your feet up as I tell you a story about
Freud and one of his disciples named Franz Alexander, for just a little bit.
In the early 1900s, Freud developed the topographical and structural the
ories of the mind.1 In his topographical theory, Freud described conscious,
preconscious, and unconscious layers of the mind. In Freud’s view our con
scious mind, our awareness, composed just a small portion of our mental
existence. Beneath this was a larger layer of our preconscious—that is, our
memories, thoughts, and emotions that we have access to when our attention
is directed to them but otherwise are beneath the surface and out of our
awareness. If I were to ask, “Who was your fifth-grade teacher?” and you
now are thinking of your fifth-grade teacher, that information was precon
scious before I asked, became conscious when you thought of the teacher,
and resumes a preconscious position in the mind once you stop thinking
about him or her. Freud saw the unconscious as the deepest layer of the mind,
and the repository of our entire life experience of memories and emotions.
In Freud’s view, the unconscious is not directly accessible to our conscious
mind. In addition to occupying a large space in our mind, he also believed
the unconscious directs a majority of our attitudes, beliefs, emotions, and be
havior. The classic metaphor used to illustrate the topographical theory is
viewing the mind as an iceberg. The relatively small, top part of the iceberg
above the surface is our conscious mind, our awareness. This is connected
directly to a much larger area of the iceberg below the surface, the precon
scious layer (below awareness). The deepest layer of the iceberg, the part that
buoys the entire iceberg above it, is the unconscious. Everything literally
rests on top of this fundamental underpinning, the unconscious mind.
In his structural theory, behavior was seen as driven by our basic needs
for pleasure (the pleasure principle) and for survival. Our primitive drives were
seen as psychosexual (libidinal) in nature—that is, aimed primarily toward
the combination of physical and mental gratification. The sources of libid
inal drives varied according to our stages of development in life, beginning
in infancy. Libidinal and survival instinct drives were described as the id of
A Brief History and Evolution of Supportive Psychotherapy 3
our personality. Our rational, conscious mind was called our ego, and our
sense of morality and social consciousness were referred to as our superego.
Freud saw personality as being shaped by keeping a balance within these
structural components of the mind while undergoing childhood develop
ment. Each person has a unique history of balancing the instinctual drives
of childhood with the reality of their bio-social-cultural environment—in
other words, balancing what we want (instinctual drives) with what we get
(actual life, which always falls short and has lots of rough road). Freud rec
ognized childhood emotional trauma as being vitally important during de
velopment and in shaping the psychological symptoms of adulthood.
These theories of Freud were born into the highly chaste, uptight Victo
rian era of early 1900. They were shocking not only because they explicitly
expressed the libidinal nature of people (what, you mean infants and chil
dren seek pleasure?), but also because they posited that a large percentage
of human behavior is motivated from unconscious processes outside of
awareness. Crudely, the notion that we often don’t really know what is driving
our emotions or behavior was very startling. Once the eyes of the world were
opened to these ideas, there was no forgetting them. Now over 100 years
later, most psychological theories of human behavior uphold some portion
of these theories to be valid even to this day.
So how did these Freudian theories allow for the evolution of psychother
apy? Freud found that when people had conflicts between their libidinal
drives, their rational “ego,” and their conscience (superego), psychological
symptoms resulted. These symptoms inevitably were a result of childhood
experiences that were conflictual and had been buried in the unconscious.
Despite being buried, however, they continued to push their way into the
person’s adult life by producing psychological symptoms. Freud found that by
letting people talk freely about whatever came to mind (free association), they
eventually revealed the origins of their psychological conflicts in disguised
form. It was up to the therapist to interpret the unconscious underpinnings
of the person’s symptoms from what was revealed in free association. The
therapist was a neutral, blank slate onto which patients projected their ideas
and beliefs. It was important for the therapist to keep neutrality in order to
minimize their influence on the material patients were producing. Patients
would lie on a couch, and the therapist would sit behind them to decrease the
influence of the therapist (facial expression or other emotional feedback) on
the patients’ thought processes. Over time and multiple therapy sessions
(daily or near daily) during which the patients would free associate, the ther
apist would interpret how patients’ associations indicated feelings they were
not aware of. The patients would see the links between their unconscious per
ceptions and their psychological functioning. In addition to this process of

free associative thinking, patients would also begin to “project” their uncon
scious perceptions onto the therapist. For example, if they grew up with a
harsh, unloving father, they would begin to experience the therapist in a sim
ilar light—as harsh and uncaring. These feelings about the therapist based on
their formative, childhood relationships were called transference and were also
a subject for interpretation. This process of interpreting free associations and
the transference allowed patients to have insight into how their personality
was shaped by their upbringing. Over time and with repeated interpretation,
patients gained greater psychological awareness of themselves, and this al
lowed improvement in their symptoms. This method of therapy was labeled
psychoanalysis, and the science of psychotherapy was born.
The “talking cure” of psychoanalysis took the world by storm and was
quickly embraced by all industrialized nations. It would remain the pre
dominant form of psychotherapy for more than half a century. Despite the
powerful theoretical fitness and popularity of psychoanalysis, over time it be
came apparent psychoanalysis was most beneficial for patients with neuroses,
or relatively minor struggles with anxiety or depression. In fact, in order for
a person to benefit from psychoanalysis, he or she had to have pretty good
psychological functioning to begin with. Patients experiencing more signif
icant symptoms or impairment from psychological distress were unable to
tolerate psychoanalysis. Often, these patients were provided a therapy by de
fault that was described as more supportive but had no clear outline of theory
or technique. The majority of the psychoanalytic community believed strict
adherence to the classic psychoanalytic technique was essential and strongly
frowned upon departures into the more supportive therapy measures.
Franz Alexander
Franz Alexander was a disciple of Freud, and although he was trained in
classical psychoanalytic technique, he began to evolve his own ideas about
what allowed the curative process to occur in therapy.2 He noted that in
classical psychoanalysis, the essential requirement for change was the in
sight the patient gained from interpretation of the transference neurosis. He
began to look at other factors that might be contributing to improvement,
factors not related to insight but rather to the relationship of the patient with
the psychoanalyst. Alexander realized that people had transformative, life-
changing experiences from relationships in many life circumstances outside
of psychoanalysis. He questioned the degree to which the insight discovered
within psychoanalysis was essential for change. He began to see the impor
tance of the therapeutic relationship (between patient and psychoanalyst) as

having curative power in and of itself. Alexander agreed with Freud that
during psychoanalysis the patient underwent transference based on earlier
life experience and emotional traumas. While Freud believed that the insight
the patient gained from this was essential for healing to occur, Alexander
felt the process of the patient feeling nurtured or comforted while reliving
emotional traumas was also a curative force. For example, if the patient had
harsh and cruel experiences with their parents and carried these expectations
into their adult relationships, similar feelings would arise in the psychoanal
ysis. According to Alexander, when the psychoanalyst would help the patient
through these difficult feelings in the therapy, the patient would experience
a different emotional response than was expected (based on transference).
The therapist’s response of acceptance, comfort, or caring would be different
than the conscious and unconscious expectations and allow emotional heal
ing to occur. Alexander called this the corrective emotional experience.
One notion of how psychotherapy works is the idea that all therapies
expose patients to their symptoms (in therapy) and that the therapeutic
process provides a different emotional or cognitive outcome. Aligning with
this notion, the concept of the corrective emotional experience can be
broadened to include the idea that all of the conscious and unconscious pro
cesses that occur during the therapy are doing so under the umbrella of the
therapeutic relationship. Patients derive benefit from telling their story, from
emotional catharsis, from insight about their life patterns, and from chang
ing their cognitive perspective, all within the experience of the therapeutic
relationship. While this is occurring on the overt level in the therapy room,
covert interpersonal processes are operating simultaneously. These uncon
scious relationship patterns are based on patients’ unique childhood develop
ment, their exposure to emotionally traumatic events, and their projection of
expectations onto the therapist. When the sum total of these conscious and
unconscious processes occurs with a comforting, nurturing, and accepting
psychotherapist, the experience is different than what has occurred outside
of the therapy and becomes a corrective emotional experience.
Alexander also promoted more engaging and comforting behavior from
the therapist in distinction from the usual “neutral” stance in psychoanaly
sis. He believed the flexibility of the therapist was critically important to ac
commodate to the patient, especially for people experiencing more severe
forms of mental illness. Alexander wrote:
In addition to the original decision as to the particular sort of strategy to be

employed in the treatment of any case, we recommend the conscious use of
various techniques in a flexible manner, shifting tactics to fit the particular

needs of the moment. Among these modifications of the standard technique
are: using not only the method of free association but interviews of a more
direct character, manipulating the frequency of the interviews, giving direc
tives to the patient concerning his daily life, employing interruptions of long
or short duration in preparation for ending the treatment, regulating the
transference relationship to meet the specific needs of the case, and making
use of real-life experiences as an integral part of the therapy.2, p.6
These modifications proposed by Alexander were a dramatic shift from

the operating principles of psychoanalysis. They included being directive
with patients in guiding them to discussing their symptoms and “real life”
events in a direct fashion, and most importantly, modulating the emotional
tone of the transference to allow patients to tolerate the therapy. These
changes were particularly effective in allowing therapy to work for people
with more severe forms of psychological illness. Alexander also stressed that
these modifications allowed therapy to be more economical in nature and
much more practical for most people needing help (fewer sessions and less
expensive). These important changes of psychoanalysis developed by Alex
ander were the beginning of what we now define as supportive psychotherapy.
Further Developments
Over the next several decades, supportive psychotherapy became recognized
as the default treatment for patients with more severe psychological symp
toms or those who couldn’t withstand the rigors of psychoanalysis. It was,
however, considered the neglected stepchild of psychotherapy because it
had no theoretical base and no set of operating principles and was used only
when one couldn’t do the preferred psychoanalytic therapy for the reasons
just listed. Saying it crudely, supportive psychotherapy was defined as every
thing that psychoanalytic therapy was not. For example, in psychoanalytic
therapy the therapist was opaque and kept a “neutral stance,” whereas in
supportive therapy the therapist was more transparent and could be more
conversational in style. In psychoanalytic therapy the therapist fostered de
velopment of regression and transference, and the aim was interpretation of
the unconscious underpinnings of these phenomena. Insight was the goal.
Contrary to this, in supportive psychotherapy the focus was on keeping a
positive therapeutic relationship and helping patients reduce the symptoms
associated with the “here and now” issues in their lives. Relief from symptoms
was the goal. Even though supportive psychotherapy was considered second
best, by necessity it became the treatment of choice for many people requiring
therapeutic help with their lives.3
As supportive types of psychotherapy began to take hold, there was a

backlash about the effectiveness or validity of nonpsychoanalytic techniques.
With psychoanalysis, the theory was that once a person improved through
gaining insight, he or she underwent a permanent structural change of per
sonality. The change was seen as curative. By contrast, changes brought
about through more supportive types of psychotherapy were seen by critics
as behavioral, meaning more transient and specific to the symptoms and not
indicative of permanent personality change. In fact, many psychoanalysts
believed supportive-type therapy was not psychotherapy at all, leading to
descriptions such as the following:
Considered a simple-minded endeavor that one can practice without train

ing, it seldom evokes theoretical conceptualization, and the neophyte psy
chiatrist is usually left to develop his own techniques intuitively.4, p.763
If it is supportive, it cannot be psychotherapy; if it is psychotherapy, it can

not be supportive.5, p.269
By necessity, psychoanalysis itself had undergone some transformation

to become more practical and to reach more people. Psychoanalytic psycho
therapy evolved as a more abbreviated form of psychoanalysis using similar
theoretical principles and techniques; however, it involved the patient sit
ting upright and facing the therapist (not on a couch) and was conducted
with reduced frequency of sessions (usually once weekly instead of near
daily). In an extensive longitudinal study developed in the 1950s, the Men
ninger Psychotherapy Research Project compared patients receiving psy
choanalysis, psychoanalytic psychotherapy, and supportive psychotherapy
over a 23-year span.6 The Menninger Institute was a center for psych
oanalytic excellence, and the main objective of the study was to critically
examine the difference between psychoanalysis and psychoanalytic psycho
therapy. The supportive psychotherapy arm of the study was placed more
as a control condition than as a rigorous technique for comparison. The study
results were quite unexpected: There were no significant differences among
the three different types of psychotherapy! This was especially remarkable
because the patients receiving supportive psychotherapy did just as well as
those receiving the other treatments (each therapy group showed improve
ment). The researchers found that psychoanalysis and psychoanalytic psy
chotherapy had more supportive elements than was usually intended and
believed these elements accounted for many of the observed changes (instead
of insight). They also concluded that change did not occur in proportion to
resolving unconscious conflict and that thinking of change as “structural”
versus “behavioral” was not a useful concept. Chalk one up—and a rather big
one up at that—for supportive psychotherapy!
There have been many other studies that validate the efficacy of support
ive psychotherapy. What is both fascinating and surprising about many of
these studies is that supportive psychotherapy often performs just as well as
the treatment under study even though it is used as a control condition. In one
1978 study looking at treatment of agoraphobia, mixed phobias, or simple
phobias, patients were randomly assigned to one of three treatment condi
tions: behavior therapy alone, behavior therapy plus imipramine (medication)
treatment, or supportive therapy plus imipramine (medication) treatment.7
Therapists in the behavior therapy groups used a manualized, highly struc
tured treatment protocol that included relaxation training and systematic
desensitization in imagination, specific in vivo desensitization homework
assignments, and assertiveness training (including modeling, role playing,
behavior rehearsal, and in vivo homework assignments). The supportive
therapy was nondirective; patients took the initiative in all discussions. The
therapists doing supportive therapy were instructed to be empathic and non-
judgmental and to encourage patients to ventilate feelings and discuss prob
lems, anxieties, and interpersonal relationships. All of the therapists in the
study had extensive training and experience in both behavior and support
ive therapy. The expectation of the researchers was that behavior therapy
would be superior to supportive therapy because it focused systemically on
phobic situations and was more structured to help patients confront those
situations directly. The researchers were stunned to find that there were no
significant differences between the therapy conditions and that patients did
well in both. They acknowledged that the results did not fit with leading ex
perts in the area of behavior therapy. They pointed out, “It was not that pa
tients did poorly with behavior therapy, rather, they did unexpectedly well
with supportive psychotherapy.”8, p.141 Chalk another one up for supportive
psychotherapy!
In a 2005 randomized controlled study looking at cognitive-behavioral
therapy versus interpersonal therapy for anorexia nervosa, once again sup
portive psychotherapy was used as a control condition.9 In the cognitive-
behavioral therapy arm of the study, the patients underwent several phases
of treatment, including psychoeducation, motivational assessment, cogni
tive-behavioral skills (including thought restructuring and homework as
signments), relapse prevention, and recovery strategies. In the interpersonal
psychotherapy arm, the patient’s life events, interpersonal relationships,
and eating problems were assessed, and links between them were high
lighted. Problem areas were identified in domains of grief, interpersonal
disputes, role transitions, and interpersonal deficits. The patient’s identi

fied problems were addressed by examining links between depressive symp
toms and interpersonal issues. Nonspecific supportive clinical practice was
added at the third arm to mimic outpatient treatment as usual in the commu
nity (control condition). In the nonspecific supportive clinical practice arm,
the patients underwent education, care, and support of their eating dis
order. The supportive therapy elements included praise, reassurance, and
advice. The study therapists were experienced in treating eating disorders
and used manual-based sessions conducted over a period of 20 weeks. The
researchers fully expected that the two specialized psychotherapies would be
superior to nonspecific supportive clinical management. Once again, the
outcome was stunning to the research team: Nonspecific supportive clinical
management was superior to the other conditions. “Contrary to our hypoth
eses,” the study authors reported, “the patients who received nonspecific
supportive clinical management had an outcome as good or better than the
outcomes of those who received specialized psychotherapies.”9, p.745 They
also noted, “A key feature of nonspecific supportive clinical management
may be the important nonspecific factors of psychotherapy: the therapeutic
alliance, empathy, positive regard, and support for a patient group greatly
in need of these.”9, p.746
This study showed that although supportive psychotherapy is often con
sidered the neglected stepchild of psychotherapy, at times it has the potential
to become the Cinderella princess. To be fair, there are studies that show sup
portive psychotherapy to be less effective than other modalities of treatment;
however, many of these studies had supportive psychotherapy as the control
group or “treatment as usual in the community.” This places a strong bias
toward the “active comparator,” which is often the treatment modality en
dorsed by the researchers. The fact that supportive psychotherapy usually
shows therapeutic benefit in the majority of studies, and sometimes shows
equality or superiority, demonstrates the power of the technique.
Over time and with ample studies to demonstrate efficacy, supportive
psychotherapy gained momentum among professionals as a practical and
efficacious method of therapy. More articles began appearing to outline the
target populations, therapeutic goals, and techniques of supportive psycho
therapy.10 Although lacking a unifying theoretical base, the techniques em
ployed in supportive psychotherapy became recognized as important tools
for a number of different therapy modalities. The supportive stance, nurtur
ance of a positive transference, empathic posture, and strengthening of cop
ing mechanisms in supportive psychotherapy became viewed as essential
components for successful therapy even among other types of psychotherapy.11
Supportive psychotherapy has become the subject of research on therapy in

and of itself (not just as a control condition), has a large evidence base, and
has been described by some as the “treatment model of choice” for a variety
of conditions.12,13 The footprint of supportive psychotherapy has now been
firmly set in stone. Within the discipline of psychotherapeutic treatment, sup
portive psychotherapy is a valid, efficacious, and sometimes preferred method
of treatment.
Supportive psychotherapy has been shown to be effective in a variety of
psychiatric and medical conditions, including schizophrenia, bipolar disorder,
depression, anxiety disorders, personality disorders, substance use disor
ders, eating disorders, perinatal stress, breast cancer, ovarian cancer, diabe
tes, leukemia, heart disease, chronic bronchitis, emphysema, inflammatory
bowel disease, back pain, and for hemodialysis patients.14–18 Supportive psy
chotherapy techniques have been adapted for medical specialties outside of
psychiatry, including for nurses and family practitioners.19,20 The wonder
ful, groundbreaking textbook on supportive psychotherapy by David Werman
in 1984 ushered in a new age in which supportive psychotherapy was con
sidered not only a bona fide treatment but also an essential therapeutic tech
nique to be taught in psychotherapy training programs.21 Since then, other
supportive psychotherapy textbooks have followed, and now supportive
psychotherapy skills are listed as a core requirement for residency training
in psychiatry in the United States.22
Discussion Questions
1. What percentage of behavior do you think stems from unconscious
drives?
2. Why does supportive psychotherapy perform so well in clinical trials,
even when it is just a control condition?
References
1. Brenner C: An Elementary Textbook of Psychoanalysis (Revised). Garden
City, NY, Anchor Books, 1974
2. Alexander F, French TM: Psychoanalytic Theory: Principles and Applica

tions. New York, Ronald Press, 1946
3. Wallerstein RS: Psychoanalysis and psychotherapy: an historical perspective.

Int J Psychoanal 70(Pt 4):563–591, 1989
4. Sullivan PR: Learning theories and supportive psychotherapy. Am J Psychia
try 128(6):763–766, 1971
5. Crown S: Supportive psychotherapy: a contradiction in terms? Br J Psychiatry

152:266–269, 1988
6. Wallerstein RS: The psychotherapy research project of the Menninger Foun
dation: an overview. J Counsel Clin Psychol 57(2):195–205, 1989
7. Zitrin CM, Klein DF, Woerner MG: Behavior therapy, supportive psycho
therapy, imipramine, and phobias. Arch Gen Psychiatry 35(3):307–316, 1978
8. Klein DF, Zitrin CM, Woerner MG, et al: Treatment of phobias, II: behavior
therapy and supportive psychotherapy. Are there any specific ingredients?
Arch Gen Psychiatry 40:139–145, 1983
9. McIntosh VW, Jordan J, Carter FA, et al: Three psychotherapies for anorexia
nervosa: a randomized, controlled trial. Am J Psychiatry 162(4):741–747,
2005
10. Werman DS: Technical aspects of supportive psychotherapy. Psychiatric Jour
nal of the University of Ottawa 6(3):153–160, 1981
11. Barber JP, Stratt R, Halperin G, et al: Supportive techniques: are they found
in different therapies? J Psychother Pract Res 10(3):165–172, 2001
12. Hellerstein DJ, Pinsker H, Rosenthal RN, et al: Supportive therapy as the
treatment model of choice. J Psychother Pract Res 3(4):300–306, 1994
13. Douglas CJ: Developing supportive psychotherapy as evidence-based treat
ment (letter). Am J Psychiatry 165(10):1355–1356, 2008
14. Rockland LH: A review of supportive psychotherapy, 1986–1992. Hosp
Community Psychiatry 44(11):1053–1060, 1993
15. Kleinman K, Wenzel A: Principles of supportive psychotherapy for perinatal
distress. J Obstet Gynecol Neonat Nurs 46(6):895–903, 2017
16. Manne SL, Rubin S, Edelson M, et al: Coping and communication-enhancing
intervention versus supportive counseling for women diagnosed with gyneco
logical cancers. J Consult Clin Psychol 75(4):615–628, 2007
17. Szigethy E, Bujoreanu SI, Youk AO, et al: Randomized efficacy trial of two
psychotherapies for depression in youth with inflammatory bowel disease.
J Am Acad Child Adolesc Psychiatry 53(7):726–735, 2014
18. Conte HR, Plutchik R: Controlled research in supportive psychotherapy. Psy
chiatr Ann 16(9):530–533, 1986
19. Williamson PS: Psychotherapy by family physicians. Prim Care 14(4):803–
816, 1987
20. Battaglia J: 5 keys to good results with supportive psychotherapy. Curr Psychi
atry 6(6):27–34, 2007
21. Werman DS: The Practice of Supportive Psychotherapy. London, Psychology
Press, 1984
22. Accreditation Council for Graduate Medical Education: ACGME Program
Requirements for Graduate Medical Education in Psychiatry. Chicago, IL,
Accreditation Council for Graduate Medical Education, 2017
CHAPTER 2
Psychodynamics and
the Therapeutic Alliance
To do good supportive psychotherapy,

the therapist must have a psychodynamic understanding of the patient. To un
derstand psychodynamics properly, we begin with a discussion of some Freud
ian concepts.
Freud was an avid scientist, historian, anthropologist, and philosopher,
and his theories often reflected an amalgamation of ideas from different
disciplines. He was inspired by the physics theory of thermodynamics when
he developed his principles of psychodynamics in human functioning. Much
as in physics, Freud envisioned psychodynamics as a conservation of psy
chological energy that occurred in the mind so that different parts of the
human psyche (the id, ego, and superego) worked toward maintaining a
balance. Psychodynamics is the study of how unconscious and conscious
forces interact dynamically to keep a state of equilibrium in human thought,
emotions, and behavior. In psychodynamic theory, when any one force be
comes out of balance, psychological symptoms result.
To complete our discussion of psychodynamics, we need to review the
concept of defense mechanisms. Freud described defense mechanisms as pro
cesses of the mind employed to keep unwanted unconscious emotions from
reaching our awareness. They are ways we protect ourselves from pain. De
fense mechanisms work through repression, as opposed to suppression, which
is the conscious and willful pushing of something unpleasant out of our
awareness (“I don’t want to think about it”). Repression occurs when un
wanted unconscious material threatens to surface in our conscious thoughts
(our ego). For example, if we experience a traumatic event that causes pain
whenever we think about it, we might employ repression to keep the mem
13
ory of it from reaching our conscious awareness. Defense mechanisms are

driven by the unconscious and occur automatically, we do not “choose” to
utilize them. They allow us to function and keep coping with the emotional
pain of our life experience. There are a host of defense mechanisms that
range from the more primitive to the more mature (Table 2–1). Primitive
defenses include denial (the feeling isn’t even acknowledged), splitting (see
ing things as all good or all bad), projection (denial of one’s own uncomfort
able feelings by seeing them in others), regression (reverting to more childish
ways of acting), acting out (acting on the difficult emotion in a physical
way), and dissociation (escaping from a painful reality in the present by be
coming out of touch). In the middle of the spectrum are the defenses reac
tion formation (feeling the opposite emotion, e.g., having loving feelings
toward a person one really hates), introjection (adopting feelings of others
as one’s own), conversion (when the uncomfortable feelings become physical
symptoms), displacement (displacing the disturbing feeling, e.g., getting an
gry at a coworker when one is really angry with the boss), and idealization
(putting someone “on a pedestal” to cope with negative feelings toward
them). Higher-order or more “mature” defenses include intellectualization
(thinking about something intellectually instead of feeling the emotion),
rationalization (making sense of a feeling to cope with it), sublimation
(using a coping activity to handle emotions), fantasy (escaping into fantasy
thinking to avoid uncomfortable thoughts), and humor.
There is an especially important and strange defense mechanism that
plays a significant role in our relationships that Freud termed the repetition
compulsion. Basically, people tend to repeat emotional experiences, even if
they are painful. For example, if a child is rejected again and again by her
parents, the pattern of seeking love despite frequent rejections would tend
to be repeated in her adult life. The unconscious need to repeat this emo
tional scenario is the repetition compulsion. We have all seen blatant exam
ples of this in relationships that seem very unhealthy for a person (especially
with an abusive relationship), and yet the person tends to repeat the pattern
in a new relationship when she finally gets out of the old one. This is an
obvious example; however, the repetition compulsion is always occurring in
relationships in subtler, less easily detectable ways. For example, if a young
child feels intense rivalry growing up with a seemingly favored older sibling,
that child might feel unloved by his parents and develop intense feelings of
rejection. Later in his adult life the person might become unnecessarily
competitive with coworkers and overzealous with seeking approval from his
boss as a repetition compulsion from the childhood sibling rivalry. The rep
etition compulsion operates on a number of different levels in our relation
Psychodynamics and the Therapeutic Alliance 15
TABLE 2–1. Defense mechanisms
Defense mechanism Description
Denial Not acknowledging the feeling

Splitting Seeing things as all bad or all good
Projection Denial of one’s own feelings by seeing them in
others
Regression Reverting to more childish ways of reacting
Acting out Acting on the difficult emotion in a physical
way
Dissociation Escaping from painful emotion by becoming
out of touch
Reaction formation Feeling the emotion opposite to the one causing
distress
Introjection Adopting the feelings of another as one’s own
Conversion When uncomfortable feelings become physical
symptoms
Displacement Displacing the disturbing feelings onto
something/someone else
Idealization Putting someone on a pedestal when upset with
him or her
Intellectualization Avoiding the feelings by thinking intellectually
about something
Rationalization Making sense of a feeling to cope with it
Sublimation Using a coping activity to handle emotions
Fantasy Escaping into fantasy thoughts to avoid
uncomfortable feelings
Humor Using comedy to cope with feelings
ships, even with our choice of marriage partner. We might unconsciously seek
a partner who repeats emotional patterns of our childhood as a way of heal
ing our earliest relationship pain. Think of it as a way we keep trying to repair
fundamental early emotional traumas in our lives, a compulsion to “master”
the pain so to speak. Much like an animal with the instinct to “go to water”
when it has been physically injured, we are continuously trying to heal our
selves of emotional pain as we go through life. The repetition compulsion
isn’t a conscious process; it’s operating under the radar throughout our rela
tionships during our lives. It’s especially important to remember this concept
in association with the corrective emotional experience as we do supportive
psychotherapy.
It’s useful to think of defense mechanisms not as “good” or “bad” but,

rather, as ways we are continuously trying to avoid pain as we negotiate our
lives. Remember the pleasure principle? We go through life like most ani
mals, trying to seek pleasure and avoid pain. Pain is inescapable, and right
from the beginning we have painful experiences. So, we do what we must
to cope with this, sometimes repetitively, and over time we develop our own
unique and individual pathways for avoiding emotional pain and pursuing
happiness. Whether our painful experiences are relatively small or very trau
matic, we develop our pathways regardless. Over time, the pathways (our
personality) become very ingrained and automatic and continue to shape
our behavior unconsciously even if the path is highly illogical or unhealthy.
At one time the path may have served a vital, life-saving purpose. For ex
ample, when a child is being abused, it’s healthy for that child to dissociate
during the experience to avoid the intolerable pain of it. For an adult to disso
ciate repeatedly in situations that require awareness, however, becomes un
healthy and maladaptive. Part of what we do in supportive psychotherapy is
help people find a new path, by discarding patterns of behavior that are
maladaptive and forming healthier ones. The better we understand what
their path has been in life and how it relates to their current functioning, the
more effective we are in doing supportive psychotherapy.
For the purposes of supportive psychotherapy, we broaden the concept
of psychodynamics to include not just the Freudian concepts of id, ego, su
perego and unconscious/conscious processes, but also the myriad factors
that influence human behavior outside of this paradigm. We include genet
ics, biological, developmental, sociological, and cultural factors among
other forces (such as behavior learning theory and behavioral ecology) that
affect a person. There are other good models of psychodynamic understand
ing, including the ego psychology model of Heinz Kohut (behavior is
shaped by our psychological need for growth in our self-awareness)1 and
the existential model of Victor Frankl (behavior is driven by the need for
meaning in our lives).2 The common emphasis of psychodynamics remains
connecting present to past—that is, making sense of “now” based on where
the person “has been.”
If this sounds pretty overwhelming to pull all together into one psycho-
dynamic formulation, it’s because it should. When we look at any one be
havior, emotion, or thought of an individual, we must picture ourselves
attempting to examine the entire world by looking at just what sits in our own
perceptual field. Think of the immensity of the world as representing the
billions of processes of the mind, and then think about our puny little view.
In other words, we’re missing a whole lot about a person every time we fo
cus our attention on any one perception. There are a multitude of factors
influencing behavior at any one moment, and even with that tangible per
ception sitting “in front of us,” there lies a vast “underneath” (unconscious)
we must learn about to make sense of the person. It’s important to stay
humbled when attempting to understand people, to never quite feel like we
“totally nailed it” on how or why a person behaves the way he or she does.
This way we stay open to incorporating new data, including data that might
not fit into our prior psychodynamic understanding of a person. Our psy
chodynamic formulation must constantly grow based on new information.
The psychodynamic formulation of a case is a springboard—a starting point
and a flexible concept—and not a fixed formula. This complexity of gener
ating psychodynamic hypotheses while constantly changing them with new
data is part of what makes doing psychotherapy so exciting. What will the
next turn be in this person’s story, in our understanding of “why”? You must
be a historian and a detective to stay on your toes!
Perhaps the best way to understand psychodynamics is to define it as the
study of why people think, feel, and act the way they do now, based on who
they are, and what their past has been. We have ways to whittle down the
enormity of this task just enough for the practical purpose of doing psycho
therapy. First and foremost, we learn about their past: What is their his
tory? What was their childhood like? (I usually ask, “What was life like for
you growing up?”) How did they “fit” in the family? What were the emo
tional highs and lows of their upbringing? What relationships had impor
tance for them? What were their dreams and fantasies when growing up?
This list is not exhaustive but gives an idea of the type of information that
is critical to forming a psychodynamic formulation. Next is finding out
about who they are now and their current functioning: How is life going
now? What relationships are important now? Are there any patterns in their
relationships? How is their work? What symptoms do they have? What cul
ture/subculture do they identify with? What is their explanation for why they
behave and feel as they do? (In other words, get their psychodynamic formu
lation. Don’t worry, it’s not cheating to ask.) The way patients answer the
last question gives us much more information than just the answer; it gives
an indication of their level of psychological sophistication, awareness, and
ability to critically examine themselves. This becomes especially important
when we discuss pacing while doing supportive psychotherapy.
Once you’ve gathered enough of this type of information, you can begin
to piece together a psychodynamic formulation, bearing in mind it’s a start
ing point and not a final product. One way to build the psychodynamic for
mulation is to pretend you’re writing a short story about the patient. Can
you make the pieces of the patient’s story fit together so that his or her cur
rent behavior makes sense at this time? Let’s examine a case as an example
for developing a psychodynamic formulation.
Case Example
Alicia is a 27-year-old Alaska Native American woman, married, with two
small children. She is a high school graduate and enrolled in college full
time to study criminal justice. She has chronic pain (various places but mostly
pelvic) and mood swings. She has been kicked out of the mental health
clinic because of angry, demanding, intrusive behavior. She has filed a com
plaint against the mental health clinic for discharging her unfairly. She is also
awaiting surgery for her chronic pelvic pain; however, the gynecology clinic
has declined the surgery because of the patient’s labile and chronically argu
mentative behavior.
OK, let’s start. Other than the information given in black and white here,
what kind of things are you hypothesizing about Alicia as you read this first
little bit about her? What kind of things do you want to know? If you’re
starting to write your short story about Alicia, what information is critical
for you to get started? Even with just the limited information we have, we
can make some assumptions, realizing they’re preliminary and subject to
change with new information. As an Alaska Native American woman, she
has probably experienced some racial and gender discrimination. She is
hard working, raising two children and going to college to improve her po
sition in life. She has a fighting spirit, although we’re not sure why she has
become such a fighter. She has significant interpersonal issues, enough to
get her kicked out of a mental health clinic (usually not so easy a thing to
do) and to have gynecological surgery denied. Let’s get more information.
A new psychiatrist joins the clinic and agrees to begin working with Alicia
as a “fresh start.” She is argumentative and pushy in the first session and has
demands for things he should do to help her (e.g., help to get her surgery
approved). She expresses her perception that he will likely be ineffective
and “lumps” him in with others in a position of power and authority who
have failed to help her in the past. The psychiatrist weathers the insults with
out engaging in argument and manages to learn a little about her childhood.
She is the older of two girls by 1 year; their father left when she was a young
child. Her mother was an alcoholic and often intoxicated to the point of be
ing unable to care for her children. When Alicia was little, she often cared
for her younger sister, including taking care of her meals, clothing, and school
needs. She was capable and confident, even at a young age. She was a smart,
rambunctious student in high school and often partied, stating, “I’m smart
and didn’t need to study much.” She sees herself as a person who knows
what she wants, and others frequently let her down, especially through in
competence. She admits she is sometimes “flighty” and “talks too much.” She
has pressured speech, flight of ideas, poor concentration, and reports severe
insomnia. Her history is concordant with a diagnosis of bipolar disorder.
She does not trust medication or doctors and does not agree to take psychi
atric medication.
We now have more data for the psychodynamic formulation as more

pieces begin to fill in her story. Her parents were largely absent from her
childhood. Her father was literally absent and her mother emotionally ab
sent and also not available as a source of guidance or comfort. Alicia learned
to fend for herself at an early age and was forced into a parenting role as a
child by circumstance. What effects did these events have on her develop
ing personality? How was she comforted when dealing with an intoxicated
mother and sister who needed a parent? One hypothesis would be that she
was overwhelmed by the abandonment and developed defenses against
feeling helpless or afraid. This included denying her feelings and becoming
physically adept. As a young child she was unable to consciously experience
her great fear and sadness and instead became a hyperactive, fast-talking
“fighter” who didn’t acknowledge her more sad feelings. She has poor in
sight about how her behavior causes others to reject her. Her psychological
motor runs high to avoid the inevitable depression underneath. From early
childhood she wasn’t able to trust the most important people in her life, and
this theme likely continues to color her interpersonal relationships. People
can’t be trusted, and when she wants something, she needs to fight to get
it. Her mood swings cause significant impairment in her life, and she likely
has untreated bipolar disorder.
The psychiatrist and Alicia meet weekly for supportive psychotherapy. Al
though she often displays a fighting demeanor with him, he is able to soothe
her enough to form a therapeutic alliance. He acknowledges her pain and
the “unfairness” of her situation with the gynecologic clinic. She begins to
see him as an ally in her fight against the unfairness of life. Their sessions
become more collaborative, and he is able to guide her to look at herself in
limited fashion. She is able to admit, “I have a hard time asking for anything”
during one of the sessions, and they are able to talk about how uncomfort
able it is to feel needy. She is unable to look at the hurt of her childhood
abandonment and minimizes the effect it had on her, stating, “You just get
over it.” She also discusses that she “doesn’t like to lose” and that often life
seems like one big battlefield in which she is stuck in the middle. She has
a difficult time feeling pity or empathy, especially for herself. Because Alicia
has developed a good therapeutic alliance with her psychiatrist, she eventu
ally agrees to take psychiatric medication, and her mood stabilizes consid
erably. With the help of her psychiatrist she is eventually referred to the
pain clinic and is able to achieve a moderate amount of improvement of her
chronic pelvic pain without the need for surgery.
OK, now let’s build more on our psychodynamic formulation.
Alicia underwent significant abandonment in her childhood with the ab
sence of her father and the severe alcoholic illness in her mother. She likely
experienced extreme anxiety, helplessness, and loneliness at an early age.
She was overwhelmed by these emotions; however, being the older child,
she was thrust into the caretaker role for herself and her younger sister. She
learned to strongly defend against any feelings of helplessness or neediness
because these would likely have impaired her ability to survive. She was smart
and had good physical ability and became a hyperactive, strong “fighter” as
a means to cope. She avoided introspection and experienced the world as a
harsh “enemy” of sorts, for which there was no room for empathy. She un
consciously avoids closeness with others and is unaware of the extent her ag
gression affects her personal and professional relationships. Her inability to be
empathic with herself—to appreciate the sad elements of her childhood—
interferes with her ability to be empathic with others. This interferes signifi
cantly with her interpersonal functioning, as “fighting” becomes the modal
communication style. Being a Native American woman in a predominantly
white male culture also likely adds to her feelings of being the underdog and
needing to watch for inequity in her relationships. She unconsciously expe
riences the white male psychiatrist as an authority likely to withdraw his
support or affection, perhaps in a way she experienced with her father or
mother. She often perceives the psychiatrist as “noncaring” as a projection of
her own inability to be empathic, and thus she expects to be treated in a sim
ilar fashion. Prominent defenses include denial (of her dependency, sadness,
and needs for nurturance) and splitting (lumps people into all good or all
bad, and often all bad). She has chronic pain of various types, and likely her
inability to examine her own sadness or emotional pain contributes to her
chronic physical pain via somatization defenses.
Although this is an initial psychodynamic formulation, I wouldn’t call it
a good one. It’s an adequate psychodynamic formulation and good enough
for purposes of starting therapy with Alicia. It meets the criteria of telling a
story that makes sense and of explaining why Alicia is suffering the way she
is now, based on her past. It also explains the interaction between her and
the psychiatrist and allows for some prediction of how the relationship will
play out in therapy. It’s important to point out that even though the uncon
scious psychodynamics might be apparent to the therapist, they may not be
appropriate for direct discussion with the patient. In the case of Alicia, she
may never consciously appreciate the extent of her abandonment and the ef
fect of this early trauma on her current relationships. However, the therapist
is greatly aided by understanding this dynamic because it will guide him in
knowing which interventions Alicia can tolerate and assimilate into her cop
ing repertoire. Her lack of ability to empathize was strongly linked to her
survival as a child, and it remains a powerful defense against feeling over
whelmingly sad or afraid. This psychodynamic understanding will enable
the therapist to better pace the therapy, allowing enough comfort for Alicia
to feel she is being helped and supported without being too provocative or
confrontational. When these interactions occur in therapy, and Alicia begins
to trust the therapist ever so slightly and not “fire” him for being inadequate,
she will be undergoing the beginning of a corrective emotional experience.
An important consideration for constructing a psychodynamic formu
lation is to have it make sense, regardless of how “crazy” a person’s behavior
or life might seem. A good mantra to adopt is that behavior has meaning.
Taking the perspective that the behavior is or was adaptive for the person
in some way, even if not apparent to logical reasoning, is the approach to
take. Even if the behavior is apparently damaging to the person, is the pain
the person brings upon himself or herself allowing the avoidance of a
deeper pain? Sometimes the behavior might have been adaptive to a devel
oping child, given his or her emotional, physical, psychological, and cul
tural circumstances at the time. When these childhood adaptive methods
become repeatedly ingrained, they can persist into adulthood even if they are
then highly maladaptive. In the case of Alicia, she was a survivor of severe
childhood neglect and developed a psychological way to survive that allowed
her to avoid complete emotional devastation. When we look at her behav
ior and the way she handles her interpersonal relationships as an adult, it
can look pretty “crazy.” By viewing it through the lens of the psychodynamic
formulation, it all makes perfect sense.
Now that we’ve established the importance of developing the psycho-
dynamic formulation, we can examine how this is used in forming a good
therapeutic alliance. The therapeutic alliance is the working relationship be
tween the therapist and patient. The word “working” is meaningful and im
plies both effort and action, because the therapeutic alliance is not a static
position but a fluid, dynamic state. The therapeutic alliance begins to form
the minute you meet the patient and changes throughout the therapeutic
relationship. We can define the therapeutic alliance as “good” when patient
and therapist are working together toward common goals and experiencing
the relationship as positive. The therapeutic alliance is strongly linked to
successful therapy outcomes, and some would argue that a good therapeutic
alliance is the central element of healing in the therapy relationship.3 Main

taining the therapeutic alliance is the number-one job of the therapist and
can be viewed as essential to doing supportive psychotherapy. Disruptions
in the therapeutic alliance are common when working in psychotherapy and
should be viewed as opportunities for healing (in the manner of the corrective
emotional experience). In other words, sometimes working on the therapeu
tic alliance is the therapy, regardless of material that’s discussed. The most
important qualities of the therapist for doing a good job—that is, sustaining a
good therapeutic alliance—are empathy, flexibility, and nurturance. Let’s take
a closer look at how each of these qualities influences the therapeutic alliance.
For the purpose of doing psychotherapy, we define empathy as under
standing why a person feels or behaves the way he or she does. This can
include having compassion for his or her behavior based on understanding
but not on having the exact same feeling. Distilled into its purest form,
empathy is devoid of feeling or judgment. In contrast, sympathy is feeling
emotionally moved by another’s situation. Despite being distinct, the two
concepts aren’t mutually exclusive, and in fact there’s often some overlap.
The job of the therapist, however, is to develop empathy for the patient. This
may seem like a simple or obvious goal, although it can sometimes be chal
lenging. There’s a strong correlation between the therapeutic alliance and
empathic understanding on the part of the therapist. Gains in empathy
usually translate into an improved therapeutic alliance. For example, a ther
apist may have some uncomfortable feelings working with a patient who
regularly lies, cheats, and steals. These behaviors of the patient would over
flow into the therapy as well, causing a degradation of the honesty within
the sessions as well as increasing the tendency of the therapist to distance
himself or herself from the patient. This combination would impair the
therapeutic alliance, because both parties might pull back (consciously and
unconsciously) from trying to make the therapy work. If the therapist learns,
however, that the patient grew up on the streets and had a very traumatic
childhood, the empathy gained from this understanding might lead to a
more compassionate approach with the patient. This greater compassion
would very likely be felt by the patient on a number of levels; from the tone
of voice of the therapist, to the nuances of the therapist’s body posture, and
to his or her line of questioning, the patient would feel it. Most patients have
a strong gut feeling and would be able to provide an unambiguous answer
to the question, “Does your therapist understand you?” An answer of “yes”
would usually be indicative of a good therapeutic alliance.
A second quality of the therapist that is important for developing a
good therapeutic alliance is flexibility. Patients come in an infinitely wide
variety of colors and flavors. (That’s the fun part!) There’s no doubt that no
two people are identical. Some patients will have personality characteristics
that will make forming and keeping a good therapeutic alliance an easy
task. More often than not, however, there will be challenges. This is be
cause often the problems and symptoms of the patient are interpersonal in
nature and will likely become a factor in working together with the therapist.
Imagine if you were playing a game of catch and had only one mitt. When
someone throws a baseball at you, you have the perfect equipment to catch
it. Catching a baseball is clean and easy when you have a mitt. It would also
work well for a lacrosse ball, and sort of OK for a tennis ball. But if someone
were to throw a football or soccer ball at you, the mitt simply wouldn’t work.
You would have to adapt or change your equipment completely to be a good
catcher with the different objects being thrown. If you have one and only
one “style” of working with patients, you are bound to fail with a significant
amount of people in psychotherapy. By the very nature of people, you need
to be flexible to make the relationship work in psychotherapy, to form a
good therapeutic alliance. Patients will always bring their own interpersonal
capability to the relationship. Because the therapeutic alliance is by defini
tion an interactional process, it’s your job to make it work with their per
sonality. By intention I haven’t included a list of “patient characteristics” for
making a good therapeutic alliance, because these are beside the point. I’ve
known psychotherapists who do not treat certain types of patients because
they’re too difficult; for example, they will not treat people with borderline
or narcissistic personality disorder. While I believe it’s good for therapists
to know their limitations, I also believe in a growth model for psychothera
pists. Learning to be flexible, and to adapt to the multitude of different pre
sentations that patients bring to us, will keep us growing and developing
new skills as psychotherapists. Want to know the best part of this “continuous
interpersonal capability improvement model”? A “side effect” of this approach
to being a better psychotherapist is that it can help our growth in relation
ships outside of therapy (but please deny you read this here, as it would be odd
to include that in a textbook of psychotherapy).
There are situations where attempting to form a therapeutic alliance in psy
chotherapy is not a good idea. People with sociopathy are not good candidates
for psychotherapy and usually are only in therapy for social pressure reasons
(e.g., they have been court ordered to do so or are there to satisfy a marital part
ner). People with sociopathy might want their situation to change but generally
have no genuine interest in changing themselves. Although there is some de
bate, most professionals believe psychotherapy with sociopathic individuals is
not beneficial at best, and possibly even contraindicated.4 Sometimes people
who are seeking controlled substances will undergo psychotherapy with a

psychiatrist in a concealed effort to get the prescriptions. If it becomes clear
during the sessions that the person only wants the drugs and isn’t truly in
terested in doing psychotherapy, there’s no sense in attempting to form a
therapeutic alliance, and usually therapy should be terminated.
The final quality of the therapist for creating a good therapeutic alliance
is nurturance. To examine nurturance of the therapist in a historical per
spective, we take a short diversion to look at the work of D.W. Winnicott.5
Dr. Winnicott was both a pediatrician and a psychoanalyst who developed
groundbreaking theories about the early mother-child bonding experience
and how that shapes the development of personality. He described how ini
tially the mother is completely caring for every need and nuance of the infant,
comforting the infant when distressed and feeding when hungry. The early
infant experiences soothing and gratification in the completely nurturing
environment of the mother. As the infant undergoes weaning, it experiences
more distress and unpleasant states of being, and the mother becomes dis
tanced by necessity because she can no longer provide a totally comforting
environment. The mother continues to nurture the child, however, not com
pletely or immediately, and the child learns to tolerate unpleasant emotional
states as well as delay of gratification. Winnicott described “good enough”
mothering as being totally available for the early infant experiences but allow
ing appropriate intermittent or delayed gratification as the child developed.
He saw the mother’s physical and emotional nurturance as a safe “holding
environment” from which healthy development of the infant occurs.
Winnicott viewed psychoanalysis as a “holding environment” for the pa
tient, one where the patient can experience “good enough” parenting via the
therapist. When the psychotherapist is both trusted and comforting, it al
lows the patient to examine the wounds and disappointments of his or her
life in a nurturing setting. Winnicott believed the safe and nurturing hold
ing environment is a necessary ingredient for psychotherapeutic healing.
For patients to expose themselves and tackle the pains and sorrows of their
lives, they must feel safe in the psychotherapy. The nurturance of the psy
chotherapist is an essential quality for this holding environment to occur.
The therapist should expect disruptions to the therapeutic alliance as a
natural part of doing psychotherapy, much as disruptions occur with any in
timate relationship. The range of possible disruptions covers the gamut of
human interaction and sometimes can be quite evocative to the therapist.
For example, if a patient consistently devalues the therapist, this can invoke
feelings of hurt, anger, or insecurity. These feelings in the therapist can un
dermine their nurturance and impair the therapeutic alliance. In situations
like this, it’s especially important for the therapist to see the devaluation as
an important part of the patient’s psychology and address it in a way that is
not retaliatory. In other words, the therapist must not be retaliatory with his
or her own negative reactions and must work to improve the therapeutic al
liance in a manner that will guide the patient to learning as the repair takes
place. The learning may be subtle for the patient; for example, he or she might
experience a sense of acceptance as the therapist does not react in ways most
people would to the patient’s toxic interpersonal manner. Depending on the
overall strength of the therapeutic alliance before the disruption, the patient
may also learn from a gentle confrontation of the behavior if it’s done in a
supportive manner by the therapist. The bottom line is that the therapist
takes all the responsibility to repair the therapeutic alliance when it’s broken
and also takes the position that the repairing process has potential benefit
as a correctional emotional experience.
Early in my career, I obtained a research grant to study the effects of a
psychiatric medication (intramuscular fluphenazine) on people with multi
ple suicide attempts.6 Patients were recruited from the emergency depart
ment when they were treated for a suicide attempt and had several prior
attempts. They met with a research nurse for several hours at study entry,
at which time she gathered a psychiatric history and obtained baseline mea
sures on mood and self-harm inventories. Then they met monthly with the
same research nurse to get their injection of the medication and repeat the
psychometrics. These visits with the research nurse lasted about 30 minutes,
and she asked detailed questions about their self-harm behavior to com
plete the study measures. The patients in this study often had multiple se
vere problems (e.g., substance abuse, legal problems, personality disorders),
and many of their charts were “flagged” to alert emergency department per
sonnel that they were difficult to care for (e.g., by fighting with staff or do
ing self-harm behavior while in the emergency department). The research
nurse was an empathic, flexible, and nurturing individual (her name was
Victoria, and we called her “Queen Victoria”). The study lasted a year, and at
termination the patients were asked on exit interview, “Was this study valu
able to you?” Many of the patients commented that the “therapy” with
nurse Victoria was most valuable. Of course, there was no psychotherapy
component of the study. These “difficult” patients experienced a compas
sionate individual carefully listening to their pain in great detail and in a
nonjudgmental way. The good therapeutic alliance with nurse Vicki allowed
them a healing, corrective emotional experience.
To summarize, developing a psychodynamic formulation provides a road-
map of the patient’s psychological life, a structure for doing supportive psy
chotherapy, and a tool for continuous hypothesis testing as therapy proceeds.

The psychodynamic formulation also allows for the development of empa
thy in the therapist. Empathy, along with flexibility and nurturing qualities
in the therapist, helps form and maintain the therapeutic alliance. Patients
need to feel safe in the therapeutic environment. Disruptions or challenges
to the therapeutic alliance allow for healing opportunities as correctional
emotional experiences. Developing and maintaining a good therapeutic alli
ance is an essential ingredient for doing successful supportive psychotherapy.
1. Can you teach empathy?
2. Can you do psychotherapy with a poor working alliance?
3. If you don’t have empathy for the patient, can you still do good psycho
therapy?
References
1. Kohut H: The Analysis of Self: A Systematic Approach to the Psychoanalytic
Treatment of Narcissistic Personality Disorder. New York, International Uni
versities Press, 1971
2. Frankl V: Man’s Search for Meaning: An Introduction to Logotherapy. Bos
ton, MA, Beacon Press, 1962
3. Flückiger C, Del Re A, Wampold B, et al: The alliance in adult psychother
apy: a meta-analytic synthesis. Psychotherapy 55(4):316–340, 2018
4. Gibbon S, Duggan C, Stoffers J, et al: Psychological interventions for antiso
cial personality disorder. Cochrane Database Syst Rev 6:CD007668, 2010
5. Winnicott DW: Transitional objects and transitional phenomena: a study of
the first not-me possession, in Essential Papers in Object Relations. Edited by
Buckley P. New York, New York University Press, 1986, pp 254–271
6. Battaglia J, Wolff TK, Wagner-Johnson DS, et al: Structured diagnostic as
sessment and depot fluphenazine treatment of multiple suicide attempters in
the emergency department. Int Clin Psychopharmacol 14(6):361–372, 1999
CHAPTER 3
Getting Started and the
Behavior of the Therapist
I can distinctly remember how excited I was

getting assigned to my first office for doing psychotherapy when I was a
psychiatric resident. Not only was I going to be doing psychotherapy, which
to me was cause for great celebration, but I also had an office to be furnished
and decorated however I pleased. Yay! These were big firsts for me, and now
all these decades later, I still believe the psychotherapy office is a sacred place,
a powerful place, a place for great intimacy and life changing events to hap
pen. There should be ample planning and consideration for both the physical
space and the psychological events that happen there. This chapter examines
the physical space of the office, the office atmosphere, the structure of ther
apy sessions, and the behavior of the therapist.
Thinking through step by step how you want the psychotherapy experi
ence to be for patients will guide you in creating an office space. How would
you like patients to feel while they’re in the waiting area? Creating an invit
ing, comforting atmosphere can begin even before the session starts. Some
therapists have snacks, coffee, and drinks available in the waiting area. I’ve
heard some even have chocolate available as well, which is almost cheating
in my opinion. (Did you know that one chemical compound found in choc
olate, phenylethylamine, actually causes feelings of sensual attraction in the
brain?) Soft lighting and comforting music played at low volume can also
help set a relaxing tone as the patient waits. Finally, if there are office staff
working in the waiting area, training them in some interpersonal basics for
making people feel comfortable can help create a pleasant atmosphere.
Your office space is where it all happens, and therefore planning it down
to the finest detail deserves all the emphasis you can give to it. The primary
27
goal is to make your patients feel comfortable. Lighting should be mid

range; if it’s too bright, people will feel as though they are exposed or under
interrogation, and if it’s too low, it can make some patients feel afraid or
anxious. Computer screens should be neutral, and noise interruptions from
electronic devices kept to a minimum. Letting the patient have an option for
seating is best, with either a couch or two chairs so that the patient can choose
his or her distance. When it comes to decorations, art, and personal effects,
there are many directions you can go. The one thing you can be certain,
whatever you choose to place in your office will be thought about intently
by your patients and will occupy some of the psychological space in the
room during sessions. For this reason, avoiding art or décor that’s too provoc
ative is likely a good idea. Having said this, it should be mentioned that
Freud was a connoisseur of archeological artifacts and had thousands of
these in his office, including busts of Greek gods, Egyptian death masks,
and totems. These items were highly provocative, yet somehow he developed
the science of psychotherapy in that office, so maybe there is some wiggle
room for how you decorate yours.
Now we focus on getting started: your first session with the patient.
Most important in the first session is to establish the beginnings of a thera
peutic alliance with the patient. If a person feels “heard” in the first session,
that will usually pave the road for further therapy. Sometimes therapists will
focus on getting the information they need to fill out intake forms or to get
the historical facts necessary for insurance purposes. Granted, this is import
ant; however, if patients don’t feel heard or don’t feel that they “got some
thing” from the first session, they might decide to not follow up, and the
information gathered won’t be of much use. Patients must feel that their pain
was directly addressed in the first session. Toward the end of the session it
will also help if the therapist lays out the expectation of what further psy
chotherapy will be like—a quick guide of “what to expect in your therapy,”
if you will. If patients leave the first session feeling more confused, or emo
tionally worse for having expressed themselves, they’re less likely to con
tinue with psychotherapy. Sometimes in the first session patients will open
up about intense pain they’ve been withholding for a long time. They’ll
have an emotional catharsis, and it’s then important that the therapist pro
vide support and guidance for them to compensate from such intense out
pouring of feeling. Validating the importance of their emotion and putting
a supportive bandage on the wound will help them recover and benefit from
the experience. Giving practical advice on some things they can do immedi
ately to help their situation will likely solidify their first session as beneficial.
If they feel that their pain was addressed in the first session and they feel un
Getting Started and the Behavior of the Therapist 29
derstood, they’re likely to continue in psychotherapy. In a funny kind of way,

one of the important goals of the first session is to get the patient to the next
session.
A caveat to this is that some patients feel so much better after one ses
sion of psychotherapy they don’t return because they believe “it worked.”1
Many patients don’t have the same theoretical model of psychotherapy as
the professional therapist—that is, they don’t share the concept that it takes
multiple sessions and “working through” to make true progress on most
psychological problems. To many patients who improved with “single-session
psychotherapy,” it was simple: “I had a problem, I talked with a professional
about it, they helped me feel better...end of story.” Never underestimate
the power of words.
For patients who have not been in psychotherapy before, the first ses
sion is often anticipated with great anxiety. Even though most people have
exposure to what a therapy session looks like on television shows, movies,
and videos, sitting face-to-face with a therapist in real life is a lot more anx
iety provoking. You might need to offer guidance throughout the first ses
sion to explain what will be covered and how it will be accomplished. In
addition to initially explaining the process of therapy, you can lower anxiety
by getting the patient to talk first about “easy” or neutral topics, for exam
ple, “Where are you from?” “What kind of work do you do?” “Tell me about
your current living situation.” Such questions and requests provide structure
and help ease patients into talking about themselves without exposing emo
tion. Once some of these basics are covered and you sense the patient is
more comfortable, you can then ask, “What brings you in?” Asking about
the presenting problem in such an open-ended way is nondirective (answer
is not directed by the influence of the therapist) and allows you to get an
unadulterated sample of how the patient sees things. If patients are able to
talk about their situation without interruption for a significant amount of
time, it’s worthwhile to let them do so. The free flow of what a patient tells
you in this first encounter is rich with meaning on many levels. Notice the
flow of their associations: What links do they put together in cause and ef
fect? Do they self-reflect on their situation or see themselves primarily as a
victim? What is their level of psychological understanding of themselves?
What is the quality of their relationships?
Some patients will not be able to talk about their problems in a free-flow
ing manner. For these patients, you will need to provide more structure and
guidance to get a robust description of the problem. The flexibility of the ther
apist becomes crucial in becoming a guiding and supportive force immediately
in these situations, to help the patient feel anchored. The patient may find it
difficult to talk because he or she is feeling intense emotions, or alternatively,

may have alexithymia (inability to talk about feelings) and have chronic lim
itations with expressing himself or herself emotionally. Either way, your job as
therapist is to adapt the interview to the patient so he or she feels guided
through the process. These are the first steps for building the “holding envi
ronment” a patient will need to feel for psychotherapy to proceed.
When patients are able to talk without interruption or with minimal
clarification, I let them do so for at least half of the allotted time. This is
especially important in the first part of the session. It is much better to make
notes of what needs clarification and come back to it later than to interrupt
the flow of the patients’ ideas or emotions. In the second half of the session
the therapist can complete the initial assessment by asking clarifying questions
and obtaining the necessary personal history. When patients are talking, let
yourself give expressive feedback in small doses to prevent them from feeling
alone or abandoned. It can be a very raw experience to talk about such inti
mate things in front of a stranger, and patients can feel adrift quickly if not
anchored by emotional feedback from the therapist. Nod your head, wince
if they talk about painful things, grunt at times, and give small verbal utter
ances that support, confirm, or sympathize with what they are expressing.
This can be done without derailing them from their train of thought (“Wow,
that sounds painful”; “Oh....”; “Hmm, that must have been difficult”; “You
must have been proud...”; “Oh my...”). Silently staring at the patient with
out any reaction for extended periods of time is discouraged in the initial ses
sion because this tends to increase anxiety.
For patients who have been in psychotherapy before, it’s vitally impor
tant to ask what that experience was like for them: “What did you find use
ful and nonuseful with the therapy?”; “What worked for you?”; “What did
you learn from the experience?” You should reassure the patient that you will
use this very important information to help guide the current psychother
apy. If the patient had an unpleasant experience in a prior psychotherapy,
you should outline what you’ll do differently to make the current therapy
better. This is especially important if the patient had aversive or even trau
matic experiences in therapy. You can emphasize that you’ll actively try to
avoid this and spend extra time to analyze what went wrong previously, fol
lowed by a plan of correction.
If the patient had an outstanding, positive experience with prior ther
apy, it’s important to validate this while at the same time predicting that the
patient will notice some differences as he or she begins to work anew. Pre
dicting some initial disappointment will help soften the expectation that the
new therapy will immediately replicate the “holding environment” of the
prior, where the patient enjoyed a good therapeutic alliance. Patients are
likely to feel some loss of intimacy as they start the new therapy. For these
patients with good prior psychotherapy experience, the therapist can help
them grieve what they have lost from the prior therapeutic relationship. In
addition, it’s sometimes helpful to discuss what “good things” they’ll likely
import into the current therapy from the prior experience. Finally, the new
therapist can nurture a positive perspective by pointing out that because the
current therapy will be completely novel, there might be things learned that
are both new and different in a good way.
In the wrap-up part of the first session, you should address any intense
emotions by checking in with the patient on how he or she is doing. Imme
diate intervention methods can be employed, such as breathing exercises or
visualization, if the patient needs help getting stabilized. This should be
tended to at least 10 minutes prior to the end of session; otherwise the patient
may leave feeling emotionally gutted and without a way to cope. Patients in
such circumstances might feel the initial session made them worse and may
not return. For such patients it’s also useful to predict that they may have
some emotions surface even after the session has ended. Reviewing coping
methods the patient can use for these after-session emotions is also helpful.
You might suggest some activities for after the session to help the person
recover—for example, meeting with a loved one, talking with a good friend,
having a shared meal, or some other activity that is social but not stressful.
In the final part of the session, you should give the patient a brief summary
of the psychodynamic formulation, tailored to the patient’s understanding.
You should look for confirmation from the patient that the initial formula
tion holds some fidelity (“OK, here is what I’m thinking at this time about
you and your situation. How does this sound to you? If it’s off, please tell
me how to make it better”). You can also present a brief proposal for how
psychotherapy will proceed from this first session onward, including types
of personal material that will likely be covered, frequency of sessions,
scheduling and cancellation policy, and possible “homework” assignments.
One of the most freeing aspects of doing supportive psychotherapy is
that therapists can “be themselves.” But what exactly does this mean? In
supportive psychotherapy the therapist is not the emotionless “blank screen”
onto which the patient projects his or her unconscious conflicts. The ther
apist doesn’t have to act “neutral.” Instead, the therapist can be a friendly,
warm, nurturing person who has inflection in his or her voice and conveys
a genuine concern for the well-being of the patient. The therapist can be emo
tionally expressive, including being especially sensitive and tender when the
patient is expressing pain, as well as expressing joy with patient gains or tri
umphs. Most trainees find their “groove” when starting supportive psycho
therapy because they finally feel they can use their genuine good will and
caring in a therapeutic context. The joy of healing is an important part of
what makes many people enter into the psychotherapeutic fields of work.
You can finally let yourself be you and a psychotherapist at the same time.
Trainees in psychotherapy (e.g., psychiatry residents, social work in
terns, psychology interns) often feel anxiety with their lack of therapy ex
pertise and sometimes worry that patients will see them as inexperienced and
therefore ineffective. These anxieties can be inflamed further if the patient
draws attention to it: “You’re a trainee, right? Have you done this before?”
There are a few ways for psychotherapy trainees to cope with this. First and
foremost, trainees should not deny their inexperience and should admit it
without apology. This can be coupled with the information that they will
have supervision throughout the therapy. Even more important, however,
is to impress upon the patient that they want to do a good job and therefore
will learn whatever they need to in order to be helpful. “Yes, I’m a beginning
therapist and I want you to know that I’ll have a faculty supervisor at all
times during my care for you. Even more important for you to know is that
I really want to do a good job, so if what I’m doing doesn’t seem helpful, I
want to learn how to make it better. During our therapy together, I’ll be
checking in with you frequently to make sure you feel you’re making prog
ress.” In my experience supervising psychotherapy, I’ve found that the far
majority of patients enjoy the keen interest and enthusiasm of psychother
apy trainees and that the inexperience of the therapist rarely becomes an is
sue during treatment. Interestingly, studies looking at therapist experience
and psychotherapy outcome often do not find a significant correlation.2
In supportive psychotherapy, there is an important distinction between
being friendly versus being friends. The therapist-patient relationship is
not a friendship. There is no reciprocity with the patient: the therapist
doesn’t rely on the patient, expect anything personally from the patient, or
ask the patient for anything. Often when the therapeutic alliance is espe
cially good, the patient might consider the therapist a friend. Occasionally
patients will state, “I consider you a good friend” or ask, “Are we friends?”
It’s important in these circumstances to validate the intimate, good feelings
the patient has about the relationship while at the same time mentioning
how the relationship is not reciprocal, and therefore not a friendship. Ther
apists can emphasize that they will do their job so much better because the
relationship is not, in fact, a friendship (“It allows me to focus solely on help
ing you”). Sometimes the discussions around this issue of friendship lead to
rich material that can yield good psychotherapeutic dividends.
As we discussed in the prior chapter, a good therapeutic alliance is the

essential ingredient for successful supportive psychotherapy. Like most re
lationships, the therapeutic alliance will ebb and flow over the course of the
therapy. The time spent during psychotherapy in a positive therapeutic al
liance is like putting money in the bank: it builds on itself and might need to
be drawn upon to help during more difficult times (“We’ve worked through
a lot together; we can get through this”). The empathic, flexible, and nur
turing qualities of the therapist will maintain the equilibrium of the therapeu
tic alliance, bringing it back to the positive when it’s disrupted. Disruptions
or problems in the therapeutic alliance should be viewed as opportunities
for learning rather than negative events. In fact, sometimes turbulence in
the therapeutic alliance can be an indication that important issues are brew
ing in the therapy (the storm before the calm). Repairing the therapeutic
alliance in and of itself is often a correctional emotional experience.
An important component of doing supportive psychotherapy is taking
care of the patient’s emotional well-being during the psychotherapy. The
therapist is responsible for eliciting emotions from the patient, modulating
the degree to which this occurs, and anticipating how it might affect the pa
tient after the session. Exactly how much elicitation and modulation occurs
in the therapy depends upon numerous factors, including: How well does the
patient handle strong emotions? Does he tend to act out with strong emo
tions? How well does he compensate after getting in touch with difficult
emotional issues? What is the patient’s history of coping? Does he have a ten
dency to harm himself or others when distressed? Does he abuse substances
as a way to cope? Have healthy ways to cope and self-soothe been addressed
in the psychotherapy?
Answers to these questions are vital in determining the degree to which
emotions are opened up in the sessions. First and foremost is to ensure that
patients have healthy ways to cope with strong emotions outside of the ther
apy sessions. This can include a variety of nonspecific and specific techniques.
Generic coping methods can include mantras, self-affirmations, relaxation
techniques, journaling, and cognitive reframing. More specific coping plans
are tailored to the patient and can include a wide range of activities. Some
examples are talking with a support person (e.g., best friend, someone in
their inner circle), exercising, taking the dog for a walk, watching specific
videos, or listening to music. The patient can be a consultant to figure out
which coping plans will work best, because sometimes activities outside of
the therapist’s expectations might be soothing for the patient (e.g., han
dling a pet snake might be comforting to some while a terrifying thought
to others). The bottom line is that when patients leave the session, they have
been educated to expect “after-shocks” of emotions and have coping methods

at their disposal to deal with them.
Navigating the balance of how much to “open up” and how much to
“cover up” is difficult terrain for psychotherapists, especially with beginning
or novice therapists. The art of doing good psychotherapy is based upon
how well the therapist handles this balance. Having strong emotional ca
tharses is important for healing, and the more comfortable the therapist is
in sitting with someone in pain, the better he or she usually is able to handle
it. It can be very distressing to witness emotional agony, and therapists can
modulate the emotional expression to the level they feel confident in work
ing with. It’s important for therapists to remember that they’re in control
of the session. They can bring in techniques to help calm or soothe the pa
tient as need be, to keep the emotional level tolerable for the patient. If the
amount of catharsis appears to be getting out of control, or the behavior of
the patient becomes alarming, the therapist can assertively give directives to
take deep breaths and focus on their physical presence in the room (“ground
ing”) as a calming measure (“Take a deep breath and let it out...you are here
in the room with me . . . look around the room . . . feel your feet on the
floor...you are safe here”). Another subtler technique used to decrease the
level of emotional intensity is to shift from discussing feelings to exploring
facts. For example, asking patients, “How long ago did this happen?” or
“Where were you living at the time?” will surreptitiously decrease their
emotional intensity while they begin to give the factual answers. The thera
pist should control the time of the session, so that if strong emotions or
traumatic material is uncovered, there is ample time to help the patient com
pensate before the end of the session.
On the other end of the spectrum, sometimes the therapist will be uti
lizing methods to help patients “open up” more to their emotions. There are
many reasons a patient might be resistant to expressing emotion; however,
at the basis of most are anxiety or fear of pain. Assuming a good therapeutic
alliance, the therapist can coach the patient into allowing the feelings to
emerge if they appear near to surface but the patient is resistant. Encourage
ment mixed with safety statements can help the patient to experience the
emotion, for example, “It’s OK, I’m here with you, and we can handle this,”
or “It’s OK to have these feelings...let them come. They’re a natural part
of you.” These statements reinforce the notion that the patient isn’t alone,
that the therapist can handle it, and that the patient is in a safe environment
for the feelings to emerge.
It’s natural for people to want to avoid pain, even if that avoidance is
causing other painful symptoms. Sometimes the job of the therapist is to
provide the “nudge” that patients need to move into a different emotional
position, one that will allow healing. This means taking patients into un
pleasant emotional territory, getting them out of their “comfort zones.”
Having a strong therapeutic alliance (nurturing holding environment) will
allow this nudging to occur.
Case Example
Isabel is a middle-aged woman with chronic depression, low self-esteem,
and guilt. She is rarely able to feel good about herself. She lost a twin sister
in a drowning accident when they were children, an accident that she sur
vived. Despite carrying inappropriate guilt about this event for decades, she
has actively avoided talking about it in psychotherapy. The therapist believes
her persistence in guilt is an important contributing factor that keeps her
depressed. She has been in psychotherapy for a year, and there is a good
therapeutic alliance.
ISABEL: I’ve told you before, I don’t want to talk about it.
THERAPIST: You’re right, you’ve told me that before. I’m trying to
respect your wish to avoid that, but I feel you carry it inside
in a way that keeps you depressed. I keep wondering if it
might help you heal to talk about it.
ISABEL (looking anxious): You might be right, I don’t know...?
THERAPIST: What are your worries about what will happen if you
do talk about it?
ISABEL: I don’t know, I just know I don’t want to talk about it.
THERAPIST: My guess is it’ll be painful to talk about, and you’re
naturally avoiding the pain of it. I think it might be like let
ting some pus out of a wound. It’ll likely hurt some, but then
it’ll allow the healing to take place. But maybe just talking
about what your fears are would be a beginning. Let’s try
that....
ISABEL: I just know I’ve always kept it down, sort of like if I don’t
talk about it, it won’t hurt as much. They tried to get me to
talk about it after it happened. Took me to a therapist. But I
wouldn’t talk, and they eventually gave up on me.
THERAPIST: Yes, you were protecting yourself. You were probably
traumatized by it, and my guess is you feared being over
whelmed in some way. What is it like keeping silent about
it—how’s that for you?
In this example, Isabel has been traumatized by an event in her child

hood and strongly suppressed a number of emotions related to it. She likely
suffers from posttraumatic stress disorder, and her depression is epitomized
by guilt and the chronic suppression of unpleasant emotion. The goal of the
therapist is to get her talking about it in a marginalized way, to begin the

process of accessing her guilt. In the example, Isabel has started talking
about it in a way that’s tolerable. The therapist has nudged her into this
uncomfortable emotional territory. Over the course of another year in psy
chotherapy Isabel is eventually able to examine the traumatic events of her
childhood and come to a better understanding that her guilt was excessive.
The pacing of psychotherapy is another core skill of the therapist that is
hard to define but critical to good therapy outcomes. Pacing of how much
to nurture, how much to explore, how much to confront, how much to
“open up,” and how much to “close up” is the rhythm of psychotherapy. More
seasoned therapists develop a good sense for pacing based on years of expe
rience; however, even for veteran therapists, each and every person is unique,
and what has worked for many may not work for a particular patient. A
good rule of thumb for how to handle most perplexities in psychotherapy
is for the therapist to get a consultation from the patient. Checking in often
with how therapy is going for the patient and how he or she is doing outside
of the sessions can provide help for pacing. In fact, frequently checking in
with the patient is a useful technique both within and between sessions (it’s
hard to do too much of this). Some patients are not capable of providing
such consultation feedback, but most will give at least some information
that can be useful for the therapist. Generally, patients will have a gut feeling
for if they’re making progress overall, or if the therapy feels bogged down
versus too intense. If the therapist experiences frequent boredom with the
sessions, this may be a clue that therapy pacing is too slow. It may also be
an indication that the patient is evading a sensitive topic. More active con
frontation or elicitation of feeling may be indicated (e.g., “It seems to me
that we have been stuck lately; does it feel that way to you? Any thoughts
about this? Are there some things that you’re uncomfortable talking
about...maybe avoiding? What can we do to make this better?”). Contrary
to this, if the patient seems to become destabilized frequently during or after
sessions, it may be an indicator that the pacing is too fast, and efforts should
then be made to strengthen defenses and shore up coping skills. One adage
for psychotherapy is to teach patients how to cope before opening up things
they need coping for. This is a worthwhile adage; however, like most things
in life, it should not be seen as a rule, because sometimes issues arise and need
attention “out of order.”
Patients bring a wide variety of themes, personal material, and emotions
to the sessions. Although the therapist is sensitive to the patient’s needs,
this should not be confused with allowing all directions to occur in the psy
chotherapy sessions. Some patients will talk on endlessly about mundane
matters that do not seem much related to their problems. Some will attempt
to talk about current events, political or otherwise, to engage the therapist
in conversation and avoid talking about themselves. Some patients will
have problems with thought processing and simply can’t talk in an orga
nized fashion. The psychotherapist is the one responsible for structuring
the sessions and making them worthwhile. At times, this might mean in
terrupting the patient to redirect him or her to more meaningful thought
content. At other times, it might be slowing down the emotional catharsis
so that the patient can learn some coping skills. The therapist is the ring
master of the psychotherapy, making sure the “acts” flourish but controlling
the flow and sequence of events. In general, every session should have an
opportunity for the patient to speak freely without interruption, an oppor
tunity for the patient to experience emotions, an opportunity for the ther
apist to provide nurturance or feedback, and a “wind-down” toward the end
of session for the patient to compensate.
In some ways the qualities of a good psychotherapist are like a good par
ent—allowing expression and encouraging growth and self-sufficiency
while maintaining proper boundaries. Boundary maintenance is an impor
tant psychotherapeutic technique both in what happens with the patient
and in what happens with the therapist. In the strictest sense boundary
maintenance refers to keeping a professional boundary with the patient; that
is, no personal gain or financial or sexual relationship should exist outside
of the therapy. In rural or remote regions, this may be impossible because
there will be an overlap of roles due to the small or isolated population. For
example, the therapist may be treating the daughter of the sheriff in a small
town, where both therapist and sheriff often interact in a professional ca
pacity and have developed a casual friendship. Under no circumstance is a
sexual relationship with a patient, past or present, ever condoned. The trust,
dependency, and intimacy that develop naturally with the patient in the
course of psychotherapy make the patient vulnerable to emotional exploita
tion. Simply put, developing a romantic relationship with a patient is an
abuse of power by the psychotherapist. Sadly, this is not a rare occurrence
mostly because of therapists who do not keep a healthy emotional balance
in their own lives (we discuss this further at a later point in this chapter).
Boundary maintenance also includes enforcing some rules for patient
behavior in psychotherapy. This can include not meeting with a patient
who is intoxicated from drugs or alcohol (the patient can be politely in
formed to reschedule the session for a time when they are not intoxicated).
If a patient becomes physically, sexually, or verbally threatening in a way
that is not redirectable, the therapist will need to terminate the session and
act to ensure his or her safety (fortunately, this is an uncommon occurrence

in psychotherapy). A psychotherapist cannot do therapy if feeling threatened
or afraid, and these conditions are acceptable grounds for termination of
treatment.
In distinction from the strictest definition just discussed, boundary
maintenance includes many more nuanced behaviors that need the proper
management by the therapist. First and foremost is time management. It is
the therapist’s duty to keep track of time during the session so that the ses
sions end appropriately, both with actual clock time and with the patient’s
emotional state. Sometimes patients will thwart even the most rigorous
time management efforts by the therapist by bringing up an important issue
at session end. These “doorknob” issues must be handled with calm mea
sure. If the issue can wait until the next appointment, the therapist can say,
“This sounds like a very important issue that we should give ample time to
discuss thoroughly, let’s start with it next session,” or “If you want to schedule
another session soon to discuss this further, we can do that.” If the end-of
session issue is a true emergency—for example, the patient reports immi
nent suicidal ideation—the therapist must address it immediately regardless
of the chaos it will cause to the schedule (so, you wanted to be a psychother
apist?). Often patients will want to get more time with the therapist than
what is allotted. There are many factors that contribute to this phenome
non, but overall it’s sufficient to say that time management skills by the
therapist are a very important part of boundary maintenance. Good bound
ary maintenance is not just a function to keep order in the therapy; it also
serves as modeling for patients to learn healthy boundary setting in their
own lives.
Psychotherapy is a very emotionally intimate undertaking, for both pa
tients and therapists. For some patients the psychotherapy hour occupies
the most intimate moments of their lives. Part of the naturally occurring
process of psychotherapy is for patients to want more intimacy from the
therapist, to know them personally or in a special way. Boundary mainte
nance also includes handling attempts by the patient to develop a friendship,
as well as what the therapist personally reveals about themselves. The amount
of personal information revealed by therapists covers a wide range, and
there is no set standard with what is considered appropriate disclosure.
With psychoanalysis the therapist reveals practically nothing about them
selves, and this opacity encourages transference, which is a vital process for
successful psychoanalysis. With the evolution of supportive and other types
of psychotherapy (interpersonal, cognitive-behavioral), therapists have be
come more transparent in a personal way. Some therapists give patients sub
stantial personal information about themselves, including their private cell
phone numbers or social media connections. In the 1960s, some unique
therapists encouraged both patient and therapist to be completely nude for
the sessions in order to encourage transparency and intimacy by having
“nothing hidden” between them in the therapy.3 While intriguing, nude
sessions can, I think, be placed in the “outlier” category (even if that approach
is fun to think about). But questions still remain: How much personal in
formation is too much? Does more disclosure help the therapeutic alliance?
Should therapists answer questions about their religious beliefs or sexual ori
entation? Can therapist disclosure help a patient in unique ways that other
methods do not?
The best guiding principle for answering these questions is for thera
pists to ask themselves two critical questions: “Is the purpose of giving this
personal information for the benefit of the patient?” and “Is the patient the
driving force for this disclosure?” The biggest dangers for therapist disclo
sure are when it occurs for the benefit of the therapist and when the therapist
wants to disclose for his or her own personal reasons. As mentioned earlier,
psychotherapy is an intimate process, and therapists will often develop
warm feelings for their patients. It can be very tempting at times for the
therapist to share personal information with a patient, especially when both
therapist and patient have a mutual fondness for each other. The need of
the therapist to share can be based on his or her countertransference. By fo
cusing on answers to these two questions, the therapist will have a guide to
appropriate disclosure.
Information about the psychotherapist that is public knowledge—pro
fessional credentials or experience—does not pose a boundary maintenance
issue. For example, questions such as “Where did you get your degree?” or
“Do you have much experience in treating people with bipolar disorder?”
can be answered readily. There are other situations in which therapist dis
closure might seem straightforward and easy to address. For example, if the
patient asks, “What side of town do you live on?” or “How long have you
lived here?” these questions might be answered without much ado. More
personal questions might include, “Are you a Christian?” or “Are you mar
ried?” Therapists can decide whether they want to share more personal in
formation such as this. If they do, answering in a straightforward manner
without much added information will usually suffice. Some patients will
feel less likely to engage in therapy if the answer is not what they wanted,
for example, if the therapist does not share the same spiritual belief. In these
circumstances patients can be comforted that their spiritual beliefs are im
portant and will be integrated into the therapy. These patients can also be
reassured that psychotherapy can work even if the religious beliefs between
therapist and patient are not the same. If the therapist chooses to decline
an answer, he or she can do so in a supportive and boundary setting manner:
“Sorry, but I’d prefer to keep my personal information out of your therapy.
I believe it actually helps us in working together if the focus is on you.”
The therapist can choose to answer inquiries about their personal infor
mation by asking the patient, “What would my answer mean to you?” This
gives the patient an opportunity to articulate a core belief, for example, “I
can only trust a Christian person; therefore, my therapist must be a Chris
tian.” This can lead to useful discussion as well as an understanding of emo
tions or experiences underlying the belief. It can also give the therapist time
to think as well as additional information about how he or she wants to an
swer the personal question. For example, the therapist might answer, “Well,
no, I’m not a Christian, but I believe I can understand and appreciate how
important your Christian faith is for you, and integrate that into my work
with you. If that’s not enough, I’d be happy to help you try and find a ther
apist who is also a Christian.” Sometimes the actual answer from the ther
apist is less important than patients feeling safe that they can express their
beliefs in a supportive or accepting environment.
The patient may ask personal questions of a much more intimate na
ture, for example, “Are you gay?”; “Have you ever been abused?”; or “Do you
have any personal experience with mental illness?” Answering these more
intimate questions will have powerful effects on the therapeutic relationship,
and the therapist should give ample consideration for how he or she answers.
If the therapist chooses to answer the question, great care should be taken
on how much detail is shared, with special concern for not using the oppor
tunity for their own catharsis. Patients sometimes feel a deepening of the
therapeutic experience when the therapist discloses intimate information,
and this can be quite beneficial for the therapy. In this way therapist disclo
sure can enhance the corrective emotional experience. Alternatively, shar
ing such personal information can sometimes affect patients in ways that are
countertherapeutic. If the patient has a strong negative reaction to the per
sonal information shared, it can damage the therapeutic alliance. For exam
ple, if the patient believes strongly that only a heterosexual therapist can
help him or her, it’s sometimes difficult to overcome this barrier when the
therapist doesn’t conform to the patient’s preference. There are few abso
lutes with therapist disclosure, and a useful exercise for therapists is to de
cide their own boundaries for answering personal questions before they occur.
Case Example of
Appropriate Therapist Disclosure
Rachel is a 30-year-old military psychologist who was employed overseas
in the Iraq war. She developed an aggressive form of breast cancer and re
turned to the United States for medical treatment. She had served several
consecutive stints overseas and developed a romantic relationship there.
Her life was fully engaged there, and once back in the United States she felt
lonely, isolated, and depressed. She did not have much family support and
had considered her social network in the military as her primary support. Her
military “family,” and her boyfriend, remained in Iraq. She started seeing a
psychotherapist and developed a good therapeutic alliance.
RACHEL: Everything seems surreal being back here. It’s so differ

ent there, in the war. I just don’t connect with anybody here.
I’m in a whirlwind of medical appointments for the breast
cancer, but that all seems unreal too. Except for the part about
dying...that’s terrifying. I’m in a depressed fog.
THERAPIST: Have you considered attending a breast cancer support
group? A lot of people have gotten tremendous benefit from
the support groups, and there is even some evidence it can af
fect the outcome of the breast cancer in a positive way.
RACHEL: Yes, I was referred by my oncologist, but I just feel that I
wouldn’t really get benefit given that I’m a professional psy
chologist. It seems those groups are more aimed for laypeo
ple. No offense, but I think I’m above that level by being a
psychologist. I doubt I would fit in.
THERAPIST (who is a psychiatrist): I can see why you might feel that,
Rachel. I must tell you, though, that I once derived great
benefit from being in a public support group where I was the
only professional. I’m sure I thought about things differently
than most people in that group, given my psychiatric training.
But the emotional focus of the group, the benefit of being
with people who shared the emotional experience for trau
matic events as I had, was helpful to me.
RACHEL: Wow, really? I wouldn’t have expected that. I just wrote
those off as not likely to be helpful given my professional ex
pertise. What was it like for you being in the group?
THERAPIST: I initially wanted to keep that I was a psychiatrist a se
cret, because I didn’t want to make other group members un
comfortable. As part of the group introduction, however, we
all had to talk about what we did for a living, and so I shared
that I was a psychiatrist. There was some initial surprise and
a few jokes, likely triggered by some unease with having a
“shrink” in the room. But eventually that seemed to fade away,
and I became just like any other group member.
RACHEL: Was it hard for you to share your emotions there?

THERAPIST: Initially, yes, it was hard to get out of the groove of
wanting to help the others in the group, many of whom were
in life circumstances much worse than mine. One group mem
ber actually called me out on this, said that I was being too
much a “helper” and not helping myself. I was then able to
make the switch and focus on myself, on my needs. And yes,
I was then able to share my feelings in a genuine way.
RACHEL: Maybe I’ll give it a try.
In this example, the therapist decided to disclose his personal experi

ence with a support group, hoping that Rachel would find some benefit
from his disclosure. The patient was not requesting the information, so it
was a risky intervention for him to choose. It may have been partly moti
vated by his countertransference, especially as he liked Rachel and felt a
professional closeness to her. He felt that because he and Rachel shared
some collegiality of both being mental health professionals, it would likely
help. The therapist hoped that by sharing his experience, and modeling the
challenges of doing it along with the potential benefit, Rachel would be
more likely to pursue it. The amount of personal information shared was
“just enough” to achieve this goal. Although Rachel had some exploratory
questions, the therapist did not give specifics on his traumatic experience
or go into great detail of his emotional catharsis. He gave her enough in
formation to resonate with his experience and possibly move forward with
her own. Rachel actually did start attending a breast cancer support group
and found the experience immensely helpful.
Case Example of
Inappropriate Therapist Disclosure
Myra was a psychiatric resident working for a training program under an

educational visa (she was an immigrant from her native Syria). The Iraqi
war was ongoing, and most of her family were remaining in Syria, under
considerable danger from the war. Myra was doing psychotherapy with a
narcissistic man who spent the majority of the sessions lamenting the vari
ous injustices of his life. He was what some people might call a “chronic
complainer.” As Myra listened to him berate people for relatively minor of
fenses, she became angry, thinking about the grave danger her family was
in compared to the trite issues he was so worked up about. It became intol
erable to Myra, and she finally burst out with, “My family is getting shot at
as you speak...do you not understand that so many of your ‘injustices’ are
really very petty and you need to let them go?” The patient became very si
lent. He and Myra had enjoyed a good therapeutic alliance, and he had
never seen Myra react this way before. He genuinely asked about her family,
and she spent the remaining part of the session telling him the very precar
ious situation her family was in. He left the session with his head bowed.
Myra discussed these events with her supervisor. It became clear that
she was in an emotional crisis, and the possibility of her taking a leave of ab
sence from work was discussed. She was able to discuss how her disclosure
was coming from her emotional need and not from the patient. The possible
consequences on the patient were anticipated, including that he might feel
guilt or shame for his “petty” grievances but also that he would be hurt or
angry from feeling attacked by her confrontation. Myra did not take a leave
of absence, but she did get some extra support from her training program.
She resumed psychotherapy with her patient and attempted some repair from
her disclosure session. This included her giving an apology to the patient
and explaining in generic terms that she was undergoing a personal crisis.
She also told that patient that he should not need to weigh the importance of
issues when talking with her. With subsequent sessions he appeared to com
plain less and asked periodically how Myra was doing.
Although it is difficult to evaluate in total whether this example of therapist

disclosure caused damage to the therapy, it was clear that the patient talked
less about his troubles, which likely was a negative outcome.
This last example of therapist disclosure brings up a vital point for psy
chotherapy, namely, that the mental health of the therapist is correlated
with psychotherapy effectiveness. Qualities of the therapist shown to posi
tively influence psychotherapy outcomes have included emotional intelli
gence, empathic capacity, effective management of interpersonal ruptures,
and effective management of difficult emotions.4 Given that the therapeu
tic alliance is the cornerstone for everything that is built in psychotherapy,
and that the therapist is the “anchor” leg of the therapeutic alliance, it makes
sense that good mental balance in the therapist will be linked with success.
Doing psychotherapy can be intimate, intense, and evocative for the ther
apist. When deep emotional scars are opened with the patient, the process
is likely to trigger similar feelings in the therapist. The therapist should
have a host of methods to cope with feelings that arise in therapy in order
to keep his or her balance and continue to work without developing what
has been labeled “compassion fatigue.”5 Coping methods for working with
the job-related stress of doing psychotherapy include strategies for at the
office and outside of the work setting. To directly address compassion fa
tigue, the therapist should have ample opportunity for supervision, a
chance to talk about cases in a confidential fashion with a mental health
professional. It is best not to do this with an administrative supervisor, be
cause therapists must feel free to talk about things in the therapy that might
not be going well, or feelings they might not want an administrative super
visor to hear. The purpose of supervision is for both learning and decom
pression for the therapist, and this is best accomplished in an atmosphere

of openness and trust with the supervisor.
Methods to address emotional tension and stress during the busy work
day can be built into a therapist’s schedule. Sometimes after a particularly
emotionally “draining” session, the therapist can do some relaxation tech
niques or physical movement before the next session. This can include just
a few minutes of yoga breathing or posture, or any other movement that
allows the feeling of decompression. After an intense session, especially when
trauma has been discussed, the air in the room can feel thick with emotion,
and I find it useful to walk out of the room, leaving the door open to allow
wafts of the lingering emotionality to escape prior to starting the next session.
Often during my career people have asked, “How do you do it? How do
you listen to all that pain and suffering without letting it get to you?” In ad
dition to the methods just discussed, I’ve implemented a number of bound
aries to keep myself mentally healthy and fresh for doing psychotherapy.
During the workday I almost always take lunch while doing something re
laxing and non-work-related, such as talking with a colleague about non
work-related things or reading fun or relaxing material. I attempt to keep
this strict boundary unless something interferes beyond my control. Having
a break during the workday from exposure to pain and suffering is essential
for regaining perspective. I also do not bring any patient-related work home
with me, preferring instead to stay later at the office if need be. I might work
on a scholarly enterprise while at home, but I do not work on anything pa
tient related after leaving the office. I contain any “on-call” (after work
hours) emergency issues to the minimum required, taking care of the situ
ation on hand and subsequently placing my notes for the encounter out of
sight, so as not to be reminded of the patient issues later. I don’t discuss
work matters about patients at home, even if kept confidential. Essentially,
I make every effort to contain the association of working with pain to my
physical work site. These efforts help to keep the monumental pain and suf
fering of my patients from contaminating my thoughts and feelings outside
of work. I believe keeping these boundaries decreases compassion fatigue
and allows my empathy and nurturance to blossom while I’m with patients.
Now, in the twilight of my career, I’m just as excited to do psychotherapy
as I was at the beginning.
Keeping mental, spiritual, physical, social, and cultural health will help
overall to decrease compassion fatigue and increase psychotherapy perfor
mance. Having a hobby, robust social network, and regular exercise can all
contribute to good mental health balance. Humor can also help coping and
mental health maintenance.6 Earlier we discussed the situation in which a
therapist violates the ethical professional boundary by having a romantic re

lationship with a patient. In many of these circumstances, the therapist was
lonely and depressed and developed a belief that he or she would help the
patient by providing the “true love” the patient needed.7 When we examine
these boundary violations in retrospect, it is easy to see that the therapists were
meeting their own needs for intimacy while talking themselves into believ
ing it was healing for their patients. Had these therapists been taking better
care of their own emotional health, it might have lessened the chance of
their boundary violations with the patients.
While pointing out the importance of keeping your own good mental bal
ance in being a psychotherapist, I must emphasize this does not mean hav
ing no mental problems of your own. Rather than striving toward a notion
of static, perfect mental health (I doubt such a thing exists), you might in
stead work on understanding your strengths and vulnerabilities as well as
your unique life story that has brought you into becoming a psychotherapist.
Your life story will continue to evolve as you do psychotherapy with your
patients. The better you understand yourself and how people affect you, the
better you will employ your unique personality as a healing force in psycho
therapy. We discuss this concept with greater detail in later chapters of this
book.
1. Some psychoanalysts believe that “you can only take a patient as far as
you have gone,” meaning, the level or depth of the therapist’s under
standing of his or her own emotions would be the limiting factor in how
deep the therapist would be able to help patients in understanding
theirs. What do you think about this?
2. People often ask, “What should I look for in finding a good psychother
apist?” Write a short “guide” to answer this question.
3. When psychotherapy fails, is it useful to examine it as a failure of the
therapist? What would be the pros and cons of using this concept in
post-therapy review of the case?
References
1. Rockwell WJ, Pinkerton RS: Single-session psychotherapy. Am J Psychother
36(1):32–40, 1982
2. Goldberg SB, Rousmaniere T, Miller SD, et al: Do psychotherapists improve
with time and experience? A longitudinal analysis of outcomes in a clinical set
ting. J Couns Psychol 63(1):1–11, 2016
3. Nicholson I: Baring the soul: Paul Bindrim, Abraham Maslow and ‘nude psy
chotherapy.’ J Hist Behav Sci 43(4):337–359, 2007
4. Kaplowitz MJ, Safran JD, Muran CJ: Impact of therapist emotional intelli
gence on psychotherapy. J Nerv Ment Dis 199(2):74–84, 2011
5. Figley CR: Compassion fatigue: psychotherapists’ chronic lack of self-care.
J Clin Psychol 58(11):1433–1441, 2002
6. Gremigni P: Humor and mental health, in Humor and Health Promotion.
Hauppauge, NY, Nova Science Publishers, 2014, pp 173–188
7. Denman C: Boundaries and boundary violations in psychotherapy, in Abuse
of the Doctor-Patient Relationship. Edited by Subotsky F, Bewley S, Crowe
M. London, RCPsych Publications, 2010, pp 91–103
CHAPTER 4
Transference and
Countertransference
Developing a thorough understanding of

transference and countertransference is absolutely, undeniably, unequivo
cally, and ultimately the single most important skill in becoming a good
supportive psychotherapist. Did I make my point? In Freudian terminol
ogy, transference is the process of the unconscious feelings of the patient that
get “projected” onto the therapist based on family of origin relationships.
Freud described transference as primarily an unconscious phenomenon, out
side of the patient’s awareness. For example, if a patient was angry with the
therapist for “no good reason,” it might be because he or she had felt
slighted by the therapist’s apparent lack of attention and this touched on
deeper, chronic issues of feeling unloved that the patient felt in early child
hood. Thus, the patient had “transferred” his or her anger onto the thera
pist from the largely unconscious emotional trauma. In most circumstances,
the transference would have been stimulated by conscious processes, for ex
ample, the patient would have been aware of feeling slighted by the thera
pist and also would have been aware of feeling angry. In psychoanalysis, the
conscious anger felt by the patient was real; however, the analysis of the trans
ference uncovered the deeper, unconscious feelings that were the underpin
nings of the patient’s anger. Whereas transference described the feelings a
patient has toward the therapist, countertransference described the projec
tion of feelings (unconscious) of the therapist onto the patient.
Psychoanalytic theory dictates that most feelings and behavior originate
from unconscious processes. In the evolution of nonpsychoanalytic psycho
therapy, a much broader definition of transference has emerged to include
any feelings the patient has toward the therapist, either conscious or uncon
47
scious. This view does not deny the distinctions between the two, but it does
accept a definition of transference that describes whatever feeling is identi
fiable to both patient and therapist. The interplay between unconscious and
conscious feelings is always present, and in any circumstance, one might pre
dominate. In the previous example of the patient who felt slighted by the
therapist, it’s not hard to imagine a therapy situation in which the therapist
had actually been less attentive and that this reality triggered the deeper feel
ings of inadequacy from childhood that fueled the more intense feelings of
rejection.
It’s important to realize that unconscious processes are playing a role
even in situations in which certain feelings appear to be “justified,” “reason
able,” or “normal” reactions. For example, let’s imagine a situation in which
a therapist slaps a patient in the face (do I have your attention here?). If in
this situation the patient becomes angry with the therapist, would you say
it’s pretty much just a conscious reaction to being slapped? Yes, anger is an
emotion often correlated with pain from physical punishment; however,
there are myriad responses a patient might then have with his or her anger.
Based on their unique childhood history, the patient might express his or her
anger mixed with expressions of guilt, shame, fear, aggression, or compla
cency. These responses would be affected by the patient’s unconscious un
derpinnings. In any transference situation it’s useful for the therapist to be
thinking of both unconscious and conscious components of the feelings
that are expressed in the room.
One of the essential elements of supportive psychotherapy is to develop
and maintain a good therapeutic alliance. Regardless of the specific thera
peutic goals that are overtly stated, a good therapeutic alliance is the substrate
that allows healing processes to occur. In addition, a positive therapeutic
alliance is often the healing process in and of itself (think of a healing rela
tionship from point of view of the corrective emotional experience). Trans
ference is a ubiquitous phenomenon in the therapeutic relationship. The
patient always has a range of feelings toward the therapist. When the trans
ference is generally positive—that is, when feelings toward the therapist are
categorized as “good”—it’s not addressed in any direct way. With a positive
transference the therapist simply allows the good feelings to continue and
nurtures this when appropriate.
Example
PATIENT (displaying a positive transference): You’re a great doctor;
you’re the best one I’ve ever had.
Transference and Countertransference 49
THERAPIST (allowing positive transference): Thanks, James, I appre

ciate that. And I also want to point out that you are 50% of
the equation for us working so well together.
THERAPIST (unnecessarily addressing the transference): James, why do
you think it is important to compliment me?
In this example, the positive transference might involve an unconscious

need for idealization of the therapist; however, it is not causing a problem
in the therapy and so is humbly accepted along with a little nurturance for
the patient being “50% of the equation.”
Transference is only addressed directly when it impairs the therapeutic
alliance. The methods used to address transference can vary, and always with
the aim of repairing the therapeutic alliance so that psychotherapy may con
tinue. The therapist must address negative transferences in an assertive fash
ion and with some urgency, because otherwise therapeutic failure is a real
possibility. Even though the therapeutic relationship involves two people, the
therapist and patient, the therapist must shoulder the majority of the respon
sibility to repair the alliance. Sometimes working through the repair of a neg
ative transference can be a corrective emotional experience ipso facto.
Anger toward the therapist is a frequent negative transference that usu
ally requires intervention in supportive psychotherapy. There are multifacto
rial causes of an angry transference, and it is the job of the therapist to distill
these down to those that make sense to both patient and therapist. There
are no right or wrong methods in doing this; simply, the goal is to repair the
relationship so that it can move forward again. There are as many techniques
for repairing an angry transference as there are patients.
Case Example
Jeanne is a hard-working mother of two, and her life is frequently in chaos.
She has frequent romantic relationships that end with conflict, and the
same happens with her work. She is a highly emotionally volatile person
and extremely sensitive to feeling slighted or put down. It is hard to talk with
Jeanne about these traits because she becomes defensive and angry. She was
the only child of a mother and father who both abused alcohol and were
themselves often involved in angry, volatile, and dangerous arguments. Her
childhood was characterized by either disingenuous, lavish attention or a
complete lack of attention. She carries a desperate need for intimacy that
few ever meet in her personal life.
JEANNE (angry at therapist for changing her appointment time, as he

has done on several occasions lately because of some personal fam
ily issues): I can’t believe this shit. You treat me like I don’t
matter. You act all caring, but really you’re just a paid profes
sional and not a friend. I’ve been really depressed lately. You
don’t care what’s going on with me.
THERAPIST (soothing and repairing the therapeutic alliance): I’m
sorry, Jeanne, your angry feelings make sense. I’m sorry espe
cially because the timing is horrible, with you going through
this tough stretch. I understand you’re hurt, and I really would
like to hear about what’s going on with you if you can tell me.
THERAPIST (possibly not enough soothing, and too soon to examine her
anger): I know you’re disappointed, Jeanne, and you’re angry.
Maybe we can take a look at what’s making you angry in this
situation?
THERAPIST (defensive and unlikely to help the situation): I did give
you more than 24 hours’ notice to change appointments, and
I had some open appointments at other times you could have
scheduled. Why didn’t you schedule one of those?
In this example, a series of appointment changes by the therapist were

one cause of the angry transference in Jeanne. Her statement about “not a
friend” belies an unconscious belief that the therapist should be treating her
as if she were a personal friend, a significant other. This theme of unre
quited love plays a role in Jeanne’s frequent interpersonal conflicts. Al
though this type of disappointment is a frequent cause of her pain, she’s not
going to be able to address these while she’s hurting so badly. She’s too in
flamed to analyze herself. Even though her feelings are academically cate
gorized as “negative transference,” she feels hurt and disappointed in a very
real, very unacademic way. The feelings of hurt are the same, regardless of
the degree that unconscious conflicts play a role. Although the therapist
gave plenty of notice to change appointments, addressing the “right” or
“wrong” of what happened will not lead to a repair of the therapeutic alliance.
The sole goal of the therapist at this time in the therapy is to help Jeanne
soothe the hurt and angry feelings of abandonment—that is, to repair the
therapeutic alliance. There may possibly be an opportunity to examine her
role in her frequent feelings of abandonment; however, she will only be able
to address these when in a more emotionally stable state.
A number of therapeutic techniques are commonly employed when ad
dressing an angry transference. First and foremost is to acknowledge the
validity of the patient’s angry feelings. In addition to validating the patient’s
feelings, this also sets the stage for a potential corrective emotional experi
ence. The therapist should also take a critical look at his or her role in the
conflict and apologize, if the apology is sincere. Insincere apology is not a
good idea and will usually cause a greater rift in the therapeutic alliance.
The therapist should offer solutions to repair the conflict. This structure
and guidance from the therapist will help the patient through the difficult
angry domain by reducing the patient’s sense of being out of control. Finally,
the therapist can provide reassurance to the patient that together they can
successfully work through the conflict. These interventions improve the
likelihood for a successful repair of the transference and also that the pro
cess will be a corrective emotional experience.
Case Example
Brian is a 60-year-old man with a chronic delusion that he is under constant
surveillance. He believes that his every word and action are broadcast
around the world and, thus, that he has no privacy. He suffers greatly from
these beliefs. He has been in therapy for more than 20 years and persever
ates on his beliefs without change. Although he depends on therapy to help
him cope, he resents the “power and authority” that he projects onto the
therapist. For years his therapist has been consistently supportive and com
forting to Brian even though his intense, inflexible, and often angry presen
tation is wearing to the therapist. On one occasion the therapist had been
up all night because of a family emergency and was feeling irritable. His pa
tience was low, and during the session with Brian he was somewhat rude in
telling him that he needed to quit complaining and change. Brian reacted
angrily to this, he abruptly stood up and yelled to the therapist, “You’re re
jecting me! This is ME, and if you can’t accept me for who I am, you’re not
doing your job. I’m not coming back.” Brian then abruptly left the session.
The therapist knew that Brian’s reaction was warranted, because the therapist
had been coarse in his remarks. He decided to send a handwritten apology
letter instead of calling Brian on the phone. He wanted to carefully craft his
words and give Brian the opportunity to read the letter, perhaps several times,
without the intense emotion that talking about the incident might evoke.
Here was his letter:
Dear Brian,
I have been thinking about our last meeting and would like to apologize
for my part in the conflict. I certainly did not intend to upset you; rather,
I was attempting to make a point and did so in a clumsy fashion. I am
sorry for this. I hope we can continue to keep working together in a col
laborative fashion, as I think we have been. I look forward to seeing you
at our next session.
Brian came to the next therapy session and was very moved by the letter.
His resentment of the “authority” of the therapist had softened consider
ably, and he was paradoxically better able to examine his perceptions and
chronic anger with the therapist. The therapeutic alliance had improved
significantly from the repair work on an angry transference.
Psychotherapy is an intimate process, and it’s not unusual for patients

to develop strong positive feelings toward the therapist. In some circum
stances a patient will develop loving feelings toward the therapist. Love is a
term that is often not used in textbooks of psychotherapy because it is im
possible to define. Other than biological states of arousal and sex, we simply
can’t pin love down in a scientific way. Paradoxically, despite being impos
sible to define, “love” is almost always present to some degree with a good
therapeutic alliance in supportive psychotherapy. For many patients, the hour
in therapy represents some of the most intimate moments of their lives.
They talk about themselves and reveal emotions that they’ve never openly
expressed with any other person. With a caring, sensitive therapist, there’s
bound to be development of loving feelings as therapy progresses. The
spectrum of loving feelings encompasses a wondrous and wide variety of
states, from altruistic and familial to romantic. When the loving feelings to
ward the therapist are of a romantic nature, this is called an erotic transference.
Usually the therapist will notice clues that the patient is developing
feelings of attraction; for example, the patient might start dressing-up more
for sessions, wearing perfume or cologne, or giving indirect verbal cues
(“Maybe we should hang out some time?”). Most of the time these feelings
are not revealed in a way that impairs the therapeutic alliance. The therapist
can make statements in subtle ways to dampen the romantic spirit without
need for direct interpretation. Sometimes the patient will give gifts to the
therapist as part of an erotic transference. If the gift is small and of relatively
low value, the therapist can accept the gift while making a statement that
reinforces the professional boundary (“Thanks, this is nice, but please no
more gifts. I can’t accept them as part of my professional ethics”). If the gift
is of a relatively large monetary value, such as jewelry, the therapist needs
to return it and discuss the importance of keeping a professional boundary.
The therapist might use the opportunity to discuss the patient’s loving feel
ings connected with the gift, and this can yield good therapeutic benefit.
When an erotic transference becomes intense, it can disrupt the thera
peutic alliance and then must be addressed. With a powerful erotic trans
ference, the patient feels he or she is romantically in love with the therapist.
As with a negative transference, the patient does not feel his or her love as
an artifact of therapy or unconscious neurosis. Simply put, the patient feels
in love. As with anyone in love, great care must be taken when addressing
this in a way that gently disrupts the fantasy that the love will be returned
romantically. Also, addressing erotic transference is best done in a way that
allows the patient to “save face” and not feel humiliated by having exposed
his or her loving feelings.
Case Example
Sheri is a divorced young woman with social anxiety, panic attacks, depres
sion, and marked loneliness. Her father sexually abused her, and she has had
multiple bad experiences with men in her romantic life. She has been in
supportive psychotherapy for about a year and has felt compassion and un
derstanding from the therapist. She has developed romantically loving feel
ings for her therapist.
SHERI (crying while talking about how good the therapist has been with
her): You’ve been so good to me, I think about you a lot; in
fact, I’ve been having some dreams about you. I think I’m
having some strong feelings for you.
THERAPIST (had been sensing some erotic transference): Are you talking
about romantic feelings?
SHERI (shamefully shaking head): Yes.
THERAPIST (accepting, nurturing, and setting boundary): Sheri, it’s
good you’re in touch with your loving feelings. These are the
most precious feelings a person can have. It’s natural for you
to have loving feelings toward me, as you’ve intimately shared
yourself with me and I’ve treated you kindly. I’m sure you
know I can’t reciprocate romantically with you; however, I
think we can learn a lot about you and what allows you to
love, and that will help you with future relationships. I’m glad
you let me know your feelings.
THERAPIST (likely demeaning and not empathic): This is called an
“erotic transference,” Sheri, and it happens to people in ther
apy. It might seem like love; however, it’s more of a process
of the therapy. As therapy goes on, it will diminish.
THERAPIST (likely too harsh): We can never have a romantic rela
tionship, as it’s an ethical violation of my practice, so you will
have to let go of those feelings.
In this example, Sheri has summoned the courage to expose her loving
feelings to her therapist. Because she was sexually abused by her father, she
likely has intimacy trauma and has blurred boundaries with romantic and
nonromantic feelings in relationships. It will be useful to examine these
boundaries eventually; however, at this time in therapy the exposure of her
loving feelings must be treated with great tenderness. At the same time the
therapist provides encouragement for her openness and normalizes her
feelings, he sets the boundary for the professional relationship (“can’t recip
rocate”) while doing so in a supportive fashion. He also opens the door for
examining her loving feelings in the future.
There are occasions when an erotic transference is more predatory than
loving in nature and causes markedly uncomfortable feelings in the therapist.
This occurs most commonly when a male patient becomes sexually provoca
tive with a female therapist. Some patients will be able to examine their in
appropriate sexual behavior and benefit from understanding it. This will need
to be assertively handled by the therapist (“Your language and demeanor are
sexually provocative, are you aware of this? I think we need to take a look at
this and understand it”). In cases where the patient is unwilling to examine
or change the incendiary behavior, it will need to be extinguished by firm
boundary setting from the therapist (“Your provocative behavior makes me
uncomfortable, and I will not be able to continue to work with you if you con
tinue it”). Simply put, a psychotherapist cannot do therapy if feeling threat
ened in any way. In cases where the therapist feels threatened and the patient
is unable to either examine or change his behavior, it is best to refer the patient
to a different therapist. In these cases, the referral should be to a therapist
where there is less likelihood of problematic sexually provocative behavior
(e.g., a young female therapist referral to an older male therapist).
Occasionally when therapists are working with mentally ill patients, a
psychotic transference will develop in which the patient becomes out of
touch with reality in regard to the therapist. Psychotic transference can in
clude a wide variety of beliefs—for example, that the therapist is a govern
ment agent, a devil, a family member, or in love with the patient. Firm and
gentle contradiction of the psychotic transference is required without resort
ing to argument. Argument usually fuels the fire for the patient to defend
his or her delusional belief more strongly. Usually decreasing the time du
ration of the sessions, lowering session frequency, and decreasing the inten
sity of the therapeutic work can attenuate the psychotic transference.
Case Example
Jennifer is a bright young law student with a diagnosis of schizoaffective
disorder. She has been struggling with law school coursework, having some
depressed mood, social isolation, and difficulty concentrating. She had a
tumultuous relationship with her father while growing up. She is very en
gaging and intellectually provocative in the therapy sessions, often challeng
ing the therapist’s point of view. The therapist, a psychiatry resident, likes
her and enjoys their sessions, especially with the rigor of therapeutic confron
tation. He sees her as similar to himself, a bright graduate school profes
sional. Lately Jennifer has been getting more extreme with her perspective
to the point of being paranoid. The therapist has continued to challenge
her beliefs in a rigorous way.
JENNIFER (angry): I know what you’re up to. I’ve seen this before.
Every time I have a good idea or know what I’m doing, you
knock me down. You’re trying to control my life. You’re jeal

ous. You’re just like my father.
THERAPIST (continuing to uncover instead of lowering the intensity):
What about me makes you think I’m like your father?
JENNIFER (with continued arousal): You act like him and look like
him and dress like him...I can tell the way you look at me.
THERAPIST (challenging her belief, increasing her agitation): Don’t
you think it’s illogical that I would be so much like him, even
to the point of looking at you the same way?
JENNIFER (starts rocking her body and yelling at the therapist as her fa
ther): Keep it up...you always hated me! You can’t stand it
that I’m smarter than you!
This example illustrates that transference and countertransference are

always interactive. The therapist had some mirroring countertransference—
that is, identifying with the patient and enjoying their similarities. He un
consciously felt she could handle rigorous confrontation based on his own
ego strengths. His feelings for Jennifer diminished his ability to perceive
the extent to which she was seriously mentally impaired and losing a grip
on reality. His interventions needed to be much less challenging as she was
escalating in the session. Her underlying serious mental illness and current
stressors were contributing to a decline in her reality testing and develop
ment of a psychotic transference. An alternative method to handle the sit
uation is illustrated in the following:
JENNIFER (angry): I know what you’re up to. I’ve seen this before. Every
time I have a good idea or know what I’m doing, you knock me
down. You’re trying to control my life. You’re jealous. You’re just like
my father.
THERAPIST: OK, Jennifer, let’s take a deep breath and let yourself relax. I’m
Dr. B, just a psychiatry resident trying to help you. Maybe I’m not
doing such a good job of it; I’m sorry if I’m upsetting you. Let’s work
more on helping you find ways to feel better...more calm and safe.
Here the therapist is purposefully and directly using calming methods to

decrease the intensity of the session. He diminishes his stature (“just a psy
chiatry resident”) to lessen the competition she feels with him (her father
in the psychotic countertransference). His focus at this time is to lower the
emotional intensity and establish reality as much as possible.
Understanding countertransference not only is important for the ther
apist; it’s essential for doing good psychotherapy. In Greek mythology the
theme of a “wounded healer” was manifested by Chiron the centaur and
also by Asclepius the god of healing, both of whom endured physical and
emotional traumas that later allowed them to have extraordinary healing

powers. At the turn of the nineteenth century, Carl Jung, a psychoanalytic
disciple of Freud, determined that the “wounded healer” phenomenon ap
plied to most people entering the psychotherapy professions because they do
so in an unconscious attempt to heal their own emotional issues or “wounds.”1
At least one study has shown empirical support for this notion, with the
finding that 73.9% of counselors and therapists identify one or more
“wounding experiences” as influencing their career choice.2 Because coun
tertransference involves elements of both unconscious and conscious pro
cesses, the very best method for therapists to understand this is to undergo
their own psychotherapy. Becoming a patient of their own psychotherapy
reveals insights to developing therapists that simply cannot be learned by
any other method. Issues of trust, dependency, helplessness, intimacy, loss,
defensiveness, and transference will all likely emerge in the process of ther
apy. Developing therapists will then bring deeper awareness of these issues
into their own psychotherapy practice. Therapists in their own therapy will
also come to understand some of the patterns of their unconscious pro
cesses. Understanding these issues from the perspective of the patient will
allow much better analysis and comprehension of their countertransference
as it emerges with their own psychotherapy practice.
A requirement to becoming a psychoanalyst is for each analyst-in-training
to undergo his or her own psychoanalysis, and I believe all students of psy
chotherapy should be required to have their own psychotherapy experience
in equal fashion. Other forms of learning self-awareness through profes
sionally guided discovery (i.e., nonpsychotherapy introspection experiences
such as encounter groups, spiritual guidance groups, and meditation) can
also help therapists develop better understanding of their own psychology.
For understanding countertransference, however, I believe the discovery
vehicles should have an outside observer to best address the personal un
conscious processes in the therapist. We’re all wounded healers, and the
better we understand this, the better we will be able to understand and uti
lize the feelings that arise in us as we do psychotherapy.
“We are not machines” is as simple and self-evident a statement as one
can make. Despite this obvious truism, therapists often expect that they will
have no emotions while doing psychotherapy. In fact, therapists are going
to have the same range of feelings in countertransference that patients have
in transference. It is inherent in the therapeutic process. Although therapists
acknowledge this, they sometimes have difficulty in accepting the feelings
that arise with countertransference. Somehow a prevailing feeling that works
its way into the mind of the therapist is that it’s “wrong” to have feelings
toward the patient.3
I’ve found it useful to conceptualize four different “stages” in therapists
for coping with countertransference. Stage 1 is denial. With denial, therapists
disavow having feelings toward their patients. They may deny one or more
feelings, or categorically deny that they have any feelings at all toward pa
tients. Most beginning therapists have some denial with accepting coun
tertransference because it feels somehow “unprofessional.” Denial in the
beginning therapist is natural, and usually gaining therapy experience with
good supervision helps move the therapist out of this stage. Therapists who
remain in denial of countertransference are actually dangerous to patients
in psychotherapy, because such therapists are much more likely to act out
their disavowed or unconscious feelings in the therapy itself. For example,
if the therapist dislikes the patient but is unaware of these feelings, she is
likely to reject the patient in unconscious ways that the patient will feel. She
might send strong rejection signals with body language, the tone of her
voice, or use of rejecting language. In more extreme examples, the denial of
countertransference can lead to malignant acting out, such as when a thera
pist has a romantic relationship with the patient. Within the psychiatric
profession a frequent rationalization given by psychiatrists who had roman
tic affairs with patients was that it was to “help” the patient (“for the patient’s
own good”). The profile of the psychiatrist in many of these circumstances
was that of a lonely, depressed (often divorced), middle-aged man (cited in
prior chapter). These boundary violations occurred largely because the psy
chiatrists were not in touch with their own needs and acted out on their
countertransference feelings of attraction to the patient.
Case Example
Mark is a depressed and anxious young man who is highly dependent and
often asks his therapist for guidance and support. Some people might de
scribe Mark’s presentation as “clingy.” The therapist is a strongly positive,
independent, assertive young man who grew up in poverty. He has over
come great odds to become successful, and his colleagues would describe
him as a “self-made man.” Mark’s dependence and whining demeanor are
aversive to the therapist; however, he keeps an outwardly positive stance
with Mark. Mark’s weakness causes unconscious fear in the therapist, and
he is in denial about the degree to which Mark upsets him. One beautiful
sunny day, the therapist decides to leave work early and go bike riding.
While on his bike ride and enjoying the sunshine, he suddenly realizes that
he forgot his appointment with Mark. The therapist had been meeting
with Mark weekly on the same day and time. He was not a forgetful person
and rarely missed an appointment of any type.
This is an example of denial causing an acting-out of countertransference

by the therapist.
Stage 2 is reluctant acceptance. In reluctant acceptance the therapist ad
mits having countertransference, but with embarrassment or shame. Re
luctant acceptance is uncomfortable for the therapist but a necessary step
toward accepting countertransference. Sometimes reluctant acceptance
leads a therapist to be overly friendly with the patient to compensate for his
guilty feelings. Overall this is much less likely to interfere significantly with
the psychotherapy than denial.
Stage 3 is acceptance. In Stage 3 the therapist accepts that she has feelings
for the patient and can do so without shame. She recognizes countertrans
ference as a perfectly natural phenomenon in the process of psychotherapy.
With Stage 3 the therapist can operate more freely with her countertrans
ference, and the possibility of acting out is markedly reduced.
Stage 4 is embracement. With embracement, the therapist not only ac
cepts the feelings but realizes that they likely have significant meaning to
the current therapeutic process. In other words, countertransference actually
becomes a valued and important tool in the psychotherapy. With embrace
ment the therapist realizes that the countertransference he experiences is
likely felt by others in the interpersonal life of their patient. This valuable
insight not only enhances the psychodynamic formulation but leads the
therapist to choose appropriate strategies and techniques for intervention.
Because countertransference is a blend of both conscious and unconscious
feelings, it’s also a mixture of what is happening with both patient and ther
apist. It’s most definitely a “two-way street.” Although both patient and
therapist processes are involved in countertransference, the degree to which
each is involved can vary. For example, if a therapist is depressed and un
dergoing a difficult divorce because her spouse cheated on her, she might
feel angry toward a patient who is discussing his own guiltless infidelity. In
this example, the countertransference might be heavily weighted toward
being mostly an issue for the therapist and not important in the patient’s
therapy. If the therapist becomes aware of her countertransference, she can
cope with it directly in a number of ways and avoid having it interfere with
the psychotherapy. If she is not aware of her feelings, they likely will be
expressed in unconscious ways to the patient and have a significant detri
mental effect on the patient. In another example, a therapist might notice
that he had recently become very bored in the sessions with a patient where
previously sessions were rigorous and emotionally exciting. The boredom

countertransference of the therapist might reflect that the patient is avoid
ing something important and filling the session with “light” material in an
attempt to evade more painful, significant issues. In this example, the anal
ysis of the countertransference would be a useful tool for the therapist to
more actively prompt the patient toward looking at these issues.
While countertransference is a natural process of doing psychotherapy,
there are “red flags” of countertransference that indicate it needs special at
tention. These “red flags” indicate feelings that can have harmful results if
not processed in direct fashion. They include the following:
1. Believing that your relationship with the patient is “special” and not
subject to the usual rules of professional conduct. This can also include
believing “I’m the only one” who can help the patient.
2. Doing something with the patient outside of the normal therapeutic
activity (something that you do not do with any other patient). For ex
ample, walking the patient to his or her car, becoming friends on a social
network, or giving the patient your personal phone number.
3. Dreaming about the patient, especially if this occurs more than once.
4. Daydreaming excessively while in the therapy session, being mentally
“outside of the room” for extended periods of time.
5. Dreading seeing the patient’s name on your schedule or hoping for a
cancellation. Alternatively, looking forward to the session, especially to
tell the patient something about your life.
6. Having intense feelings about the patient or therapy session that stay
with you well beyond the therapy hour. This can include having frequent
fantasies about the patient.
7. Keeping something from the therapy secret or hidden from psychother
apy supervision.
8. Initiating contact with the patient outside of customary procedures.
Some might question, if the countertransference feelings are generally

good, why bother to analyze them? For example, a psychiatrist once re
ported to me that she gives her cell phone number only to certain patients
whom she can trust. What’s the harm? While it might help those “special”
patients to have her telephone number, at the same time the special nature
of their relationship might influence the psychiatrist in ways that are detri
mental to the psychotherapy. What if part of what makes them special is
that in a deep, emotional way they remind her of herself, of her struggles
to feel trusted or accepted by others? Her countertransference might then
strongly shape her therapeutic interventions with the patient. Generally,

patients want to be liked by their therapist, and therapists want to be liked
by their patients. What happens if the patient then disappoints her, violates
her trust? Might she react unconsciously in ways that are punitive? Might
she also miss opportunities to confront the patient because she has too much
of an unconscious investment in mutual trust? Countertransference acting-
out may seem to open the therapist’s eyes to a particular perception of the
patient; however, it does so at the expense of becoming blind to another. If
the psychiatrist were to give her cell phone number to all her patients, this
would be less likely of a countertransference issue.
In the real estate business there is a saying about buying a good home,
and that is, “location, location, location.” In becoming a good psychother
apist, it is, “supervision, supervision, supervision.” Most psychotherapy
trainees have case supervision built into their educational programs. For
some therapists, supervision stops once they graduate. I don’t understand
this, because countertransference doesn’t stop with graduation. It’s impor
tant to continue supervision throughout one’s career for professionals doing
psychotherapy of any type. Supervision usually involves reviewing a case
with an experienced psychotherapist, preferably one with therapy supervision
experience as well. Supervision can also be done in a peer group, among
similar or different types of therapy professionals. One of the most inter
esting and effective group psychotherapy supervision experiences I’ve had
was with a group composed of a psychiatrist, psychologist, social worker,
marriage and family counselor, and chaplain. The heterogeneity of the group
allowed for “thinking outside of the box” much better than with a group
composed solely of psychiatrists. Video or audio recording the psychother
apy (with patient permission) for review later in supervision can be partic
ularly useful, because the supervisor can help analyze the dialogue in more
intricate fashion as well as examine transference and countertransference.
There are differences among what is termed case consultation, supervision,
and what I call “safe supervision.” With case consultation, the therapist re
views a therapy case with a supervisor, usually focusing more on the content
of dialogue between the patient and therapist. There is low personal risk to
the therapist with case consultation, because the review does not involve ex
amining the processes of psychotherapy. With supervision, the processes of
the therapy are open for analysis, including transference and countertransfer
ence. This is risky for the therapist, because divulging his or her feelings is
part of the supervision. Mirroring the very psychotherapy the therapist is
reviewing, if there are feelings of mistrust in the supervisor, or if the super
visor doesn’t embrace the natural process of countertransference, the ther
apist isn’t likely to divulge much about these feelings. This would then limit
the effectiveness of the supervision. In safe supervision, the therapist is able
to talk about countertransference with impunity. This freedom to explore
countertransference with a trusted supervisor is what gives safe supervision
its depth and power. It’s vitally important for every psychotherapist to have
the opportunity for safe supervision.
Case Example
Joe is a single young man in psychiatry residency and learning psychother
apy. He is working in therapy with a young woman who has loneliness and
depression. She is a beautiful woman and frequently compliments Joe. Joe
is somewhat lonely and notices his feelings of attraction for the patient are
interfering with his focus in the therapy.
JOE: I’ve found myself lately staring into her eyes during the ses
sion, sometimes daydreaming instead of listening to what
she is saying.
SUPERVISOR (bolting upright with alarmed look on her face): What
are you telling me? You can’t be doing that!
JOE (quickly realizing this is not safe supervision): Of course, that just
happened once. I put it out of my mind, and we’re back on
track now. Let me tell you about what she was saying...
In this example, Joe opens up to the supervisor to process his counter-

transference. She is alarmed by his erotic feelings toward the patient and re
acts disapprovingly. Joe quickly adapts to his supervisor’s reaction and
learns to hide his countertransference from her. Paradoxically the supervi
sor’s disapproval of his feelings is more likely to encourage acting out from
Joe than if she had guided him through them.
Case Example
Carl is a married young man in his final year of psychiatry residency and
doing psychotherapy with a young lady who is a prominent actress in the
community. Carl is shy, and his patient is exotic and alluring. She has of
fered him tickets to see her in her current play. Carl has a trusting relation
ship with his supervisor and is asking if it would be appropriate to attend her
performance.
CARL: She offered me tickets to see her performance. I’ve heard it’s
a good play. I would sort of like to go, but I’m wondering if I
should. I don’t know...what do you think?
SUPERVISOR: Let’s look at this more closely, Carl. What are your
feelings about her?
CARL: I do think about her now and then, more than other pa
tients. I mean, she’s such an interesting person.
SUPERVISOR: Yes she is. Do you have any feelings of attraction to her?
CARL: Well, yes, I guess I do. Not a lot, but she is attractive.
SUPERVISOR: When you think about her, what type of things do
you imagine?
CARL: I imagine watching her in the play and having feelings of
knowing her in a special way, like I know her more than other
people watching her, that I am special in her life.
SUPERVISOR: Sounds like she is affecting you in a powerful, some
what erotic way. If she weren’t your patient, do you think you
would have any desire to see the play?
CARL: No, I wouldn’t go; I don’t really go to plays.
This is an example analysis of an erotic countertransference with safe

supervision. Carl is a senior-level psychiatry resident and has a fair degree
of experience in both therapy and supervision. Carl and his supervisor have
a good working relationship, and he is able to answer some provocative
questions, including answering questions about his attraction to the pa
tient. The supervisor guides Carl through some of the “red flags” of coun
tertransference, including his frequent thoughts of the patient outside of
the sessions and his contemplation of attending her performance. The tran
script shows just the beginning of Carl’s analysis of his countertransference.
With further supervision, Carl was able to understand why the patient was
evoking his feelings and also identified some erotic transference that was
occurring with the patient. Carl used the information learned in supervi
sion to reach a better understanding of his countertransference. He decided
that attending the performance was not a good idea.
Supervision can sometimes be helpful with countertransference even
when there is no specific resolution or insight gained. Much as in psycho
therapy, the act of revealing feelings in supervision in and of itself can allow
a release of countertransference.
Case Example
Jason is an experienced psychiatrist and working pro bono at a clinic serving
indigent patients. His therapy patient, Connie, is an unemployed, obese,
and narcissistic young lady with a diagnosis of depression. She is seeking
disability for her depression and puts intense pressure on Jason to do the
necessary paperwork to make this happen. He sees her depression as mild
and not meeting disability criteria. She has complained to the clinic admin
istrator about Jason, that he is not meeting her needs. The therapy sessions
are mostly battles, because Connie is always in crisis and pressuring Jason to
“give her” disability. Jason feels Connie exaggerates her symptoms. He be
gins to dread the sessions and has fantasies of her quitting. He is also re
pulsed by her, both by her physical appearance and her schemes to “work the
system” by getting disability. He knows these are “red flags” of countertrans
ference and brings the case into supervision.
JASON: I’m having a hard time finding anything likeable about this
patient. She repulses me, both physically and her personality.
Our sessions are battles; she is always bringing a crisis into
the session and answers “Yes, but...” to any solution-based
problem solving I attempt with her. I’m starting to dread when
she is on my schedule.
SUPERVISOR: Tell me about her upbringing, Jason. What was her
childhood like?
JASON (startled when he realizes he doesn’t know anything about her
childhood): Wow, I don’t know anything about her childhood.
I guess because each and every session is a battle, I haven’t
had time to get to know her.
SUPERVISOR: That is impressive Jason, that you don’t know. You al
ways know the childhood history on your patients. Tell me
more about your repulsive feelings.
JASON: She just seems to be the opposite of all my values—hard
work, responsibility, honesty. I’ve had patients like her before
without this strong of a repulsion, I’m not sure why I can’t ac
cept her better.
SUPERVISOR: Interesting, you have no empathy for her. I’m guessing
there is something about her that you have a hard time accept
ing in yourself. Something you are repulsed by in yourself.
JASON (feeling stunned): I have no idea, but just you saying that
makes me feel like it rings true. It makes sense to me. I feel
it must be true, although I can’t put my finger on what it is.
Jason experienced a strong preconscious moment in the supervision,

where although he wasn’t exactly sure what feelings he was suppressing, he
had a “gut feeling” the idea was valid and important. Jason believed there
was something he saw in Connie that repulsed him about himself. Al
though he investigated this idea further in supervision, he was unable to
clarify what the repulsion was. He decided to spend the next therapy session
with Connie getting to know her better, regardless of her “battle-ready”
presentation.
CONNIE (acting irritated): I don’t even know why I come here. You aren’t
helping me, and my depression is horrible.
JASON (diffusing the battle): I’d like to help. I feel like we’re so often engaged
in a battle, I’m missing something important about you. How about
we put the current problem aside for a minute so that I can learn
more about you?
CONNIE (continued irritation): I can’t just put the problem aside. I have bills
to pay, and my depression is bad.
JASON (continuing to diffuse the battle, provide validation and structure): I un
derstand your urgency. I’m just able to do a better job of understand
ing what is happening here and now when I know where you came
from, your childhood, and what life was like for you growing up.
CONNIE: I really don’t want to talk about that. It wasn’t very good.
JASON: Maybe we can just start out easy, like where did you grow up, and
tell me a little about your family?
Jason ended up getting a good history of Connie’s childhood and family

experience. Not surprisingly, she had endured a significant amount of cru
elty and alienation as a child, and she often felt unloved. She likely was con
tributing to Jason’s neglect of hearing her story by avoiding it herself, either
consciously or unconsciously. By listening to her life story, Jason developed
a sense of empathy for her that he previously didn’t appreciate. The repug
nance he felt toward her softened, and he was better able to work with her.
Connie seemed to respond to his softened stance in kind, and she lessened
her attacking stance. With these improvements in the therapeutic alliance,
Jason and Connie were able to make significant progress in therapy. Con
nie’s depression improved, and she was able to obtain a job. While Jason
never did figure out exactly what he saw in Connie that might have been a
self-repulsion, talking about his countertransference in supervision allowed
his empathy to develop and resulted in an improved therapeutic alliance.
Countertransference can sometimes be used by the therapist by giving
feedback about his or her own emotions to the patient directly. This tech
nique must be used with caution because it usually affects patients in pow
erful ways, sometimes to the detriment of therapy. If the patient feels he has
hurt or angered the therapist, he might subsequently censor his material in
effort to protect the therapist. Alternatively, he might harbor resentment
and withhold material, thus sharing less in a passive aggressive way. Gen
erally, the therapist should shy away from revealing personal angry or hurt
feelings. In limited circumstances the therapist can make use of angry or
hurt countertransference feelings when shared with the patient in a non-
personal way.
Example
PATIENT (angry, raising voice and pounding his fists at times): Why
are people so stupid? Idiots! All I did was ask for the sales
manager, and they called security. I’m not the criminal, I’m
the victim! They ripped me off. Next thing you know, the
police are there, and I’m getting a public disturbance citation.

Those frickin’ cops hate me!
THERAPIST (feeling slightly afraid from the angry intensity in the room):
Even just hearing about it now from you, I can understand
how you might make some people afraid. You have a lot of
intensity. I want to help you with this, but maybe take a few
deep breaths and get yourself recentered, to help you feel calm
as we go over this.
THERAPIST (less preferred because it is too personal): You’re making
me feel afraid right now, so I can understand how you fright
ened those people.
In the first example response, the therapist is using her fearful counter-
transference by giving feedback in a nonpersonal way (“might make some
people feel afraid”) and coupling this with some gentle confrontation (“You
have a lot of intensity”). In the second example response, the therapist has
admitted feeling fearful and sympathizes with the people who called secu
rity on the patient. The patient might then experience this as a rejection
from the therapist, feeling “unheard,” and further see himself as the victim.
He also might see the therapist as frail and unfair, much like so many other
people he feels embittered about. Alternatively, the patient may feel some
empathy for scaring the therapist and subsequently try to restrain himself
more in the sessions to avoid upsetting the therapist further.
Probably the most useful sharing of countertransference in supportive
psychotherapy is for the therapist to express confusion or perplexed feelings.
Example
PATIENT: I told them I didn’t want to work there anymore. I’ve de
cided it was too stressful. Besides, I like the manager and felt
we were making progress. I actually thought he was someone
I could relate to, maybe even as a friend. The people there
were mostly weird, but I did like some of them. I know work
is good for me, but maybe it was time for a change.
THERAPIST (feeling confused): I’m feeling confused, I hear you say
ing a bunch of things you like about work and the people, but
also that you need to leave. Help me understand this better.
The therapist in this example shares his feeling of confusion. Seeking

clarification by saying, “Help me understand this better,” is preferred to the
therapist asking, “Please explain this better,” by putting the emphasis on the
therapist’s lack of understanding as opposed to the patient not explaining
well enough. This emphasis is supportive of the patient and more likely to
increase her effort in responding. Another useful, supportive way to seek

clarification is for the therapist to ask, “I’m curious about...”
Therapists often develop strong feelings of admiration, caring, affection,
or nonerotic love for their patients. These countertransference feelings en
compass a wide variety of origins and personal situations. We might admire
their perseverance in the face of severe hardships, their perspectives on life,
their values, or their sense of humor. We might feel great compassion for
their life struggles and fantasize about taking them home with us to provide
the love and nurturance they never had and so strongly need. Or they might
just remind us of someone we love. In most circumstances, these positive
countertransference feelings are not problematic as long as the therapist is
aware and able to sublimate them in the therapy. The patient will usually
sense this benevolent attitude on the part of the therapist and sometimes
seek direct confirmation of it. This can place the therapist in an awkward
position, “Do I tell the patient that I like her?”
Case Example
Bob is a shy, socially anxious, intelligent young man and has been in sup
portive psychotherapy for several years. He was severely bullied in adoles
cence, to the point he dropped out of school and became socially phobic.
The therapist genuinely enjoys Bob’s perseverance, wit, and kindness to oth
ers, which are especially admirable given his childhood abuse. Bob admires
the therapist and feels safe with him.
BOB: I’m just too nervous to join that group. I feel like people in
general don’t like me. I don’t even like myself very much.
What is there to like?
THERAPIST: We’ve talked about this before, Bob. Together we have
looked at so many things about you that are likeable. Are you
having trouble getting in touch with what you like about
yourself...feeling it at this time?
BOB: I know, I know. I can say those things, but I still don’t like
myself, and I don’t feel like people like me. Do you like me?
THERAPIST (genuinely): Yes, Bob, I do like you. You have so many
good qualities, it’s easy to like you. I think what’s most im
portant, however, is that we need to keep working on you lik
ing yourself. That’s our challenge. I think when you like
yourself better, it’ll be easier to believe that others like you.
THERAPIST (dodging the question, acceptable): I can understand your
question, Bob, but I need to shift the focus on what you feel.
What’s most important is that you like yourself. We’ve talked
about your many likeable traits, but you have a hard time be
lieving you have these. We need to understand better what

stops you from believing in yourself.
THERAPIST (dodging the question, less acceptable): Bob, I really can’t
answer that question for professional reasons. Let’s take a
look at what you feel about yourself instead.
In the first response example, the therapist readily admits to liking Bob
and subsequently challenges Bob to like himself. The therapist genuinely
likes Bob and keeps his countertransference minimal via a short answer, then
encourages a deflection from his own personal feelings to those of Bob’s.
On some level, Bob believes that the therapist likes him. By risking the
question, he gets some immediate validation for his feelings within the safety
of the therapeutic relationship. This validation can be a corrective emotional
experience. In the second response example, the therapist purposefully
avoids giving a personal answer to Bob and keeps the focus on Bob’s percep
tion. Some might argue this is a better answer, avoiding any countertrans
ference acting-out from the therapist. One possible shortcoming of this
approach is that it doesn’t allow for a direct validation of Bob’s feelings. There’s
no one correct answer to this situation. In the last response example, the ther
apist has set a firm limit. It’s less empathic and somewhat brisk, and this
might lead Bob to greater censure of what he reveals in future psychotherapy
sessions.
1. Years ago, some psychiatry training programs required that their resi
dents undergo their own psychotherapy as an essential part of their ed
ucation. What do you think about this idea?
2. A patient starts wearing very heavy perfume or cologne to the sessions,
and this is aversive to the therapist. How do you handle this? Is this in
dicative of transference and/or countertransference?
3. A therapist has a patient who writes beautiful poetry. The therapist is
moved by the patient’s poetry and asks if he can share it with some
friends (while keeping patient’s name confidential). Is this OK?
4. Is it ever OK to tell a patient that you love him or her? Under what cir
cumstances?
References
1. Jung C: Fundamental Questions of Psychotherapy. Princeton, NJ, Princeton
University Press, 1951
2. Barr A: An investigation into the extent to which psychological wounds in

spire counselors and psychotherapists to become wounded healers, the signif
icance of these wounds on their career choice, the causes of these wounds and
the overall significance of demographic factors. Master’s thesis, Glasgow,
Scotland, University of Strathclyde Counselling Unit, 2006
3. Gabbard GO: Lessons to be learned from the study of sexual boundary viola
tions. Am J Psychother 50(3):311–322, 1996
CHAPTER 5
Strategies and Techniques
There are so many creative ways to engage

and guide people in the therapeutic process, to isolate a few for this chapter
seems a little short sighted. I’ll do my best to outline the more common
strategies and techniques that form the bulk of what we do in supportive
psychotherapy.
Listening
Can we call listening a technique? Not only is listening a technique, but it’s
the most powerful skill of supportive psychotherapy and likely the most im
portant skill in all psychotherapies for that matter. In each and every ther
apy session, most patients will feel better if they experience feeling “heard.”
I debated whether to include listening as a supportive psychotherapy tech
nique; however, after decades of supervising psychotherapy, I can say with
out doubt that there are different levels of effective listening among
therapists and that effective listening is correlated with therapy outcomes.
Keen attention and focused listening are powerful tools for the therapist to
have. The best judge of listening technique comes from the patients, be
cause they always have a sense for if they are “listened to.” Good eye contact
and receptive body posture that emanates “I am here for you” from the ther
apist help patients feel heard. Good listening also includes careful atten
tiveness to the body language, emotional tone, and overall bearing of
patients in the sessions. Watching for incongruence between what patients
are saying and how they appear emotionally is part of good listening tech
nique. Checking in periodically to ensure that you’re understanding a pa
tient is good technique; however, avoid interrupting when the patient is in
a flow of important ideas or feelings. If you have a burning question, make
69
a mental note to bring it up later in the session in order to avoid interrup

tion. Checking in, or what has been called “active listening,” includes suc
cinctly saying back to the patient what you are hearing (e.g., “What I’m
hearing you say is...,” “OK, you’re saying...”). Effective listening not only
helps the patient in a direct fashion but also aids the therapist in better
comprehension of the patient. It goes without saying that you shouldn’t be
distracted by cell phones or computer screens while listening to the patient.
Plussing
I first became exposed to the word “plussing” early in my career when
studying crisis intervention techniques under the tutelage of Dr. Douglas
Puryear (see Helping People in Crisis).1 Simply put, plussing is promoting a
positive atmosphere in the therapy by finding the good in the patient and
accentuating the positive in the patient’s situation. In a way, it’s putting on
rose-colored glasses and seeing what the patient presents as half full. Some
times this means looking intensely for the positive when it’s hard to find. If
the patient is feeling low because of chronic failures, you might point out
that he has continued to keep trying regardless and that his resiliency is ad
mirable. Plussing also includes finding ways of letting the patient know
“you did well.” I believe the term “plussing” captures the technique better
than “praise,” because it describes a wider range of positive feedback, with
smaller and more distinct gradations. Also, “praise” is often associated with
religious meaning, whereas “plussing” sounds more neutral. Plussing might
be a simple nod of the head while saying “nice,” in response to the patient’s
telling you she completed an assignment, or finally read a book, or asserted
herself in a situation in which she would typically be too passive. The plus-
sing also can be more demonstrative, time-consuming, and scrutinizing:
“Give me details of what happened,” you might say. “I want every little
morsel so that we can fully understand this nice growth of yours.” Many of
our patients feel a chronic debt of praise throughout their lifetime. Many
have had a lifetime of negative feedback, both from within and outside of
themselves. Whenever you’re plussing patients, you’re feeding an extremely
malnourished emotional part of them. Like the proverbial “water in the
desert,” plussing can allow an oasis to spring. Plussing is best done in re
sponse to things the patient can genuinely feel good about. If the patient
doesn’t feel good about it, plussing may result in an empathic failure on the
part of the therapist. The therapist must be attuned to the proper amount
of plussing that the patient can tolerate and benefit from. This will often
become apparent by paying attention to the response of the patient to the
Strategies and Techniques 71
plussing. If the patient hunkers down on negativity following a plussing

statement from the therapist, it might be a clue that the plussing was too
far removed from the patient’s suffering. In general, however, plussing pro
vides positivity to the patient and yields dividends as therapy progresses
with very little downside.
Example of Plussing
Austin is a middle-aged man with depression. He was previously work
ing and had a social life as well as a significant other; however, chronic
alcohol use, pessimism, and neglect led to loss of job and relationships. He
has marked loneliness, multiple medical problems, and a socially isolated
lifestyle.
AUSTIN: I’ve finally made an appointment to see my doctor about

my chest pain. You know I hate doctors, but I’m tired of not
knowing what is going on.
THERAPIST: Good job. I know how much you hate doctors, so it’s
a good sign you are taking care of yourself.
Possible Unempathic Example of
Plussing
AUSTIN: I went and saw a movie this weekend. The theatre was
crowded, and I had to wait in line forever to get a ticket.
Sometimes I think it’s just not worth it...even trying.
THERAPIST: Well, at least you gave it a try Austin...getting out of
your apartment and doing something, even if you didn’t want
to. Good for you for trying.
AUSTIN (with shrug of his shoulders): If you say so...
In this example, the therapist gave a reasonable plussing response, be

cause Austin was socially isolated and depressed, rarely venturing out be
yond his apartment. Austin responded to the plussing by saying, essentially,
“I don’t see it the way you do.” Because Austin’s response was less than an
endorsement, this might indicate that he didn’t feel positive about the plus-
sing that the therapist had provided. It’s hard to know from this example,
however, because he might have experienced a small positive effect from the
plussing but was nonetheless feeling more indebted to his depression. The
therapist can determine this further by clarifying Austin’s response.
THERAPIST: I guess from your response, you aren’t giving yourself much
credit for going.
AUSTIN: I used to be so capable, do so much...I was working and actually

had a social life. It’s hard for me to feel good about much of anything
I’m doing these days, I feel like such a loser.
By this response Austin has guided the therapist further into understanding
his dismay. In comparison to “who he was,” Austin can’t feel good about even
small improvements in his current situation. The therapist now has a num
ber of avenues to explore this feeling of incompetence. The initial plussing
might have been an empathic failure, but by the therapist being attentive to
Austin’s response, it led to further useful therapeutic work.
In my experience supervising therapists of all types, I’ve found that many
younger therapists or students find it hard to let themselves freely provide
plussing for patients. Sometimes younger therapists or trainees find it hard
to express caring, I believe because caring seems to go against keeping a
professional boundary in the early phases of learning psychotherapy. In a
way, plussing flows into a caring stance for the therapist. With supervision
and experience, most new therapists will begin allowing themselves to use
plussing more frequently and will subsequently experience a “freeing” ef
fect in their therapy. Plussing begets more plussing, allowing the psycho
therapy experience to become even richer for therapists. Patients feel the
positive atmosphere, and this fertilizes the opportunities for corrective emo
tional experiences.
In teaching plussing techniques to professionals from various specialties
(e.g., social workers, psychologists, family therapists), I’ve encountered the
most resistance to using plussing from psychiatric residents. I believe this is
as a result of the “medical model” of education, in which pathology forms
the basis for technique and practice. Seeing and curing illness are the focus
in medical training. The modal emotional stance is one of “distance” from the
physician. Plussing is somewhat counter to this stance because it involves
more expression and emphasis on strength focused interventions. I ac
knowledge that physicians need to keep a distance from patients for their
own emotional survival, because dealing with death and dying is hard when
they have invested their feelings in their patients. Doctors have a hard time
allowing themselves to express emotions with patients, especially positive
ones. The majority of people entering the help professions genuinely enjoy
helping people, and therefore plussing is actually a natural expression of
their attitude or beliefs. In paradoxical fashion, when doctors actually “let go”
and use plussing, it requires less mental energy than withholding the emo
tions. Doctors usually enjoy their practice better when they allow themselves
the natural rewards of plussing. I’ve worked with family practice physicians
on using plussing techniques, and they uniformly report greater satisfaction
in their medical practice when doing so. Plussing can be especially helpful
when working with the “difficult patient” because it can be disarming of the
tension when a patient’s usual behavior pattern is to induce conflict in rela
tionships with health care providers.2
Example
PATIENT (a patient whose help-rejecting personality and chronic com
plaining make him difficult to work with): I’m not sure why I
even tell you these things, you don’t ever do anything about it.
THERAPIST (plussing response): Well, I give you credit for your for
titude, you don’t give up easily.
PATIENT (with a chuckle): Yes, I’ve been called ‘stubborn’ a time or
two.
In this example, the patient was “baiting” the therapist for an argument
by accusing her of being ineffective. The therapist felt offended by the
statement (natural emotional reaction); however, instead of giving a defen
sive answer (“I feel like we have accomplished some things together”), she
gave a plussing response. This caused a chuckle in the patient and disarmed
the potential conflict instead of increasing it.
One of the “side effects” of becoming a good psychotherapist is that prac
ticing the techniques and experience of doing supportive psychotherapy can
stimulate growth in the therapist. As I’ve learned to allow myself to use
plussing with patients in psychotherapy, I’ve become better able to provide
praise to others outside of the therapy situation as well. There is very little,
if any, downside to becoming a “plussing” type of person.
Explaining Behavior
Most of our patients in psychotherapy are in an emotional jungle, with feel
ings and behaviors that feel foreign to themselves. They’re a stranger in the
land of their mind. Why do I do that? Why do I feel this way? Why am I so ner
vous? Why can’t I succeed? Why can’t I get a girlfriend? Why am I always mad?
Why does everyone treat me like crap? One of the most powerful tools for sup
portive psychotherapy is to help the patient through this jungle, to provide
a clear path for some answers. The jungle metaphor is especially apt here,
because the goal is not to help the patient escape the jungle. Rather, in sup
portive psychotherapy we are helping patients to find paths through it, or
clear spaces in it where they can rest, or places to find comfort or shelter.
Explaining their behavior can help patients into these more comforting places.
Although feelings and behaviors are complex, the explanations provided by
the therapist needn’t match the complexity. The explanations of behaviors

just need to make sense to the patient. In an earlier chapter we discussed
the importance of having a decent psychodynamic understanding of the pa
tient in order to do good supportive psychotherapy. We as therapists can see
ways through our patient’s jungle without the hindrance of being emotionally
lost in it. The better we understand the patient’s psychodynamics, the better
we can explain behavior to the patient. Because of our training and experi
ence, we might understand the patient’s psychodynamics in ways that the
patient can never fully understand. The art of good supportive psychother
apy then becomes explaining it in ways a patient can tolerate and understand
and that can lead to improvement of their symptoms. In psychoanalysis, the
technique of “interpretation” is to uncover the unconscious drives and im
pulses of the patient, to bring the unconscious conflict to his or her conscious
awareness. This is not usually done in supportive psychotherapy, because in
most cases the interpretation wouldn’t be understood or, even worse, wouldn’t
be well tolerated and would make the patient more anxious or disturbed. In
supportive psychotherapy what is practiced more has been called an “upward
interpretation”—in other words, interpreting patients’ symptoms by describ
ing them in ways that are accessible to their understanding and conscious
awareness.
Case Example
The patient, a young woman named Jane, grew up in a household devoid
of love or compassion and underwent both emotional and physical cruelty
from her parents (both were alcoholics). She has chronic depression, low
self-esteem, loneliness, and substance abuse. She often winds up in relation
ships that are abusive to her and stays in them despite marked unhappiness.
JANE: Why can’t I ever just feel happy, like, just normal happiness
that most people seem to feel? I always feel like I’m in a cave
and can’t just feel the sun on my face. I don’t even know why
I’m with Joe (boyfriend who is abusive), because I don’t know
if I love him. I don’t know if I can love anyone. I should just
give up.
THERAPIST (explaining behavior): It makes total sense that you suf
fer the way you do, Jane. Your life from the very beginning
was filled with sadness, pain, and suffering. It’s like you were
in training from the very beginning to feel bad about yourself.
I’m sorry you have suffered so much Jane. It isn’t fair...this
wasn’t your fault.
Jane has chronic emptiness and despair from the traumatizing effects of
early childhood neglect and abuse. In psychoanalytic terms, she has inter
nalized the aggression of her parents and in a repetition compulsion fashion

reenacts these traumas in her adult life with herself as the victim. It is un
likely she will ever fully understand the depths of her traumatization with
insight into this dynamic. She feels like an alien, not like the other humans
around her who seem to be able to feel happiness spontaneously and lead a
“normal” life. She relies on drugs and alcohol to provide good feelings or
escape from bad ones. In this example, rather than try to have her under
stand the unconscious dynamic, the therapist explains her behavior to help
her feel less like an alien and more like an unfortunate person who underwent
abuse in her childhood. Jane can benefit from this perspective and other re
peated therapeutic interventions that help her be less harsh on herself for
her unfortunate childhood.
Explaining behavior can also include normalizing the behavior. As just
described, many patients feel like emotional aliens. It is hard for them to
believe, on a gut level, that they’re “normal” or similar to anyone else. The
closer you can see their behavior and emotions as being a natural, psycho
logical evolution of their particular life history, the better you will be able
to view them as more similar than different from other people. We’re all just
human beings struggling to get through life, avoiding pain and seeking
pleasure. In fact, when you perceive their problems as being fundamentally
similar to your own, the only difference being the particular lens through
which you are viewing them, the better you will see their behavior as “nor
mal.” Explaining behavior in a way that normalizes it can help the patient
feel less of an emotional alien.
Example (Normalizing)
THERAPIST (to Jane): I believe finding true love is maybe the hard
est struggle each and every one of us faces in our lifetime. In
timacy is hard for everybody.
Confrontation
Confrontation is therapeutically “holding a mirror” to the patient so he might
see how his own patterns of behavior are contributing to his suffering. In
confrontation, therapists point out to patients what they are doing, usually
when the patients are not seeing the patterns or connections themselves.
The confrontation might involve pointing out how their attitude keeps
them suffering, or how their patterns of behavior contribute to their symp
toms. Therapeutic confrontation should not be confused with the lay use of
the term, which usually implies some kind of angry tone. On the contrary,
therapeutic confrontation works best when done with an inquisitive or gen
tly exploratory tone. Confrontation is a very powerful tool for the therapist
and is most effective when coupled with a good therapeutic alliance. Simply
put, patients will tolerate confrontation better when they have trust in the
therapist. There is a strong correlation between the therapeutic alliance and
the effectiveness of confrontation. The stronger the therapeutic alliance, the
stronger the confrontation the patient will tolerate. For this reason, con
frontation technique is usually not successful if attempted too early in the
psychotherapy.
Case Example
Joanne is a bright young computer analyst. She also has a pattern of fre
quently losing jobs when she becomes furious with her boss. Her pattern of
behavior includes initially idealizing her bosses, finding them intelligent and
caring (and sometimes attractive). Later, when she feels slighted from lack
of attention, she becomes furious and sees her bosses as people who pur
posefully want to keep her down and hurt her emotionally. Her occupational
problems cause significant distress and impairment in her life.
JOANNE: I’m so sick of Allen [boss]. I get sick just looking at him;
he repulses me. He’s an asshole, and I’m so sick and tired of
working with assholes.
THERAPIST (likely too coarse of a confrontation): This has happened
before; why do you think you keep getting into these situa
tions, Joanne?
In this example, Joanne is likely feeling too raw, too exposed to com
fortably examine her pattern of behavior in the way posed by the therapist.
She needs to feel some strength and support from the therapist in order to
examine herself. The way the therapist posed the confrontation was like
shining an examination light on a crime suspect. Asking questions with a
“why” often has that effect in supportive psychotherapy, and in most cir
cumstances using “why” as a lead in for understanding will put the patient
in somewhat of a defensive stance. Here are some alternative examples of
confrontation with this patient that might allow her better introspection:
THERAPIST: So sorry Joanne, I know this type of situation has happened

before, and I know how much you’re sick of it. Maybe if we approach
this like a computer problem to be solved and put in the data of in
teractions and feelings between you and Allen, we might understand
it better?
In this example, the therapist first connects empathically with her anger
and frustration prior to shifting attention to a confrontation of her behavior
pattern. The therapist uses the language of “we” to examine the problem,
making it a joint endeavor between them, as opposed to the therapist point
ing a spotlight on Joanne. Using “we” when examining behavior is comfort
ing to patients in many situations, especially when used with confrontation.
Also, by making it more like a computer problem to be solved rather than
a defect in her character, the therapist softens the “personal” attack.
Another, slightly more provocative example if the patient can tolerate it:
THERAPIST: I know how infuriated you must feel Joanne. We’ve talked be
fore about how this has been a pattern in your work relationships.
You liked Allen initially and now can’t stand the sight of him. Let’s
be curious cats here, and maybe together we can learn something
useful.... Help me understand the change in your feelings.
In this example, the therapist asks “help me understand” instead of ask

ing “why?” This phrasing puts emphasis on the therapist not knowing in
stead of on the patient not telling. Joanne is then in position of helping the
therapist by explaining her behavior. The “help me understand” method of
inquiry is almost always successful in encouraging patients to look at their
behavior without feeling scrutinized in a critical way.
When the therapist anticipates that an intervention or topic might be
emotionally difficult for the patient to look at, he or she might give advance
notice to the patient to help the patient prepare. This can take the form of
getting permission from the patient to address the hot topic (“Is it OK to
ask you about X? I know it might be upsetting to talk about, but I also think
it might be helpful.”). In a direct way the therapist and patient together can
decide how to modulate the rough emotional terrain, with clear opportunities
outlined for “backing off” or stopping if it becomes too intense.
Encouragement
Providing encouragement is being that “good parent” that the patient likely
did not experience enough during childhood. Therapeutic encouragement
works best when done in “just enough” amounts so that the patient doesn’t
feel like a failure should she not succeed (and disappoint the therapist).
Having a good understanding of the patient’s strengths and weaknesses, as
well as her past history, will help the therapist determine the best opportu
nities and amounts to encourage. Sometimes it’s useful to combine encour
agement with education for the patient that he will need to get out of his
“comfort zone” for change to occur. Patients often need reminders that
change does not occur easily and that improvement will not happen without
some degree of discomfort. This education about change is best tolerated
when coupled with encouragement. Encouragement can sometimes take the
form of reassurance. When the therapist is providing reassurance, the same
rule applies: to apply just the right amount for upward movement but not so
much that the patient feels too overwhelmed or inadequate to even try. Ther
apists should also avoid providing reassurance for areas outside of their area
of expertise.
Case Example
Alex was a successful stockbroker; however, he lost his job and is currently
unemployed and depressed. He has recently submitted several unsuccessful
job applications.
ALEX: I can’t do it. I’m just too nervous to work.

THERAPIST (encouragement): I know you’re discouraged, but you’ve
worked successfully in the past, Alex, and I believe you can
do it again. Because you’ve had some recent failures, you’re
anxious about trying. I know placing another application
makes you uncomfortable. You just have to get over the
hump of trying. You can do it, Alex.
ALEX: I think the whole social economy is collapsing, and I’m scared
I’m going to lose everything, all my savings. I worry about it
all the time.
THERAPIST (false reassurance): The stock market always bounces
back, I don’t think you have to worry about it.
THERAPIST (appropriate reassurance): You’ve been pretty good with
your finances and budgeting skills so far; I bet you can work
on some solutions to help you feel more solid financially and
to lower your worry.
Hope
Hopelessness is a frequent condition in many of our patients, and stimulating
hope is critical in mobilizing the patient to change. Providing hope should be
done with the same finesse as encouragement—that is, using the knowledge of
the patient’s psychodynamics to provide enough hope for the patient to see
change as a realistic opportunity rather than a “pie in the sky” type of false hope.
PATIENT: I feel my world collapsing, like, everything is going wrong all at

once. I’m getting panic attacks every day, horrible panic attacks.
Sometimes I’m ready to call it quits, say screw it, I’m done.
THERAPIST (false hope response): Don’t worry Michael, I know it’s going to
work out OK.
PATIENT: You don’t understand, Doc.
With this response the therapist is likely providing false hope. Michael
is horribly suffering, enough to think about ending his life, and the thera
pist is essentially denying the extent of his agony by saying “Don’t worry,
things will be fine.” Even though the therapist is providing hope, it’s out of
touch with Michael’s current state of mind. Michael’s response confirms
the empathic failure. In fact, the more I think about it, the more I wonder
if the words “don’t worry” would ever be an empathically sound response by
a therapist.
Here’s a better response, that would still provide hope:
THERAPIST: I know you’re suffering so much, Michael, and I also know

that you’ve been here before, suffering to this extent, and it’s gotten
better. We just have to find the right formula to get you out of this.
I feel confident we can do this.
Sometimes the patient will present with such severe circumstances that
the therapist will have a hard time seeing hope in the situation. In examples
of such hopelessness it’s important for the therapist to take the stance that
there’s always hope, even if not apparent to the therapist or patient at the time.
Although admitting not having immediate answers might seem like a grim
response, it’s actually often paradoxically reassuring to the patient, because
they will sense that the therapist really “gets it”—that is, viscerally under
stands the extent of their suffering and that there are no easy solutions.
PATIENT: I don’t see anything getting better; it’s just more of the same. It’s
hopeless.
THERAPIST: I’m as stumped as you are, Autumn, to see the way out of this
mess. I do think there are ways, I just don’t see them at this moment.
I totally understand your hopelessness. Give me time to think about
it, and maybe run it by a trusted colleague—confidentially, of course.
And I want you to keep trying as well, keep thinking. I know from
experience that sometimes solutions aren’t readily available but do
occur later. I believe there are solutions.
Metaphor
Using metaphor and painting a picture are powerful therapeutic techniques
in supportive psychotherapy, and actually utilize different parts of the pa
tient’s brain than those stimulated by many of the other more language
based techniques. Metaphors and images often arise spontaneously from

free associations in the mind of the therapist while listening to the patient.
Pay attention to these! In my experience, when this type of metaphor or im
age is shared with the patient, it often is speaking to a profound and prim
itive underpinning of the patient’s situation. When patients identify with a
metaphor or image, it often “sticks” in their mind in a very durable way.
Case Example
Stuart is a middle-aged, hard-working man with schizophrenia who is ad
ept at finding jobs out of necessity because he loses them just as often. He
has a self-defeating personality and frequently loses jobs because of “doing
something stupid,” like not calling in for work absences or getting mad at
the boss and leaving work. He painfully regrets his loss of job afterward, has
significant financial hardship, and spends considerable time and effort in
securing more work.
STUART: I’m an idiot! I can’t believe I did it again [lost job]. I know,
I know. .., I’m stupid.
THERAPIST (has a spontaneously occurring image of Stuart shooting
himself in the foot): You’re not a stupid man, Stuart. It’s like
you have this gun, and you shoot yourself in the foot every
time things are working out for you, things are going well.
We have to figure out how to stop you from shooting yourself
in the foot.
STUART: Yes! That’s it! I shoot myself in the foot!
In this example, Stuart accepts a confrontation through the use of meta

phor. His enthusiastic response to the metaphor helped the therapist deter
mine that it was apt. Had Stuart responded in a less confirmatory fashion (e.g.,
“I’m not sure what you mean, Doc” or “I’m just tired of losing jobs”), it would
have indicated that the metaphor was not powerful or meaningful to him.
Over the course of the next year, as Stuart secured a new job, the “shooting self
in foot” metaphor was used frequently as a vehicle for development of new
coping mechanisms for job stress. Stuart used the metaphor frequently in ses
sions, for example stating, “Don’t worry, Doc, I’m not gonna shoot myself in
the foot again” and “I’m throwing that gun away!” He worked on better anger
management skills and rehearsed situations on how to handle job stress. He
was then able to maintain employment at the same job for several years.
Coping Skills
Actively helping the patient develop cognitive and behavioral coping skills
covers a wide range of therapeutic techniques. It might be as simple as hav
ing the patient focus on breathing, develop mantras (“I am OK”), or do

daily physical exercise. More complicated techniques would involve help
ing the patient to develop particular coping plans for when she is experi
encing emotional distress or maladaptive behavior. For example, you might
help the patient develop a “checklist” of coping options for when she is feel
ing panicked, or ways to reduce her level of agitation when feeling angered.
Using traditional cognitive-behavioral techniques would fit under this cat
egory of skills. It’s often useful to have the patient rehearse his or her man
tra or anticipated coping skills in a concrete fashion during the session. This
gives the therapist feedback on how well the patient understands the plan,
provides some useful practice, and increases the likelihood the coping
skills will be effective in actual life settings. There are a host of cognitive-
behavioral techniques that can be employed, including cognitive restructur
ing (correcting cognitive distortions), exposure and response prevention,
progressive muscle relaxation (PMR), relaxed breathing techniques, mind
fulness meditation, and skills training. Reframing is a cognitive technique
by which the therapist suggests the patient adopt a different perception for
his or her behavior, usually one that is less negative, less harsh, and more pos
itive or forgiving.
PATIENT: I’m a failure at everything; I even screwed up killing myself.

Can’t even get that right.
THERAPIST: Maybe that is not you being a failure. Most people have very
mixed feelings about killing themselves. Maybe the survivor part of
you was stronger, saying, “I don’t want to die, things might get bet
ter.” That might be a really smart part of you.
In this example, the therapist reframes the patient’s suicide attempt as

an act of intelligence or rationality instead of a “failure” experience.
There are countless techniques for helping your patient develop coping
skills limited only by your creativity and willingness to try. In my opinion,
one of the most exciting and rewarding aspects of doing supportive psycho
therapy is letting your creativity shine when faced with the patient’s problems.
Case Example
Sharon is a 42-year-old married woman with lower-than-average intelli
gence and frequent anxiety symptoms. She is highly dependent on her hus
band (Bruce) and was causing problems at his workplace by calling him
frequently throughout the daytime, insisting he help her distress. Once she
became engaged in psychotherapy with me, she began calling my office
countless times during the day. Although she benefited from reassurance
and guidance, the effects were short lived, and she would resume calling a
short while later. I tried having Sharon use different transitional objects
(stuffed animals) and lists of coping methods; however, once she became
stressed, she would abandon these coping measures and begin calling. Sha
ron appeared to benefit most from hearing Bruce’s voice or my voice. I met
with Sharon and her husband in the office, and together we made an audio
cassette recording that she could play when feeling stressed. The recording
included both Bruce and me making soothing statements.
BRUCE (recording): You will be OK, Sharon. Take a deep breath

and relax, and I’ll be home tonight. I love you.
THERAPIST (recording): You’re just fine, Sharon. Sit down and take
a few deep breaths like I showed you in the office. That’s
right...Now think about all the good things you like: your
cat, your cuddle-bunch, your favorite TV show. You have lots
of things you can do to feel better, like coloring. Bruce will
be home tonight, and you will have a nice dinner together.
Maybe think of some things you can make him for dinner...
For a week or two Sharon continued to call the office; however, the sec
retary would tell her to turn on her “special” audio recording for support.
Eventually Sharon began calling less and began using the techniques ad
vised on the audio recording to calm her anxiety. This is a literal example
of the therapist “lending ego” to the patient—that is, providing the patient
with his own higher-order ego functions (his calmness, rationality, reas
surance, coping skills) in order to help her function. Lending ego occurs
frequently in supportive psychotherapy. One area of lending ego is that of
anticipatory guidance, where the therapist uses higher-order ego functions
to anticipate problems the patient may not see and outline coping skills
that will likely help the anticipated problems. Anticipatory guidance is
used most often for patients with poor problem-solving skills and lower
functioning.
Example
Patricia is a single mother of a teenage son, Bill, who has some drug, alco
hol, and behavior problems. She has chronic anxiety, depression, and mild
cognitive deficits. Patricia has horrible ambivalence with decision making
and often resorts to “doing nothing” when faced with family problems. She
has markedly limited problem-solving skills. She has worked with the ther
apist for more than 10 years, and he is familiar with her home situation.
PATRICIA: I think Bill’s girlfriend is pregnant. He wants her to live

with us, and I just don’t know what to do. He said she will kill
herself if we don’t take her in, because her parents are so mad
at her. I think we can afford it. I’m so worried about him. I
don’t know what to do.
THERAPIST: I can understand your distress, Patricia; being a mother
is a hard job, and this is a difficult situation. What options
have you looked at to handle this?
PATRICIA: I don’t know, I don’t know. I don’t want to make Bill
mad; he’s always mad at me.
THERAPIST: Have you talked with her [girlfriend’s] parents? I un
derstand Bill is mad, but it seems it would be important for the
parents to talk together in this situation. It might be a good
idea to keep good communication with them during all of this.
PATRICIA: Bill doesn’t want me to talk with them.
THERAPIST : Yes, I can understand from his point of view he
wouldn’t want you to. I think if you let Bill’s feelings dictate
what you do or don’t do, you’re sort of letting the teenagers
make the decisions. This is one of those situations where
adults need to put their heads together. I think it will be im
portant as you go forward to not let Bill’s feelings make your
decisions for you. He’s going to have some strong feelings,
and it will be important for you to keep being a parent and
think about what are the best options for everyone involved.
Self-Soothing
Our ability to soothe ourselves during unpleasant emotional states stems
from childhoods where parenting was good enough for us to internalize our
parent’s affections. For many of our patients, childhood didn’t have enough
of these soothing affections, and subsequently they didn’t learn to soothe
themselves. Childhood trauma can overwhelm emotional coping states and
also impair the self-soothing ability for people despite good parenting. When
there’s a deficit in the ability to self-soothe, people develop methods to feel
better that are usually unhealthy—for example, extreme mood swings, de
pression, withdrawal, substance abuse, and acting out. Acting out occurs
when the unpleasant emotional state (e.g., feeling rejected) is so unpleasant
the person has to do something physical in order to tolerate it. Getting into
conflicts, compulsive eating problems, and doing dangerous, impulsive, or
self-harm behaviors are examples of unhealthy acting-out behaviors. Help
ing patients learn methods to soothe themselves is an important technique
of supportive psychotherapy. I’ve found it helpful to explain this to patients,
that they have not learned to self-soothe enough and that this leads to act-
ing-out behavior. In my experience, most patients find this education enor
mously helpful and are able to learn healthier methods for self-soothing.
There are a number of methods one can use to help patients learn to soothe
themselves and can include healthier options for acting out (such as exer
cise). One method that is particularly useful is having patients learn a mantra
that they can use in times of emotional distress. They can actually say the
mantra out loud if need be. It is important to help them find a mantra that
fits for them, that they believe. This might take some trial and error. Exam
ples of mantras that patients have found helpful include the following:
• “I am OK.”
• “I am in control.”
• “I am loved.”
• “This will pass.”
• “I can do this.”
• “I am an adult; they can’t hurt me now.”
• “This pain is from then; I am OK now.”
The most powerful soothing experiences in supportive psychotherapy oc

cur when patients are feeling intense negative emotions that have a deep basis
from their childhood and subsequently find relief from the therapeutic en
counter. This then becomes a corrective emotional experience for the patient.
The learning that results from this is primarily emotional, although the ther
apist can highlight verbally what has happened for the patient to solidify the
patient’s experience. As the “good parent,” the therapist then becomes incor
porated into the patient’s psyche, and the patient can then “carry” the thera
pist with him into other situations requiring a soothing presence.
Case Example
John had a particularly severe childhood. His father was cruel and abusive
and often said demeaning things to him, such as “You’re ugly, you’re stupid.
You’ll never amount to anything.” John is intelligent and entered college;
however, he developed schizophrenia and had to drop out because of his psy
chotic symptoms. This made him feel even more a failure. He has chronic
social phobia and believes everyone sees him as stupid, ugly, and a failure.
He is unable to keep gainful employment due to his low self-esteem and
chronic sense that others look down on him. He is highly disabled from his
condition, and simply walking in to a coffee shop to order a coffee is highly
anxiety provoking to him. He has been in supportive psychotherapy for sev
eral years and has a good therapeutic alliance with the therapist. Recently,
with encouragement from the therapist to improve his social skills, he acted
outside of his comfort zone and joined a support group. In the support group
some members made remarks to John that he experienced very harshly. He
now wants to quit the group because he feels they are all against him.
JOHN (crying): I don’t think they like me. I don’t think they want
me in there. They think I’m stupid. I’m not going back.
Don’t be mad at me.
THERAPIST (hands a box of tissues to the patient in a caring manner):
I’m not at all angry with you, John. On the contrary, I think
it’s brave that you’ve gone to the group despite having so
many misgivings about doing so.
JOHN (blowing his nose and less tearful): No, I know you are—really?
You’re not angry?
THERAPIST: No John, not at all. I know how hard this is for you, to
go to the group, and I think it takes a lot of strength for you
to do it. You’re pretty hard on yourself. These seem to be
feelings from your past that are creeping into the situation
now. We’ve talked about this before, about how harsh and
abusive your childhood was. Now is different. You are OK
now, John; you can cope with this.
JOHN (continuing to cry, but then straightening up): It doesn’t feel
very good. But you’re right, I am OK now.
In this example, John assumes the therapist will be critical of his failure
on the basis of the severely abusive pattern of his childhood. This assump
tion or expectation is largely unconscious on John’s part. Despite the good
therapeutic alliance, he still defaults to an expectation of punishment from
the therapist in this stressful circumstance. Instead of reexperiencing the
trauma, however, he feels comforted by the acceptance and praise from the
therapist. The therapist was able to soothe his discomfort. John was able to
repeat the mantra of “I am OK now” that they had previously determined
would be fitting for these situations. They had analyzed his past abuse as
contributing to current pain many times before. Examining it again in the
context of the current situation allows working through. Working through
means applying therapeutic gains or insights repeatedly, across different ex
amples. Similar to learning a new physical skill or sport, where “muscle
memory” needs development, working through allows the emotional ther
apeutic gains to become solidified. Like most things in life, learning occurs
best through repetition. This was a corrective emotional experience for
John, and he was able to examine the basis for his feelings of rejection in a
more logical manner. This was pieced together with many other therapeutic
experiences that looked at the same issue. Together with the therapist, he
decided that one group member probably didn’t like him, but this wasn’t a
rejection from “the whole group.” Instead of acting out by leaving the support
group, he was able to return to the group and grow from the experience.
There is somewhat of a correlation between lack of ability to self-soothe
and a tendency for self-reproach. Many people are perpetually “down on
themselves,” and teaching them to self-soothe, even in very small amounts,

can begin to chip away at this very damaging attitude. In these situations, it is
as if there is an unconscious contract the patient is keeping with himself, “I
don’t deserve to be soothed.” A frank discussion about this with the patient can
be helpful. The therapist might ask generically, “Do you like yourself?” and
see what conversation ensues. When a patient says, “No”, the therapist can
begin a series of exercises to help him identify some specific things he might
like about himself. Sometimes the patient can identify only a very few, small
things. This is something to build on. The therapist can ask, “When do you
feel good?” When a patient is feeling good, at times this is correlated with
something she might like about herself. For example, a patient might notice
she feels good when helping others, and the therapist can subsequently point
out, “You genuinely enjoy helping others...can we agree that you are a kind
person when you let yourself be?” Bit by bit the therapist can help the patient
“find” things she likes about herself, and this building of self-empathy can
lead to better self-soothing ability. I sometimes let a patient know that my
hope is for him to learn to love himself. Even though the patient might feel
very distanced from this powerful notion, it sends a subtle message that he de
serves to be loved and that I think he is worthy of love. This kind of message
from the therapist sets the tone for a corrective emotional experience.
Some adult patients who have undergone harsh or traumatic childhoods
have marked self-hatred, as they have introjected the aggression acted toward
them during their early development. It can be difficult to help these patients
have any empathy for themselves, even to very small degrees. One technique
that can be particularly powerful is to have these patients bring in a photo of
themselves as a child. The therapist can have the patient look at the photo
while they explain the exercise: “Talk to yourself as that 10-year-old child
who was undergoing the abuse...you were 10 years old...did you deserve
that? Did you deserve to be treated so badly? Or did you deserve to be loved?
How do you treat 10-year olds?” It is often very hard for patients, when
speaking to themselves as a child, to direct hatred toward themselves, and
they are usually brought to tears during the exercise. While undergoing this
powerful cathartic experience, they often realize their self-hatred is not justi
fied. This opens the door for self-empathy (and subsequently self-soothing).
Humor (*Use With Caution)

Humor is a very interesting and powerful phenomenon the world over. Present
in all cultures, when something is humorous it usually addresses elements of
both truth and underlying anxiety. Using humor as a technique in supportive
psychotherapy is like firing a gun with a high-caliber bullet. When aimed cor
rectly and used in an appropriate manner, the results can be powerfully effec
tive. Used incorrectly or with poor aim, the fallout can be very harmful. It’s very
easy for patients to feel like they’re the “butt of the joke” when the therapist
uses humor, even if not intended by the therapist. When used appropriately in
therapy, in a manner of shared enjoyment between patient and therapist, hu
mor can slice through defenses and allow a deeper mutuality. When I have
used humor effectively, it almost always improves the therapeutic alliance. I’ve
also used humor that resulted in negative outcomes and then needed to do ac
tive repair of the therapeutic alliance. I usually advise beginning therapists to
stay away from using humor because it is a relatively risky technique, and more
seasoned therapists might have a better sense of when to risk it.
Comparing Pain (*Generally Avoid)

Sometimes when a patient appears to be suffering out of proportion to his or
her actual situation, or, when a patient is a “chronic complainer,” it can be
tempting for a therapist to compare the patient’s situation to people who
are worse off. In other words, attempt to have the patient see how much
better he or she has it as a way to feel better. This approach almost always
fails. Usually when this happens, the patient becomes more defensive and
often rationalizes that his or her situation is unique. In one way of looking
at it, the patient’s situation is truly unique in that no other individual has
ever lived the patient’s life or walked in his or her shoes. Comparing the pa
tient’s pain to others usually results in an empathic failure. In limited situ
ations comparing pain can be useful, for example, when done indirectly as
a way to promote hope (where others have found ways to reduce pain in
similar circumstances) or by comparing the current pain to the patient’s
own successful reduction of pain in the past.
Examples
PATIENT: Everything is so hard. I’m in debt and working overtime,
and I can’t get ahead. I’m tired of working so hard. I’m be
ginning to think the struggle isn’t worth it. Why does life
have to be so hard?
THERAPIST (ineffective pain comparison): Think of how hard it must
be for people in third-world countries. They don’t even have
the opportunity for work, or work 80 hours in a week for
practically nothing.
PATIENT: Yes, but they probably don’t have student loans to pay
off, either.
In this example the comparison of emotional pain offered no relief and

was an empathic failure.
THERAPIST (potentially useful pain comparison): I understand how exhausted

you must feel. Life’s ups and downs can be hard. You’ve found ways
to enjoy life in the midst of these painful struggles in the past, even
when your suffering seemed worse. Let’s take a look at what you did
then to feel better.
Creative Opportunities
As mentioned at the beginning of this chapter, there are boundless strategies
and techniques you can use in supportive psychotherapy, limited only by your
creativity and imagination. Storytelling, much like metaphor, can be particu
larly powerful in creating images and feelings that patients will remember and
integrate even if they aren’t fully aware of it. Storytelling might convey the
exact same information that a therapist would educate the patient with in a
more instructive format; however, when told as a story, it becomes more pow
erful and lasting. The therapist might tell a story that is really about the pa
tient but use a different protagonist. The patient will then hear the
therapeutic message of the story better than if he felt he was the “target” of
the communication. Sometimes telling a story about another patient will
provide hope and reassurance that there are real-life solutions to the percep
tion that her suffering is hopeless (details of patient used in story must be dis
guised for confidentiality).
“Striking when the iron is cold” can be useful in many situations when a
topic is so highly emotionally charged for a patient that he cannot address
it in therapy during the time he is distressed by it. In situations like this, the
therapist can “bookmark” the issue and bring it back to discuss when the pa
tient is not feeling so affected by it.
Writing it down can be helpful when the patient has difficulty remember
ing the issues to bring into the session, as a “feelings journal,” or as a method
to discuss issues that are too painful to tolerate in a spoken manner. I once
had a patient who was so anxious and humiliated by her symptoms she was
only able to address them by writing her responses during the session. She
brought a notepad to the sessions for this purpose and was able to achieve
good therapeutic benefit.
“Writing the letter you will never send” is a technique where the therapist
has a patient write a letter to a person they have unresolved issues with. The
letter is written with complete and utter abandon, without regard to caring
how it will be received and, most importantly, as though it will never be
sent. Letters written in this fashion often have profanity and reveal bad in
tentions, and this is encouraged. Sometimes writing in this fashion pro

vides an emotional catharsis in ways simply talking about it does not. In
most circumstances the patient has no need to send the letter after writing
and reading it aloud. I had a patient once who was not able to “get over” his
hurt feelings when a best friend betrayed him. It touched on issues from his
childhood where betrayal was a trauma he endured in his family of origin. He
talked about his hurt feelings at length but continued to feel depressed and
have nightmares about it, and could not “lay it to rest.” He wrote a very un
inhibited letter to the friend who had betrayed him. After reading the letter
aloud, he felt an immediate relief and his nightmares ceased.
Patient consultation can be a particularly effective technique when the
patient and therapist feel stalled on an issue (“I feel like we’ve been stalled
lately. What would you suggest we do differently to move ahead?”). To
make it more powerful than simply checking in, the therapist can ask to
role-play with the patient, having the patient assume the identity of the
therapist and vice versa. I’ve had the patient actually switch chairs with me
at times when I’ve used this technique, with the patient sitting in my office
chair. In their role as the therapist, patients often enjoy this technique be
cause it brings creative energy into the therapy room that feels qualitatively
different from the usual therapy process. Having a role-playing dialogue in
this manner, I’ve been impressed with the insights and confrontational re
marks the patients produce when acting as the therapist. They’re almost al
ways “harder” on themselves and more critical of their resistance to change.
Classroom Exercise
• Have each member of the class stand up one at a time and say
something about themselves they are proud of. Then, while
each is standing, have the rest of the class applaud, yell that
person’s name, say “hooray [name],” and generally cheer him
or her. Discuss afterward how this exercise made each person
feel while he or she was being applauded. Does plussing work
even in a contrived exercise?
• Practice waiting 3 seconds after others have spoken before
speaking. What do you notice? This exercise can sharpen
your listening skills.
1. When using humor with a patient in psychotherapy, what type of feed
back or information would you look for to determine if it was a benefi
cial intervention?
2. Seeing the patient as similar to yourself can help with normalizing in
terventions. Are there countertransference concerns with doing this?
3. We live in a highly technological age. Is it OK for a psychotherapist to
pay attention to cell phone texts or computer screens during the session?
References
1. Puryear DA: Helping People in Crisis. San Francisco, CA, Jossey-Bass Pub
lishers, 1979
2. Battaglia J: Transform dread: 8 ways to transform care of ‘difficult’ patients.
Curr Psychiatry 8(9):25–29, 2009
CHAPTER 6
Trauma
Nietzsche was only partly right when he

said, “That which does not kill us makes us stronger.” He should have
added, “unless you are traumatized by the experience.” We can acknowledge
that stressors and emotional pain are essential elements of the human con
dition, and successful coping allows growth and the development of resil
ience. There remains, however, a vast middle ground between getting
stronger from a stressor and having it kill us, and that middle ground is
when the stressor reaches the level of trauma. Trauma occurs when the
stressor causes emotional scarring, and that is persisting psychological dis
tress or impairment. Trauma changes a person. Traumatic experiences cause
not only changes in psychological processes but also physiological changes
in the brain and body.1 It’s as though a person’s entire body and mind be
come “rewired” from traumatic experiences so that the person becomes per
petually prepared for flight or fight. In a remarkable example of this,
Holocaust survivors still show pathological changes in their immune re
sponse to stress some 50 years after the event.2 While Holocaust survivors
are an extreme example of severe trauma, different levels of physical, psy
chological, and cultural trauma can affect people in a multitude of ways,
even when the stressor is not remarkable or obvious. Traumatic emotional
outcomes can become evident from a variety of stressors, for example, being
bullied as an adolescent, learning of the sudden death of a family member,
being racially targeted, or being rejected by a loved one. Repetitive, less ob
vious but deeply influential stressors can also become traumatic, for example,
undergoing repeated rejections or neglect from a parent during childhood.
Understanding the depth to which trauma shapes our lives is vital to under
standing people and culture as well as to doing good psychotherapy.
91
Imagine an infant son born to a mother who had undergone severe

abuse and neglect in her childhood. Imagine the mother had a “rough life”
involving abusive relationships and has very little understanding of herself.
Picture the interactions with her son that might occur as she raises him. If
the mother had issues of unconscious hatred or repulsion of the child, she
might not be able to appropriately soothe him when he is distressed. She
might overindulge him when he is not hungry, overfeeding him to the point
of choking or gagging if she is not attuned to his needs. By not paying at
tention, she would be eliciting repeated and marked adrenaline stress re
sponses in him during what should be the naturally comforting process of
eating. Conversely, she might ignore his cries for food or comfort, and he
would experience pain, suffering, and despair in response to his basic needs
for food and nurturance. She might also physically punish him for having
needs, to stop him from crying and irritating her. This developing boy would
be traumatized by his early life experience in a way that he will likely never
be able to verbalize. The reward systems in his brain, linked with the needs
for nourishment or comfort, would be severely dysregulated. His fundamen
tal associations between having uncomfortable emotional states and expe
riencing nurturance would be flawed. As he develops into a young man, he
would likely not be able to experience interpersonal closeness or intimacy
and instead may find comfort in substances of abuse. He might experience
chronic unhappiness or emptiness. He’s an example of a highly traumatized
person, although if he were to begin psychotherapy he would likely not re
member or have difficulty describing any specific traumatic event of his
childhood. The working diagnosis for his initial psychotherapeutic treat
ment might be “depression,” but his impairments would be highly linked to
the traumatic effects of his upbringing.
Imagine now another scenario, one of a successful and well-adjusted
sophomore college student who is raped by several men while attending a
party. She might develop posttraumatic stress disorder (PTSD) from the
experience, which can include symptoms of depression/detachment, flash
backs, heightened fear response, sleep problems, and avoidance of social
situations. If she were to undergo psychotherapy, the specific stressor (the
rape) would be addressed directly in the therapy, her symptoms would be
linked to the event, and measures would be taken to help her cope with the
trauma.
In both of these examples, the people experienced the effects of trauma.
In the case of the neglected and abused young man, the traumatic events
were nearly continuous during his upbringing and profoundly shaped his
entire existence. With the young woman, the traumatic event was isolated,
Trauma 93
and her symptoms were highly linked to the stressor. Although she was a
well-adjusted person prior to the trauma, the experience will change her sig
nificantly moving forward. These examples of trauma are on somewhat dif
ferent ends of a spectrum; however, the spectrum of trauma is not two
dimensional and must be envisioned in a polymorphous, interactional way.
There are countless ways trauma can become part of a person’s experience,
at different stages of life and with different degrees of severity. Referring
back to Freud’s pleasure principle—that is, people tend to seek pleasurable
experiences and avoid painful ones—one can assume that the sum of emo
tionally traumatic experiences plays a major role in personality development.
For example, if a person underwent repeated empathic failures with a par
ent during childhood, he or she might avoid intimacy as an adult. Avoiding
the reexperience of emotional trauma can affect many life decisions, most
often outside of a person’s awareness. Thus, emotional trauma, along with
its aftermath, plays a major role in how an individual’s life unfolds.
Therapists must be attuned to both the possibility of trauma and trauma
sequelae when doing psychotherapy. In the case of the young man just de
scribed who was neglected and abused, the psychotherapy will focus on es
tablishing trust and developing a good therapeutic alliance. Although he
would not be able to verbalize the neglect and abuse of his childhood, his
impoverished relationships and impairment in interpersonal functioning
will give the therapist a clue of possible childhood trauma. His “natural” in
stincts developed early in life will make him want to avoid trust. Also, it
may take some time for him to be able to identify his emotions, because he
learned at a very early age to avoid feeling them. His basic drives for com
fort are associated with distress or unfulfillment. Supportive psychotherapy
can help him to identify the emotions underlying his distress, even if they
sometimes make no apparent sense. He may never have any direct memory
or understanding of his early childhood deprivation; however, helping him
feel connected to his emotions and having empathy for himself will be ad
dressing the trauma in an indirect way. The repeated experiences of the
therapist understanding his emotional pain and being empathic with him
while he expresses it will ease his sense of isolation and disconnection from
others. He will learn empathy for himself by internalizing the empathy the
therapist directs toward him. Development of trust and a good therapeutic
alliance in and of itself will be addressing his trauma by allowing small, con
sistent, correctional emotional experiences.
The Centers for Disease Control and Prevention (CDC) and the Sub
stance Abuse and Mental Health Services Administration (SAMHSA)
have targeted childhood trauma as a vital public health concern and have
emphasized the importance of screening for adverse childhood experiences

(ACEs).3,4 ACEs have been linked to chronic health conditions (both psy
chological and medical), risky health behaviors, low life potential, and early
death. ACEs come from a variety of sources, including physical abuse, sex
ual abuse, emotional abuse, neglect, witnessing domestic violence, being a
victim or witness to extreme personal violence, witnessing community vio
lence, undergoing serious medical illness or procedures, bullying, school vi
olence, natural or manmade disasters, historical violence (e.g., traumatic
experiences transmitted across generations), forced displacement (e.g., po
litical persecution causing forced immigration), traumatic grief or separation,
having an incarcerated parent, military trauma, system-induced trauma
(e.g., removal from home for foster care), war, terrorism, or political violence.
The World Health Organization (WHO) has developed an instrument—
the Adverse Childhood Experiences International Questionnaire (ACE
IQ)—to guide professionals in detecting trauma with their patients.5 This
screening instrument can be extremely useful for psychotherapists, because
often patients don’t talk about ACEs for a variety of reasons. Patients will
sometimes deny ACEs because these experiences have been such an inte
gral part of their growing up experience; they might not recognize their
childhood as notable in any way. They may have repressed their ACEs and
only recall them when prompted or uncovered by the therapist. Using the
ACE-IQ can open up vital areas for psychotherapy that might have been
missed if not directly asked.
One of the most important guiding principles in working with trauma
is to assume that a patient’s symptoms make sense, regardless of how un
usual or maladaptive they seem. The evolution of most trauma-related
symptoms is to provide safety for the person experiencing them. This per
spective means understanding that current symptoms may have been adap
tive at one time to cope with the trauma, may have evolved to prepare the
person for survival in case of repeated trauma, or may allow avoidance of
pain associated with it.
Case Example
Doug is a 4-year-old boy who was raised by a mother with schizophrenia.
He underwent a number of traumatic experiences when his mother was
psychotic, paranoid, and agitated. He was eventually taken from his mother
by Child Protective Services and placed in a foster home. One morning, the
foster home parent was sick with a cold and told Doug, “I’m feeling sick to
day, Doug, I need you to be especially good because I’m too sick to deal
with problems.” Sometime later that day Doug’s foster parent called the
mental health clinic for help with Doug. “He has been hiding in the back
Trauma 95
yard for hours and won’t come inside. I don’t understand this, nothing bad
has happened, and he seemed perfectly normal at breakfast. I even made
him his favorite lunch, but he refuses to come in.” When the crisis worker
made a home visit and learned of the breakfast conversation, he hypothe
sized that when Doug heard “feeling sick,” this triggered a flight response.
In the past when Doug’s biological mother was “feeling sick,” she would be
come agitated and psychotic, and Doug would then undergo traumatic ex
periences. Even though his hiding in the backyard made no apparent sense
to the foster parent at the time, it made perfect sense when viewed through
the lens of his traumatic experience.
Despite a large number of studies on psychotherapy for PTSD, the ev

idence base remains relatively weak for efficacy or any differences between
therapies.6 Simply put, PTSD is hard to treat for a number of reasons, ei
ther with psychotherapy or with medication treatment. The majority of
psychotherapy studies are aimed toward showing the effectiveness of what
are termed “trauma-focused” therapies, such as cognitive-behavioral therapy
or prolonged exposure therapy. The central component of these therapies is
to re-expose patients to the trauma in a controlled fashion and restructure
their psychological response to it. Re-exposure usually means talking about
the trauma in some way, shape, or form with the therapist. Many of these
studies for trauma-focused therapies are carried out by institutions with ex
pertise and high investment in the therapy method under study, and this
creates strong biases.7 These biases can include therapist allegiance to the
method under study as well as use of control conditions that do not resemble
an actual bona fide therapy. Also, the trauma-focused therapies are often
compared with a “treatment as usual” or supportive therapy control group,
with the caveat that the control group not discuss the traumatic event(s) in any
fashion so as to avoid incidental “exposure” treatment, and some prohibit
anxiety management techniques.8,9 These comparison groups seem ab
surdly invalid to me, because I doubt there are many “treatment as usual” or
supportive psychotherapists who would avoid discussing the traumatic
events that led to the development of PTSD in their patient or avoid teach
ing anxiety management techniques.
The basic components of supportive psychotherapy are good for the
treatment of PTSD, with a few caveats. Establishing trust and a good ther
apeutic alliance, bolstering self-esteem, helping with problem-solving
techniques, reframing cognitive distortions, and teaching stress reduction
techniques remain mainstays of supportive therapy treatment of PTSD.
As most studies on psychotherapy indicate, developing a good therapeutic
alliance is key and predictive of reduction in trauma symptomatology for
individuals with PTSD.10 One important caveat for treatment of PTSD in
supportive psychotherapy is to establish safety measures and coping meth

ods for symptoms before talking about the trauma(s). Talking about trauma
is highly evocative and often triggers a cascade of symptoms not only within
the psychotherapy session but afterward as well. Patients with PTSD will
often have strong feelings that surface after the session and can lead to im
pulsive acting out or dissociative behavior that is dangerous. Sometimes pa
tients will not be able to identify any specific memory or flashback; rather,
they just experience a generalized restlessness or agitation that leads to act
ing out. They might feel a strong tendency to use alcohol or drugs to relieve
the discomfort. The therapist should educate the patient about PTSD, the
nature of PTSD symptoms, and the tendency to have flashbacks and “ripple”
effects outside of the therapy hour when triggered. Establishing strong cop
ing techniques and safety measures that can be practiced before addressing
the trauma directly in therapy is paramount. This practice should include
how to handle intense flashbacks and triggered feelings using breathing
techniques, coping mantras, cognitive techniques, “grounding methods,”
and possibly emergency tranquilizing medications. Also, the coping plan
should include reviewing the emergency or “after hours” contact information
in case the patient needs it. This can also include having a support person
such as a good friend or family member that the patient can call when par
ticularly triggered. The patient would discuss this with their support person
prior to trauma exposure in treatment. Simply put, the therapist should not
uncover the trauma until the patient is strong enough and has a plan in place
to cope with it.
There is no rule to dictate when an emotional trauma must be uncovered
or addressed directly in order for a person to be mentally healthy. In fact,
there is evidence that suppressing or repressing trauma can be adaptive for
patients in certain circumstances. Some studies have shown development of
PTSD symptoms is more likely to occur when people exposed to a trauma
undergo “debriefing” after the event.11 Denial can also be adaptive, as evi
denced by some studies that have shown patients with chest pain who de
nied the seriousness of the symptom had better cardiac outcomes than those
who were anxious of having a heart attack.12 The mind is always working
to protect itself, and sometimes “not talking about it” is exactly what is
needed.
Case Example
Fred is a 65-year-old married man with three grown children and works full
time in a foundry. He is a World War II veteran and was a prisoner of war
in a Japanese war camp. He underwent torture there at the hands of his
Trauma 97
captors. He has infrequent severe nightmares during which he lashes out in

a combative manner, and this frightens his wife. He also has periodic anger
episodes that “come out of nowhere,” and she believes these are from his
war experience. She demands he see a psychiatrist. He reluctantly undergoes
a psychiatric evaluation to please his wife. He tells the psychiatrist that some
times he has horrible flashbacks from his prisoner of war experience. Al
though he admits to having them, he does not describe them in detail and
states he “will never talk about it.” The only thing he has ever told his fam
ily about his prisoner of war experience is, “you learn to eat everything.” He
denies depression, is able to work productively, enjoys his family, has hob
bies, and seems relatively well adjusted. His arguments with his wife do not
seem remarkable. He has never been aggressive during a flashback. He and
the psychiatrist decide that finding ways to help his wife feel safer during
his nightmare or anger events would be a good idea.
The functioning of the patient in relationship to the trauma needs to be

evaluated to determine how aggressively trauma-focused therapy should be
pursued. Does the patient have trauma-related symptoms that interfere with
mental health or functioning? This analysis can be complicated, of course,
because many symptoms of trauma evolve for avoidance of trauma-related
emotions, and this association may not be apparent. Also, many patterns of
behavior evolve unconsciously to avoid trauma-related pain. An example of
this would be a person who has chronic depression and loneliness and avoids
intimate personal relationships. If during the course of therapy it becomes ap
parent that the patient avoids relationships because of prior abusive ones, it
may be prudent to begin to directly address the traumatic experiences.
Case Example
Rose is a 25-year-old woman who is medically hospitalized because of hav
ing a seizure. All of her medical tests are negative, and while undergoing
brain wave recording (electroencephalography [EEG]) in the hospital she
has another “seizure” that does not appear to be a valid seizure by EEG ev
idence. The physician suspects her seizures might be emotionally based
(“pseudoseizures”) and asks for a psychiatric consultation. Rose tells the
psychiatrist that she grew up in a loving family and had a good, uneventful
childhood. Her college years were equally unremarkable. She seems to be a
well-adjusted person. The only identifiable recent stressor is that she has
become engaged and is about to move into an apartment with her fiancé.
She has some anxiety about these upcoming events, although this does not
appear severe and she is able to discuss it without distress. Her parents and
fiancé confirm her history. The psychiatrist is unable to find evidence of
psychiatric illness in his consultation and suggests the patient see a psycho
therapist as an outpatient to understand better what might be underlying
her pseudoseizures.
Approximately 2 years later the psychiatrist sees Rose again under very
different circumstances. This time she has been admitted to the psychiatric
unit after a suicide attempt. She had become intoxicated and driven the
wrong way on a highway, causing a high-speed chase with police and even
tual SWAT intervention to bring her into custody. While in jail, Rose at
tempted to hang herself. Her husband and parents were mortified, having
never seen such drastic behavior in her before. While on the inpatient psy
chiatry unit, the psychiatrist confronts Rose, telling her he believes there is
something dramatically wrong in her life that she is not telling him. She
admits that there is but that she does not want anyone to know, especially
her husband or parents. Rose agrees to begin seeing the psychiatrist for psy
chotherapy.
Once in psychotherapy Rose admits that she underwent a traumatic ex
perience in college, but she does not want to talk about it. Even just hinting
about it causes her to have difficulty breathing and go into a panic. During
the initial sessions of the psychotherapy, the psychiatrist helps Rose develop
some grounding techniques for when she is upset and breathing exercises
for when she is panicked. They discuss PTSD and how it works its way into
bodily symptoms, including hyperventilation. They develop safety plans for
when she feels distressed and coping plans for when her feelings are intol
erable. These plans include signaling her husband when she needs help and
taking antianxiety medication on an “as needed” basis. Her husband agrees to
be part of the coping plan. The psychotherapy sessions do not involve ex
ploring the traumatic event until this groundwork has been put into place.
The psychiatrist eventually learns that Rose underwent a brutal rape
while in college that she did not tell anyone about, nor did she seek medical
or psychiatric help. She knew the attacker and felt deeply guilty that she
had “let it happen” to her. They initially do not explore details of the rape,
especially because Rose is terrified to do so. They spend weeks on develop
ing strengths, coping methods, and exploring the illogical aspects of feeling
guilty for the incident. Over time and after developing a good therapeutic
alliance, Rose is able to talk about the rape in a circumstantial, generalized
way. Eventually, bit by bit, she is able to talk about the rape in detail, in
cluding the worst parts of it. The attacker had forced entry into her apart
ment and physically assaulted her prior to the rape. She had fought him,
and he bludgeoned her into unconsciousness. She remembers awakening to
him dragging her up the stairs by her hair, her head bumping into each step
as they ascended to the bedroom. He threatened to kill her if she ever told
anybody. She was unable to move after the rape and stayed in her bed in a
bloodied and battered state for hours. She was catatonic, urinated on herself,
and wanted to die. She stayed in her apartment for several weeks after the in
cident, not wanting to appear in public. She told her friends she had mono
nucleosis and that was why she wasn’t going to class.
Rose experienced intense anxiety in recalling her trauma and had to put
into place all the coping techniques she had practiced; her breathing, cog
nitive reframing, grounding techniques, her “first aid” support, extra psy
chotherapy sessions, and medication. Over time she eventually was able to
Trauma 99
discuss her traumatic events without becoming panicked. She was also able
to tell her husband and parents what had happened to her and felt strongly
supported in the process. Rose and the psychiatrist were able to piece to
gether what had triggered her pseudoseizures and the high-speed incident
with police. The pseudoseizures had been triggered by the intense anxiety
associated with becoming sexually active with her fiancé, especially as she
had experienced vaginal bleeding on a few occasions after intercourse. She
did not consciously associate the rape with these events; rather, she began
to experience overwhelming panic with sexual relations. Rose felt guilty that
she wasn’t able to be intimate in a “normal” way with her fiancé. The pseu
doseizures were an unconscious expression of her deeply felt guilt yet need
for attention for her intense pain. The intoxication and high-speed chase
incident had happened soon after Rose and her husband moved into their
new home. The home had stairs, and their bedroom was on the second floor
(their prior apartment was one level). Rose was “triggered” by walking up
the stairs, especially when they would go up the stairs to retire for bed. As
with the pseudoseizures, Rose did not consciously associate the stair triggers
with the rape; rather, the mounting tension had become unbearable each
time she ascended the stairs with her husband. She felt guilty about her
symptoms and had become suicidal. As with most people who are suicidal,
a part of her wanted help even though she felt unable to ask for it. The high-
speed chase was a suicidal acting out of her intense, trauma-related pain,
along with an unconscious cry for help.
As with most cases of PTSD, the story of Rose makes total sense in retro
spect but seems inexplicable while it is occurring. Trauma has a way of trig
gering behavior that can be highly complicated and remarkable, yet totally
unconscious to the person experiencing it. Rose had suppressed the trauma
to the best of her ability, yet it was festering inside her and pushing into her
behavior in an acting-out way. She had extreme ambivalence about getting
help, desperately needing it but terrified of grappling with it. With sup
portive psychotherapy, she was able to build some strengths and eventually
cope with the trauma, allowing her to move forward with her life.
One of the difficulties in doing psychotherapy for PTSD is that re
counting the traumatic events is distressing not only for the patient but also
for the therapist. It’s hard to listen to a person recount trauma, especially
involving cruelty, aggression, or sexual or physical abuse. Sometimes a ther
apist might unconsciously lead a patient away from recounting trauma or
certain aspects of it, especially if the trauma triggers anxiety in the therapist.
In 1989 a novel method of doing psychotherapy for PTSD emerged called
eye movement desensitization and reprocessing (EMDR).13 EMDR involved
recounting the traumatic experience with a specific sequence of exposure
while the patient visually followed the therapists moving their fingers from
side to side of the field of vision. In some fashion the eye movements allowed
highly traumatic events to be recalled without experiencing the marked dis

tress usually associated with recalling them. As highly unusual as this sounds,
EMDR proved to be particularly effective and quickly became a standard
for treating PTSD. I underwent the training for EMDR and have incor
porated it into my psychotherapy practice for dealing with trauma. I believe
some reasons EMDR has become so efficacious is because it provides a
highly structured sequence for both patient and therapist to follow when dis
cussing the trauma while at the same time making it more tolerable for both.
This lessens the likelihood that both patient and therapist unconsciously avoid
the trauma or discussing more revolting aspects of it. The role of the eye
movements in EMDR remains somewhat of a controversy but seems to be
an essential component for its success.14
There are a few metaphors that are useful for thinking about trauma.
The first is a metaphor of a stressor causing a bone to break. For a bone to
break, the stress must be great enough to overcome the strength of the
bone. In some people with markedly fragile bones, a seemingly insignifi
cant stressor could cause a fracture or break. Think of an elderly person
with osteoporosis, where just a short fall can cause severe fractures. For
someone with strong, healthy bones, it would take a significant force to
cause a break. If the stressor is large enough—for example, an anvil drop
ping on a person’s arm—the bone will break no matter how strong it is.
With trauma and PTSD, much like the breaking of the bone, it depends on
the nature of the person and the nature of the stressor. For a person with a
more fragile psychological disposition (possibly a personality disorder, prior
traumas, poor coping skills), the level of stressor needed to cause PTSD
symptoms might be less than for someone with greater resilience. If the
stressor is severe enough, it will cause PTSD in any person who experiences
it. For example, victims of torture will virtually all develop PTSD. A
stressor that appears relatively minor to an outside observer might cause
PTSD in a vulnerable person. This perspective also helps us understand
how similar stresses may have drastically different emotional effects when
encountered by a child versus an adult. Thinking about the nature of the
person and the force of the stressor can significantly enhance our under
standing about trauma-related symptoms when doing psychotherapy.
Another metaphor for understanding the effects of trauma is that of
throwing a stone into a pond. The center of the stone hitting the water is
viewed as the “epicenter” of the trauma—that is, causing a significant effect
on all of those directly “hit” by it. The people at the epicenter of the trauma—
those directly involved in it—will bear the highest emotional distress. Next
are the ripple effects from the stone hitting the water, with those nearest the
Trauma 101
epicenter being the largest, and they diminish as they spread outward. Peo
ple are also affected by the ripple effects of trauma, with those closest to the
epicenter being most affected. If a shooting occurs in a classroom, the students
in the adjoining room who hear the gunshots, hear people screaming, and
have to run for their lives might be considered the “first ripple” from the
trauma epicenter. Even though these students did not directly witness the
shooting, a significant number will develop trauma-related symptoms and
some full PTSD. Envision the ripple effects spreading outward, eventually to
the parent getting a call at their work to hear that a shooting had occurred
at their child’s school. Even though some might consider this a relatively
small “ripple,” it can cause significant, persistent, trauma-related symptoms
and even PTSD depending on the circumstances of the parent.
The ripple effects of trauma can spread through families, cultures, and
even across generations. Transgenerational PTSD is a term to describe trauma-
related effects that can be “passed down” from one generation to the next.
Let me illustrate this with an example involving Alaskan Native Americans.
A large percentage of Alaskan Native Americans died from an epidemic of
measles and influenza around 1900, with some communities losing up to
50% of the population. This was called “The Great Death,” and with the
death of so many elders ensued the loss of many important cultural tradi
tions and beliefs.15 Subsequently thousands of children were left orphaned,
and the U.S. government, along with religious institutions, moved many
into orphanages. This began a process of assimilation, and over the next sev
eral decades Alaskan Native American children were removed from their
parents and villages for placement in government-run boarding schools. In
addition to forceful separation from their families (often hundreds of miles
away without capability to visit), they were required to speak only English
and were given different names. Many underwent physical, sexual, and
emotional abuse. This affected an entire generation of Alaskan Native
Americans, and many developed PTSD.16 When an entire generation un
dergoes such trauma, it can lead to a culturally shared sense of hopelessness,
despair, and concomitant psychopathology, such as high rates of depression
and alcoholism. The children growing up in these traumatized families, the
“new generation,” would be strongly influenced by the suffering of their par
ents, even though they never experienced the trauma in any direct fashion.
As a “conquered nation,” many Alaskan Native American parents coped
with their trauma by “not speaking of it,” and subsequently the new genera
tion of children shared in the hopelessness and despair of their affected par
ents without understanding any of it. Thus, the “ripple effect” of the trauma
was passed down from one generation to the next. When you’re doing psy
chotherapy with people affected by transgenerational PTSD, it’s vitally im

portant to discuss the history of their experience as well as that of their
elders. As one wise Alaskan Native American elder told me, “If you do not
know from where you came, you do not know your path in the world.”
Considering the “ripple effects” of trauma, I’d like to draw attention to
you, the psychotherapist. Listening to a person share a traumatic experience
along with witnessing his or her heartbreaking emotions affects the thera
pist, sometimes to a great extent. Stated simply, we’re not machines. We’re
affected by the intensely emotional work that we do. We’re one of the rip
ples from the trauma epicenter, solely by witnessing it through the patient.
On some occasions when listening to a person share his or her abuse expe
rience, my gut becomes knotted and I require extra time after the session to
“shake off” the heaviness of it before the next patient. Sometimes “letting
some out” in the immediate aftermath by saying to an office colleague, “I
just had a really intense session...whew!” can be very helpful. Notice that this
statement does not give any details, and is not an in-depth conversation or
supervision session, but rather is just sharing that I’ve been through an in
tense experience. This can also be done via text message or sharing in person
with a significant other after work. I also find it vitally important to exercise
on days I’ve had a heavy trauma burden at work, to release some of the “pent
up” energy from containing what I’ve endured by listening to patients. All
of these techniques can be useful to cope with the immediate ripple effects
of witnessing trauma.
When the cumulative toll of listening to trauma (“trauma burden”) causes
more enduring psychological symptoms in the therapist, this has been la
beled secondary PTSD and requires urgent attention and care. Some symp
toms of this can include feeling “burned out,” not wanting to hear patients’
stories (especially traumatic ones), frequent fantasies about quitting work,
increased conflicts with significant others, increased substance use such as
alcohol, low energy, insomnia, and depressed or irritable mood. Therapists
affected by secondary PTSD should have plenty of opportunity for supervi
sion, with a focus on reducing the trauma burden. Sometimes this might in
clude lowering the clinical case load, taking fewer new patients, or taking a
break (vacation days). We discussed compassion fatigue and the importance
of good mental health maintenance for the therapist in an earlier chapter. I
sometimes wonder if there should be something akin to Occupational Safety
and Health Administration (OSHA) standards for psychotherapists, where,
much like people who handle hazardous materials occupationally must wear
gloves for protection, therapists would be required to have supervision with
a focus on keeping the trauma burden manageable. Directly addressing the
Trauma 103
trauma burden is important for psychotherapists not only to maintain their

own mental health but also to keep energetic and creative in their work.
1. To what extent does trauma shape our lives?
2. What does it mean to “recover” from trauma?
References
1. Pitman RK, Rasmusson AM, Koenen KC, et al: Biological studies of post-
traumatic stress disorder. Nat Rev Neurosci 13(11):769–787, 2012
2. Yehuda R, Bierer LM, Andrew R, et al: Enduring effects of severe develop
mental adversity, including nutritional deprivation, on cortisol metabolism in
aging Holocaust survivors. J Psychiatr Res 43(9):877–883, 2009
3. Centers for Disease Control and Prevention: Adverse Childhood Experiences.
Atlanta, GA, Centers for Disease Control and Prevention, 2016. Available at:
https://www.cdc.gov/violenceprevention/acestudy/index.html. Accessed Sep
tember 15, 2018.
4. Substance Abuse and Mental Health Services Administration: Adverse Child
hood Experiences. Rockville, MD, 2018. Available at: https://www.samhsa.gov/
capt/practicing-effective-prevention/prevention-behavioral-health/adverse
childhood-experiences. Accessed September 15, 2018.
5. World Health Organization: Adverse Childhood Experiences International
Questionnaire (ACE-IQ). Geneva, Switzerland, World Health Organization,
2018. Available at: http://www.who.int/violence_injury_prevention/violence/
activities/adverse_childhood_experiences/en/. Accessed September 15, 2018.
6. Bisson JI, Roberts NP, Andrew M, et al: Psychological therapies for chronic
post-traumatic stress disorder (PTSD) in adults. Cochrane Database Syst Rev
(12):CD003388, 2013
7. Wampold BE, Imel ZE, Laska KM, et al: Determining what works in the
treatment of PTSD. Clin Psychol Rev 30(8):923–933, 2010
8. Neuner F, Schauer M, Klaschik C: A comparison of narrative exposure ther

apy, supportive counseling, and psychoeducation for treating posttraumatic
stress disorder in an African refugee settlement. J Consult Clin Psychol
72(4):579–587, 2004
9. Bryant RA, Harvey AG, Dang ST, et al: Treatment of acute stress disorder: a
comparison of cognitive-behavioral therapy and supportive counseling. J Con
sult Clin Psychol 66(5):862–866, 1998
10. Ellis AE, Simiola V, Brown L, et al: The role of evidence-based therapy re
lationships on treatment outcome for adults with trauma: a systematic review.
J Trauma Dissociation 19(2):185–213, 2018
11. Rose S, Bisson J, Wessely S: A systematic review of single-session psycholog
ical interventions (“debriefing”) following trauma. Psychother Psychosom
72(4):176–184, 2003
12. Levenson JL, Mishra A, Hamer RM, et al: Denial and medical outcome in
unstable angina. Psychosom Med 51(1):27–35, 1989
13. Shapiro F: Eye movement desensitization: a new treatment for post-traumatic
stress disorder. J Behav Ther Exp Psychiatry 10(3):211–217, 1989
14. Jeffries FW, Davis P: What is the role of eye movements in eye movement de
sensitization and reprocessing (EMDR) for post-traumatic stress disorder
(PTSD)? A review. Behav Cogn Psychother 41(3):290–300, 2013
15. Napoleon H: Yuuyaraq: The Way of the Human Being. Fairbanks, AK,
Alaska Native Knowledge Network, University of Alaska Center for Cross-
Cultural Studies, 1996
16. Easley C, Kanaqlak GP: Boarding School: Historical Trauma Among Alaska’s
Native People. Anchorage, AK, National Resource Center for American In
dian, Alaska Native, and Native Hawaiian Elders, 2005
CHAPTER 7
Special Populations
Borderline Personality
Disorder, Substance Use
Disorders, and Schizophrenia
Borderline Personality Disorder

Want to raise the blood pressure of your colleague? Tell him or her that you
have a patient referral for psychotherapy and that the patient has a diagno
sis of borderline personality disorder (BPD). Nothing induces distress more
in some therapists than hearing the patient they are about to start therapy
with has a diagnosis of BPD. There is good reason for this, because patients
with BPD can induce emotional distress, schedule problems, second guess
ing, uncertainty, and intense negative countertransference in their thera
pists. This is not hyperbole. Over the course of my career I’ve witnessed
some psychiatrists who don’t accept patients with a diagnosis of BPD into
their practice. There are also therapists who put a limit or “cap” on the num
ber of patients with BPD in their practice. There is no way to whitewash
this: patients with BPD can be incredibly difficult to work with. The flip
side of this coin is that most people with BPD benefit tremendously from
supportive psychotherapy, and the therapy can make a huge, positive im
pact on their lives. In my career, some of the most gratifying psychotherapy
experiences I’ve had have come from working with patients with BPD. So,
working with BPD can be like the Longfellow poem “There Was a Little
Girl”: “When she was good,/she was very good indeed,/ but when she was
105
bad she was horrid.” I hope this chapter provides you with some clinical pearls
to make the experience of working with BPD not only more tolerable but ac
tually rewarding for both patient and therapist.
First and foremost, understanding that the far majority of people with
BPD have a history of significant trauma in their childhood, including sex
ual, physical, and emotional abuse, will help the therapist have some imme
diate empathy right out of the gate. There are good reasons people with BPD
act the way they do, and seeing it in this light will help the therapist tre
mendously as therapy goes forward. They have evolved to be the way they
are, regardless of how maladaptive it might seem. Evolution is a natural
process, and they have developed the emotional “rough edges” for a reason.
Like most of us humans, they are “doing the best with what they got.” Hav
ing empathy is critically important, because working with BPD patients will
test your resolve often, and your empathic understanding will make it more
tolerable.
Part of what makes patients with BPD so difficult to treat is the nature of
their “push-pull” response. They are hurting tremendously and seeking help
in a desperate way, while rejecting it at the same time. From a psychodynamic
perspective, they have a fragile sense of self-identity as well as a chronic
emptiness that requires frequent attention, reassurance, and nurturance. The
emptiness is painful and striking to the core, so even when others are help
ing to fill the void, a powerful emotional hunger remains. Simultaneously,
they have been traumatized in association with closeness to others, so grat
ification of their needs is associated with further emotional pain. This cre
ates a very stressful approach-avoidance dilemma. Imagine you’ve just
swallowed a highly toxic poison, one that will eat at your insides in a burn
ing, tortuous manner and possibly kill you. In front of you is the antidote,
which if you swallow it will nullify the poison and not only take away the
pain but provide you comfort as well. There is just one problem: the anti
dote is inside the open, gaping mouth of a crocodile. Do you dare reach in
and attempt to grab the antidote, knowing the risk that you might be hor
ribly mutilated if not killed? Or do you take the chance with the poison, en
dure the painful, burning effects, and hope it doesn’t kill you? In this
visualization exercise, interpersonal intimacy is represented by both the
poison and the antidote for a person with BPD. Going through this exer
cise is similar in some ways to what people with BPD often feel in regard
to closeness to others—that is, desperately needing people but feeling an
impending annihilation from filling that need. This is mostly an uncon
scious conflict, but the anguish and anxiety associated with it are felt on all
levels.
Special Populations 107
The therapist working with BPD will feel this push-pull experience in
their gut. Sometimes this will be subtle; for example, the patient may indi
cate indirectly that she wants to talk about something important, but then
becomes evasive or distant when the therapist shows interest in exploring
it. It can also be blatant; for example, the patient might call the “after hours”
emergency service stating he is suicidal, but then when the therapist calls him
back, the number is busy, or worse, there is no answer. The therapist is then
put into a position of making the difficult decision of whether to mobilize
emergency services to check on the patient. Time and time again, therapists
working with BPD will find themselves feeling uncertain or “mixed up”
with what to do next in the therapy. This process of the therapist feeling
the same emotional conflicts of the patient is labeled projective identification
and can actually help the therapist gain insight into the issues the patient is
experiencing.
A teaching method I’ve employed when working with medical students
and psychiatric trainees in the psychiatric emergency service is to ask them,
“How does the patient make you feel?” prior to their talking about any
other patient information they’ve obtained from the first clinical interview.
These are some answers I have witnessed that were inevitably associated with
a diagnosis of BPD: “I feel like I’ve been in a blender”; “I feel like I’ve been
in a washing machine”; “I’m confused”; “My gut feels tied in a knot”; “I
don’t know why, but I feel angry.” Mind you, these are reactions from train
ees after a first clinical interview of a patient with a BPD diagnosis. These
reactions are not only a diagnostic clue but also predictive of what will be
experienced by the clinician while doing therapy. Even experienced ther
apists will go through the same range of feelings during the course of the
psychotherapy.
It’s critically important that a therapist prepare for projective identifica
tion while working with patients with BPD. The therapist should prepare
to feel unbalanced, tense, angry, attracted, unsure, and incompetent at dif
ferent times during treatment. The therapist who expects to feel “settled”
or “balanced” while working with patients with BPD will be more defensive
when provoked. By accepting that having strong negative emotions is inev
itable with such patients, the therapist is much less likely to act out on his
or her countertransference in a way that would be damaging to the patient.
There will be no static “zone” the therapist can comfortably settle into while
doing the therapy; rather, it will be changing and flowing like the current in
a river. The therapist is best prepared by anticipating a “ride” as opposed to
a position. Carrying this metaphor further, the therapist can also expect mo
ments when the river is slow moving, calm, peaceful, and beautiful. It won’t
always be Class-4 rapids.
Patients with BPD often have chronic suicidality, and this symptom is
particularly provocative to therapists for many reasons. Unless you’re a Zen
Buddhist master (I’m not), it’s impossible to remain calm while caring for
someone who keeps threatening to take her life. It’s bound to create inter
nal distress in the therapist. To cope with this highly stressful state, thera
pists employ a number of both conscious and unconscious defenses. These
defenses can include denial (of how stressful it is), reaction formation (see
ing the patient as “all good” and needing unconditional love), boredom
(feeling indifferent as a way to defend against the panic reactions to having
a suicidal patient), heroism (feeling the need to “save this patient at all
costs”), and self-doubt (feeling like “a crappy therapist”). Therapists should
expect to experience some collection of these feelings at times when work
ing with chronic suicidality. The most dangerous countertransference posi
tion for therapists working with a chronically suicidal patient is to deny it
has any significant effect on them. In a wonderful article entitled “Coun
tertransference Hate in the Treatment of Suicidal Patients,” the authors
pointed out the dangerousness of therapists slipping into the Faustian as
piration to “heal all, know all, and love all” with chronically suicidal pa
tients.1 We all indulge in little bits and pieces of this fantasy when doing
psychotherapy; however, it becomes particularly damaging when working
with patients with chronic suicidality. The stress of potential suicidality in
the patient will make these unconscious wishes of the therapist very unset
tling, which can lead to denial of feelings. When strong feelings are denied,
they will be acted out by the therapist in a way that rejects the patient. For
example, the therapist might unconsciously keep checking her watch
during the session or forget his appointment with the patient. Because these
patients are keenly aware of every nuance of acceptance or rejection from
the therapist, they will perceive the rejection in a very damaging way. This
can provoke more dangerous suicidal acting-out behavior.
There are a number of paradoxes inherent in working with suicidal pa
tients. First and foremost is the odd yet prevalent societal notion that the
therapist has control over what a patient does. If a patient in psychotherapy
commits suicide, the therapist is often put under the microscope, legally or
administratively, to determine possible blame. The assumption in these cir
cumstances is oriented toward finding fault: “How might you have pre
vented this?” Therapists unfortunately sometimes “buy in” to this crazy
perspective, which not only causes distress but has the eventual outcome of
making them much less effective in helping people who are suicidal. They
become overly anxious with the threat of suicidality and resort to interven
tions that might not be the best for the patient. For example, the therapist
might admit the patient to the hospital for even slight suicidal nuances, in
stead of helping him explore the underlying feelings or develop coping
plans that promote growth instead of dependence. Some therapists in these
situations never fully recover from the death of a suicidal patient and actu
ally become phobic of working with suicidality. How can one human being
have control over what another does, unless that person is a prisoner? In ad
dition to all the therapeutic tools a therapist learns for doing good work, de
veloping a strong philosophy about life, death, and responsibility is equally
important. I embrace the philosophy, “I am responsible for providing good
care to the best of my ability; I cannot control another person’s life.” As part
of this philosophy, I also acknowledge that I’m a human-type species of an
imal, prone to mistakes. I can’t know exactly what a patient is thinking, nor
can I predict the future (those things are delusional, aren’t they?). The more
therapists can accept their humanness along with the possibility of bad out
comes such as suicide, the better they become at working with suicidal
patients. One study of therapists who had lost a patient to suicide found
that therapists who accepted the misfortune as a learning opportunity were
much less distressed than those therapists who had self-reproach over the
event.2 I acknowledge that it’s important to review bad outcomes in psy
chotherapy; however, this should be done in an atmosphere of acceptance,
nurturance, and learning.
A metaphor I like to use with psychiatric residents for handling the dif
ficult countertransference of working with seemingly unmanageable psy
chotherapy situations is to imagine being asked to paint all the walls of the
psychiatric clinic with a 1-gallon can of paint. If instructed to do so by your
boss, you would go ahead and begin painting, realizing that the task is im
possible. You would have some distress from knowing there’s no way you
could complete the task; however, on a gut level you would totally accept
the unlikelihood of it. You would focus on doing a good paint job for the
section you can do. There would be no distress in the act of painting, be
cause the impossibility of completion is so self-evident. This metaphor of
“painting the wall” can sometimes be useful in working with BPD patients.
You acknowledge the irresolvable nature of it, while dutifully doing good
psychotherapy at the same time, hoping that the little patch you work on
can at least be a job well done. This helps minimize the fantasy to “heal all,
know all, love all” in an indirect way.
You may have noticed that so far this section on doing psychotherapy
with patients with BPD has focused on the therapist. Having an empathic
understanding of the patient, expecting a “ride,” and handling counter-

transference are all key elements to doing good therapy with BPD. The ba
sic strategies and techniques of supportive psychotherapy will work well for
people with BPD, with emphasis on a few. First and foremost, discussion
and education about the diagnosis is important, although often one can avoid
the actual term “borderline personality disorder.” I usually prefer to discuss
the diagnosis in terms of the patient’s symptoms, noting the extreme sen
sitivity to rejection, the mood swings, the disappointment with intimacy,
and suicidality. Viewing the diagnosis as a “no fault” brain issue is especially
important. Using the words “Your brain is just more sensitive to some of
the emotional things that everybody experiences” can be helpful. The actual
diagnostic category of borderline personality disorder has become associ
ated with such negativity, I downplay the importance of the label and avoid
discussing it directly unless the patient requests it. If the patient wants a rig
orous discussion of the official diagnosis for BPD, it can be useful to open
DSM-5 and go over the criteria jointly, asking the patient’s opinion about
whether each criterion for diagnosis is met. Patients sometimes then take
“ownership” of the diagnosis by doing this. I had one educationally sophis
ticated patient with BPD who loathed the fact she had the diagnosis; how
ever, she read a number of textbooks on it and benefited from an academic
perspective.
Another area of focus for psychotherapy of BPD is for the therapist to
employ good boundary maintenance. Patients with BPD will test the bound
aries repeatedly and in different ways, ranging from expecting time flexibil
ity from the therapist (“Can we have 5 more minutes?”) to wanting personal
time (“Can we meet at a coffee shop sometime?”). Good boundary mainte
nance not only is critical to keep therapy running smoothly but also can
provide learning experiences for the patient. Time and time again, when the
therapist keeps proper boundaries, this modeling can be internalized by the
patient as a healthy way to keep her own boundaries (which are inevitably
causing problems in her life). Also, the technique of “striking while the iron
is cold” is very useful in working with BPD. The opportunities for learning
are enhanced so much better when the patient is not in the midst of a crisis.
Learning to identify mood states, mindfulness training, distress tolerance
skills, and interpersonal effectiveness training are very important and excel
lently outlined in the dialectical behavior therapy developed by Marsha
Linehan.3 Dialectical behavior therapy skills and techniques are now con
sidered essential tools for working with BPD.
An experienced colleague of mine with a particular interest in doing psy
chotherapy with BPD patients once described his view of the process: “In the
first phase of therapy, they will (unconsciously) throw all the shit at you they
can throw, to determine if you’re strong enough to take it. You have to be ‘a
rock.’ If you keep standing through it all, and remain a consistent, balanced
presence, then the true therapy begins and healing starts to take place.” I’ve
found this perspective helpful and believe it addresses the unpleasant rage
that often emerges when BPD patients finally begin chipping away at their
issues. On some level they feel their internal chaos is horribly destructive and
are frightened of unleashing themselves onto others. Also, they don’t want
to invest themselves emotionally only to be abandoned again. I sometimes
have found it paradoxically comforting to tell a patient, “I just want you to
know that I’m strong and confident we can get through this. You don’t need
to worry about harming me with your symptoms; I can take it.” From a psy
choanalytic perspective, conveying a sense of safety is a core healing com
ponent of supportive therapy.4
Usually the initial stages of doing psychotherapy with BPD will involve
the greatest frequency of calls for help outside of the therapy hour. In the
psychoanalytic perspective, patients with BPD have poor object constancy,
meaning poor ability to internalize or “hold on to” the therapist other than
when they are physically in the session. One way to address this phenome
non is to provide a transitional object for the patient. A transitional object
is one that can remind patients that they are not abandoned, much like a
security blanket for a 2-year-old made from a baby blanket or mother’s
clothing. The therapist can give the patient her business card and write a
personal, comforting message on it to help soothe the patient when he is
distressed. The patient can keep this in a purse or wallet. Sometimes a brief,
supportive telephone call that is scheduled between therapy sessions can
also reduce emergency distress calls. Hearing the voice of the therapist can
be a powerfully soothing experience for many patients with BPD, especially
in the early phases of treatment.
Patients with BPD will often become angry in therapy, and frequently
the anger is triggered by feeling abandoned by the therapist. It might occur
when the therapist has actually physically left the patient in some way, for
example, when the therapist goes on vacation or cancels a session (even if
for a seemingly logical reason). It can also happen in much more subtle
ways during the therapy, for example, if the therapist is late, appears dis
tracted, yawns during the session, or answers a text message. The therapist
should be keenly aware of abandonment feelings as possible causes for the
patient’s anger even if the patient is not aware of it (“You seem upset. Have
I angered you in some way? Maybe if we can understand this, it will help us
learn more about the things that hurt you”). At times, patients may disso
ciate or daydream during the session as a way to cope with their anger (“You
seem distracted. Have I upset you in some way?”). When the patient is able
to identify angry feelings toward the therapist and work toward a resolu
tion, it can provide an incredibly powerful corrective emotional experience.
Case Example
Sonya is a 25-year-old single, college-educated woman working as an office
manager at a telecommunications company. She has volatile relationships,
both in her personal life and at work. She has intense romantic relation
ships that are short lived, and she frequently changes jobs because of con
flicts there. She believes she was sexually abused by her father, a Vietnam
war veteran with severe posttraumatic stress disorder and alcohol abuse,
although she has no direct memory of the abuse. Sonya has binge eating,
frequent suicidality, mood swings, chronic feelings of emptiness, and im
pulsive behavior, including reckless sexual behavior. She starts psychother
apy after a suicide attempt following a break-up with her boyfriend.
The first year in therapy is characterized by volatility. Sonya generally
likes her psychotherapist but frequently feels he does not care enough and
is often angry with him when she perceives he has not reciprocated her warm
feelings toward him. She uses the on-call system frequently for suicidal
feelings and has had several trips to the emergency department with contin
ued suicidal and self-injurious behavior. On a few occasions, when very dis
tressed from feeling rejected by her therapist, Sonya quits therapy. In each
circumstance, the therapist coaxes her to resume, encouraging her to continue
the work of psychotherapy she has invested in while educating her that hav
ing ups and downs is a natural part of the process. The therapist experiences
a number of feelings working with Sonya, including anxiety that she will
kill herself, irritation with her frequent after-hours needs, attraction to her
at times, and rejection when she is angry with him. He talks about her case
in supervision frequently. In between the frequent crises, the therapist is able
to educate Sonya about her diagnosis, help her to identify her mood states,
and assist her to develop some coping skills for when she is feeling out of
control or suicidal.
By the second year of psychotherapy, Sonya is having less frequent sui
cidal crises, although she continues to have stormy relationships. She educates
herself about her diagnosis, reading some books on BPD that sometimes
leads to intense arguments with the therapist on diagnostic symptoms she
does not endorse in herself. She has started to recognize her mood states,
emptiness, and impulsive symptoms, mostly after the fact. Her life remains
chaotic, and she has intermittent urgent therapy needs for crises; however,
the severity of her behavior has diminished.
In the following several years of psychotherapy Sonya becomes much
better at observing herself, and although she continues to have marked strong
emotional reactions to situations, she is able to modulate her responses. Her
acting-out behavior is less. She often imagines, “What would my therapist
say about this?” when in conflicted situations. For example, when angry with
her boss at work, she stews about it all afternoon but does not confront him
and quit. She brings these types of situations into therapy for discussion
(“I know, I know, I’m doing the ‘black and white’ reaction thing again”—
Sonya’s description of splitting). The therapist has fewer intense counter-
transference experiences and feels more comfortable working with Sonya.
She has suicidal thoughts at times but no suicidal or self-injurious behavior.
Her relationships remain mercurial, and boundary problems occur frequently
(e.g., dating married men). However, she has no further sexually reckless
behavior and is able to maintain relationships much longer than before. Af
ter 6 years of supportive psychotherapy Sonya moves to a different state be
cause of a job offer. She is ambivalent about seeking further psychotherapy
because she feels she has benefited from her therapy experience and her life
is more stable.
Alcohol and Other Drug Abuse

Psychotherapy with people who have alcohol and other drug abuse
(AODA)* has undergone an interesting evolution over the past several de
cades. During my psychiatric training (about 2 score years ago...) the pre
vailing wisdom was that doing psychotherapy was next to useless for people
with active substance abuse. The professional stance was that the person
needed to get their addiction under control before any meaningful work
would occur in psychotherapy. The reason for this view was based on the
belief that the anxiety that arose during psychotherapy was a necessary
driver for change, and that the addict would not tolerate the anxiety with
out acting out by using substances, therefore nullifying the potential for
change. Some psychotherapy clinics specifically excluded patients with ac
tive AODA (and actually some still do today). The obvious problem with
this perspective is that for most people it’s almost impossible to separate the
AODA issues from personal ones (i.e., those psychological issues that
would benefit from psychotherapy). As the field has evolved, more people
are now viewing “integrated” or concurrent treatment as the way to go.6
Integrated treatment consists of having an AODA counselor address the ad
diction issues in coordination with a mental health counselor addressing
psychological issues such as anxiety or depression. Although, ideally, inte
grated treatment would be available within the same clinical setting, in
*The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition,5 changed the
description of alcohol and drug abuse to alcohol and substance use disorders. Because
the AODA acronym is widely used in clinical practice, I have continued to use this for
ease of reading in this book.
practice often a psychotherapist becomes the one clinician to deal with

both. This might be because the patient is unwilling to see an AODA spe
cialist, the insurance company will not cover AODA treatment, there is no
access to integrated treatment, or other factors such as unavailability of an
AODA counselor.
I believe when a person with AODA issues comes in for psychotherapy,
it is critically important to start the therapeutic process, regardless of the im
pediments just described. It seems illogical to exclude a patient from getting
help when she is at a point of wanting it. Sometimes it will take the develop
ment of a good therapeutic alliance before a patient will accept the AODA
diagnosis and agree to AODA treatment. Sometimes the patient may need
to overcome other psychological issues before she can address the AODA
ones. Supportive psychotherapy can proceed regardless of the sequence of
treatment modalities. Although AODA specialists might be best qualified
for AODA treatment, patients are not so easily divided into compartments
and often do not see themselves that way. Developing a good therapeutic
alliance and directly addressing the issues that the patient sees as important
for her mental health needs is a good starting point. For example, if a person
seeks help for depression and has a severe alcohol use disorder, it’s common
knowledge that the continuing alcohol use will likely keep her depressed.
It’s fine to start supportive psychotherapy with the foresight that treatment
for the alcohol use disorder will happen when the timing is right. For some
patients, they might accept AODA referral upon the first psychotherapy
session. For others, it might be months or years before they will address
their alcohol use, and some never will. There’s no way to predict who will
or will not eventually tackle their AODA issues and become sober.
It’s important to let patients know that if they come to the psychother
apy session intoxicated, it’s a waste of time for therapist and patient alike.
Sometimes patients will show up for therapy with obvious intoxication. In
this circumstance, the therapist can let the patient know in direct fashion,
“You seem to be intoxicated, and I don’t believe you will benefit from a psy
chotherapy session in this state. Let’s reschedule our appointment for a
time when you’re not intoxicated.” It’s important to say this in a neutral,
nondemeaning, nonreprimanding fashion so that the patient does not feel
punished for having symptoms of his illness. At the same time, it’s just as
important to keep boundaries in the therapeutic relationship with natural
consequences for unhealthy AODA behavior (e.g., losing the session due to
intoxication).
People with AODA issues often have profound shame or guilt for many
reasons. In addition to the societal stigma against those with addictions, the
patient often has been ostracized by family or friends. These negative re
sponses are sometimes because of the lying, concealment, and even stealing
that frequently occur with AODA patients. The therapist should take spe
cial care in keeping a nonjudgmental stance with AODA patients and create
an atmosphere of acceptance. Sometimes this will be a challenge, because
similar deceptive behaviors will occur within the psychotherapy. The therapist
who expects these behaviors with AODA patients will be best prepared to
cope with the behaviors. One metaphor that is useful for dealing with AODA
is to visualize the patient as having a severe breathing disorder and the ad
diction as their oxygen tank. They may outwardly discuss quitting with the
therapist, but deep down inside, they know they can’t live without oxygen
(i.e., their substance of abuse). Nearly all patients with AODA have lied to
continue their addiction. The therapist should expect this during the psy
chotherapy as part of the process. Keeping an accepting stance toward these
patients will help them to become more honest as therapy continues.
Taking the view that the alcohol or drug use evolved for important rea
sons is important to help the therapist maintain a nonjudgmental stance.
It might be simple; for example, the patient uses alcohol or drugs and be
comes strongly rewarded by the substance, using increasing amounts and
with increasing frequency in a model of biological dependence. Although
there is scientific evidence for this perspective, for psychotherapy purposes
it’s more useful to try and answer the following questions: What does the
substance do that doesn’t happen without it? What does it allow? What
things are more easily avoided? What pain is avoided? To get answers to
questions such as these, the therapist must also ask: What is good about us
ing? What do you like about it? Keeping a perspective of the curious scien
tist looking for answers will help the therapist maintain a nonjudgmental
stance. By exploring the “benefits” of AODA with patients, the therapist is
not endorsing their substance use. Rather, it helps the patients be honest
about their substance use, and such honesty is critically important and will
be strongly correlated with the efficacy of the psychotherapy. If patients feel
the therapist is looking down on them for their AODA, they are much
more likely to lie about it. Relapses of AODA should be expected, and the
therapist should treat these as a natural process in nonjudgmental fashion.
In a paradoxical way, the therapist should also not become too compli
mentary when the patient reports periods of sobriety. If patients are too
strongly rewarded by the therapist, they might then feel more shame with an
AODA relapse and avoid reporting it. For sobriety and relapse alike, the
therapist should maintain a nonjudgmental stance and keep the attitude of
learning from the particular phase the patient is in.
Negative AODA consequences are often remarkably blatant to everyone

except the person with the addiction, and this is because denial plays such
a pivotal role in people with AODA. Losing friendships, becoming es
tranged from family, losing jobs, and becoming medically ill are all part of the
downward spiral that addicts are in but fail to see. Clarifying and confront
ing the patient with AODA is paramount for successful psychotherapy.
“Holding up the mirror” for the patient to observe how the AODA is caus
ing problems in his life should always be done in a style of shared learning.
The trick is to get the AODA patient to see what everyone else does—that
the addiction in ruining his life. The development of insight is more likely
to occur when the patient feels that his therapist is “on his side” and the dis
covery of the destructive nature of AODA is shared. This can occur regard
less of the patient accepting an AODA diagnosis. In fact, arguing about
diagnosis is almost always counterproductive. Often patients with AODA
will deny they have a diagnosis but will accept working on how their sub
stance use causes problems in their lives (“I’m not an alcoholic, but yes,
sometimes I drink too much”).
Case Example
Ava is a young woman with schizophrenia and severe cocaine dependence.
She works as a prostitute to support her habit and is frequently arrested for
this and spends time in jail. She is also occasionally physically assaulted by
men. Recently her arm was broken by a cocaine dealer after a trade of sex
for drugs, the details of which Ava is resistant to share.
THERAPIST: That must have been so painful and scary. I worry that this will
keep happening and eventually you will be killed. Does that worry
you?
AVA: Not really, it won’t happen again.
THERAPIST: Help me understand this, Ava. From where I sit, it seems like
your life is filled with so much pain and suffering. It’s so hard for me
to understand why you don’t want to change it. Maybe you can tell
me once again all the good things that cocaine does for you?
AVA: It makes me feel good. I don’t really feel good so much, and I feel
better when I use it. I like it.
THERAPIST: I get it...you feel bad so much, and cocaine makes you feel
better. You must really, really, really like it because often so many bad
things happen with your use. Is it like the good of it makes the bad
OK? If that guy had cracked your skull and then you had a brain injury
so you couldn’t move your arms or legs, would it still be worth it? I’m
just trying really hard to understand just how good it is for you.
AVA: No, I don’t want to be a paraplegic. I don’t think that will happen. I’m
not going to him again.
THERAPIST: I understand you don’t want any of these bad things to happen
to you. It just seems to me they continue to happen, even though you
don’t like it. I wish we could find things that made you feel good that
aren’t cocaine. I hear you loud and clear that you like cocaine. My
worry is that one of these days you will be permanently injured or,
worse, killed. Maybe you can keep teaching me why it is so worth it,
to keep using. Because it is still very hard for me to understand.
In this example, the therapist is confronting Ava with the negative con
sequences of her cocaine use while at the same time attempting to clarify
the positive aspects. The therapist is also making the comparison very con
crete, because Ava has limitations in abstract reasoning from her schizo
phrenia. The therapist is staying in a cooperative stance and is attempting
to get Ava to join him in this evaluation of the pros and cons of cocaine use
without making her feel judged. Her use is more of a puzzle for the two of
them to solve together, rather than her “bad” or “crazy” behavior. At the
same time, the therapist is feeling distressed about her dangerous behavior
and used the extrapolation of getting beaten into a paraplegic state to try
and “break through” her denial. This extreme example used by the therapist
was intentionally coarse, and it’s difficult to judge its effectiveness. Ava did
not respond immediately in a concerned way; however, the picture painted
by the therapist might remain in her mind as she continues to put herself
in dangerous situations. Ava and the therapist had a good working alliance
over a several-year span of working together. Tragically, she was eventually
killed in a cocaine-associated event.
Alcoholics Anonymous is one of the most successful grassroots self-
help movements in the world. The first step in Alcoholics Anonymous is:
“We admitted we were powerless over alcohol—that our lives had become
unmanageable.” In a very interesting parallel process, the first step for ther
apists working with AODA patients is to fully embrace a first step of their
own: “I admit I am powerless in stopping this patient from using addic
tive substances, and that my life is unmanageable if I believe I can control
them.”
Therapists working with AODA patients often experience “burnout,” a
stale, nihilistic condition in which they feel useless because time and time
again the patient continues to use addictive substances despite the apparent
gains made in therapy. Accepting the first step for therapists can be helpful
to decrease the likelihood of burnout. Another useful metaphor for the ther
apist to minimize burnout is to “stretch” the timeline of treatment. Instead of
expecting therapeutic gains over weeks to months, the psychotherapist vis
ualizes change occurring over years. This expectation doesn’t imply that the
therapist shouldn’t try, week after week, to help the patient change. Most
patients with AODA are going through life like a wrecking ball, destroying
relationships with family and friends and endangering their jobs and their
physical health as well. This creates stress for the therapist because of the
constant danger that the patient is ruining his or her life with AODA. The
philosophical groove for the psychotherapist is to treat the patient urgently
and hopefully, but without expectation of immediate change. Simple, right?
Schizophrenia
Schizophrenia is one of the most damaging brain disorders, and people with
this diagnosis have deficits in motivation, attention, thought processing,
thought content, planning, and executive cognitive functions. For most peo
ple with schizophrenia, there has been a tremendous decline in functioning
from their premorbid state, and addressing this loss in psychotherapy can be
beneficial. For many, their dreams from childhood and adolescence have
been shattered. Once hoping for college, a career, and a family of their own,
many people with schizophrenia end up with none of these goals and instead
are living on disability, alone, and in poverty. Many internalize this down
ward spiral of their life in a guilty way, believing they are at fault for their
position in life. Sometimes they have endured so many repeated failures and
disappointment in themselves that they have retreated to a position of con
crete nihilism in order to cope (“Nothing matters because I can’t do anything
anyway”). Asking them questions such as “What are your goals? What do
you want in life?” is sometimes overwhelming to them, and they are left to
answer with “I don’t know” because they’re so burned out. Helping them find
the motivation that once fueled their dreams can be one avenue in psycho
therapy for helping them find a zest for life again (“What were your dreams
in childhood and as a teenager? What did you enjoy before suffering with this
brain illness?”). Finding what can energize their motivation or enthusiasm
for life is a cornerstone goal for many patients with schizophrenia. Helping
them to see themselves as a person rather than a chronic illness is paramount
(from “I’m a schizophrenic” to “I am a person—with interests, goals, rela
tionships and dreams—and I am living with schizophrenia”). This means
guiding them toward the same things most of us aspire to: having love in our
lives, working, and having friendships, hobbies, and interests. This process
of rediscovering their personhood is greatly enhanced within the framework
of supportive psychotherapy. Although schizophrenia is a major mental dis
order with associated loss of functioning, most patients with this illness are
able to benefit from supportive psychotherapy.
In paradoxical fashion, when a person with schizophrenia becomes sta

ble on psychiatric medications, he or she is then more vulnerable to depres
sion. Having more psychotic symptoms and disordered thinking provides a
buffer of denial for how devastating the illness is. Sometimes when these
patients are doing their best and are able to reflect on their lives is when
they are at higher risk for suicide. In fact, the diagnosis of schizophrenia has
a remarkably high suicide rate among mental illnesses, with a lifetime prev
alence of between 5% and 10%.7 Supportive psychotherapy can be tremen
dously helpful for people with schizophrenia to cope with these realizations
and develop new avenues for finding satisfaction in life. The more a person
with schizophrenia recovers from core psychotic symptoms (e.g., delusions
and hallucinations), the greater the likelihood that supportive psychother
apy will be needed. There is sometimes an assumption within the mental
health profession that people with schizophrenia primarily need psychiatric
medication and that everything else will fall into place once the medica
tions are “right.” Nothing could be farther from the truth, and there is am
ple evidence that psychosocial interventions for schizophrenia are strongly
correlated with functioning.8 In my experience, people with schizophrenia
are rarely referred for therapy; however, supportive psychotherapy fits very
well into the spectrum of helpful psychosocial interventions for those with
schizophrenia.
Symptoms of delusions and hallucinations that occur with schizophre
nia are usually not helped by psychotherapy. Reducing the distress and in
creasing the adaptability to these symptoms, however, are highly amenable
to supportive psychotherapy. Cognitive strategies that “reframe” these psy
chotic symptoms without confronting their validity will usually work best.
Instead, the psychotic symptoms are seen more as ways of thinking or believ
ing that cause distress or impairment in functioning and therefore need
coping strategies. For the patient believing that people are out to kill him,
the focus would be helping the patient to attend family gatherings, walk to
the store, drive, and do other necessary social functions in spite of being
stalked by others. For example, one patient used the cognitive reframe of
“active resistance” (his term) for doing more social activities even though he
believed others intended to harm him. He was able to do these things by
seeing himself as somewhat of a hero by actively resisting the malevolent
intent of others. Having the patient resist negative auditory hallucinations
by “talking back” to them can also reduce the distress of these symptoms
and lessen the feeling of being controlled and powerless. A relatively new
technique of using computer animation “avatars” that embody the halluci
nations and having the patient confront them has shown some promise.9
Example
Ralph was a brilliant 23-year-old student in graduate school for metaphys
ics when he developed schizophrenia. He was married to a woman who was
very nurturing and caretaking during his many episodes of severe psychotic
illness, including some catatonic episodes that were medically dangerous.
During his psychotic episodes, Ralph would lose his sense of self and believe
he was an agent of God with the singular purpose to make others happy.
God would speak to him with messages on how to act and save humanity. He
would not eat or sleep during his psychotic episodes, either enraptured with
godliness or sunk into a demonic hell. He became lost in a psychotic world,
and his wife was essential in keeping him alive.
Ralph was not able to complete graduate school because of his psy
chotic illness and instead worked as a dishwasher for nearly 40 years. At age
62, Ralph experienced a marked decrease in the severity of his psychotic
symptoms due to improvements in his psychiatric medications. He was
suddenly awakened into a world of reality and struggled to understand his life
journey. He began supportive psychotherapy to cope with the changes in
his life. Once a promising graduate student, he struggled to come to grips
with his life as a dishwasher. In therapy, he was able to mourn “what he
might have been” if he had not developed schizophrenia. He continued to
have low-level psychotic symptoms and developed new ways to interpret
these that were better oriented to reality yet still congruent with his beliefs.
Ralph had good insight into his schizophrenia, and this made it more dif
ficult to navigate the world of reality because he frequently questioned the
stability of his thought patterns with this therapist (“Does that sound right
to you? Does that make sense? Do you think that is normal?”). After several
years of supportive psychotherapy and realistic life circumstances, he began
to trust his perceptions more. His relationship with his wife changed dras
tically because he no longer depended on her to help him function, and this
caused a strain in the marriage. Ralph often used the psychotherapy hour to
help navigate his emotions in the realistic and complicated world of intimacy.
He eventually became a peer counselor and fulfilled his lifelong dream to
help others, albeit in a reality centered fashion.
Classroom Exercise
• BPD exercise: Divide the classroom into pairs. Sitting slightly
farther than arm’s length apart, have one person extend her
arm out straight toward the other’s face, holding up her hand
in a stopping gesture, while shouting, “Help me!” Repeat the
exercise shifting roles. Discuss what it felt like for each role in
the exercise.
• Schizophrenia exercise: Have the classroom participate in
guided imagery for having the belief that their loved ones are
part of a plot to kill them. “Walk through” a typical day’s events

with this belief. What insights are gained in this exercise?
1. To what extent does trauma shape our lives?
2. What does it mean to “recover” from trauma?
3. What other metaphors or philosophies might be useful to cope with the

dilemma of treating AODA patients urgently, but with no expectation
for immediate change?
References
1. Maltsberger JT, Buie DH: Countertransference hate in the treatment of sui
cidal patients. Arch Gen Psychiatry 30(5):625–633, 1974
2. Hendin H, Haas AP, Maltsberger JT, et al: Factors contributing to therapists’
distress after the suicide of a patient. Am J Psychiatry 161(8):1442–1446, 2004
3. Linehan MM: Cognitive-Behavioral Treatment of Borderline Personality
Disorder. New York, Guilford, 1993
4. Werman DS: On the mode of therapeutic action of psychoanalytic supportive

psychotherapy, in How Does Treatment Help?: On the Modes of Therapeutic
Action of Psychoanalytic Psychotherapy. Edited by Rothstein A. Madison,
CT, International Universities Press, 1988, pp 157–167
5. American Psychiatric Association: Diagnostic and Statistical Manual of Men
tal Disorders, 5th Edition. Arlington, VA, American Psychiatric Association,
2013
6. Drake RE, Essock SM, Shaner A, et al: Implementing dual diagnosis services
for clients with severe mental illness. Psychiatr Serv 52(4):469–476, 2001
7. Hor K, Taylor M: Suicide and schizophrenia: a systematic review of rates and
risk factors. J Psychopharmacol 24(11):81–90, 2010
8. Dixon LB, Dickerson F, Bellack AS, et al: The 2009 schizophrenia PORT
psychosocial treatment recommendations and summary statements. Schizo
phr Bull 36(1):48–70, 2010
9. Craig TK, Rus-Calafell M, Ward T, et al: AVATAR therapy for auditory ver
bal hallucinations in people with psychosis: a single-blind, randomised con
trolled trial. Lancet Psychiatry 5(1):31–40, 2018
CHAPTER 8
Termination
It was 1984, and I was a psychiatric intern

at the Baylor College of Medicine about to begin my first seminar on sup
portive psychotherapy. I felt like I was “living the dream” and couldn’t be
lieve that I would actually be doing psychotherapy sometime soon. Me,
John Battaglia, a therapist! It seemed like such an exciting thing, doing psy
chotherapy, and I had great anticipation for the course. The faculty member
teaching the course was a tall, distinguished-looking, middle-aged gentle
man sporting a cowboy hat and cowboy boots. He strode into the classroom
with long steps and the complete command of a wise and experienced leader.
He then began speaking with his thick Texan twang, “I’d like to tell you
about Shirley, a patient I treated in psychotherapy for 18 years...” What,
wait a minute—18 years?! I felt an immediate sense of disappointment. How
could someone be in psychotherapy for 18 years? Even worse, how does a
psychiatrist do therapy with the same patient for that long? My precon
ceived notion of psychotherapy was that therapists helped people by deftly
leading them toward insight so that they would have a “light bulb—aha!”
moment that would change their lives, thus no need for further therapy. In
other words, I thought insight from psychotherapy allowed change, followed
by the patient then going on his or her merry, much improved way. Eigh
teen years didn’t fit that. How could psychotherapy possibly be beneficial for
that length of time? Although my gut impression was negative, as the course
went on, I eventually began to understand how “18 years of psychotherapy”
is not a contradiction in terms, and eventually the supportive psychotherapy
course became one of my favorite seminars during my internship year. And
in case you haven’t noticed, doing and teaching supportive psychotherapy
became a cherished endeavor throughout my psychiatric career.
123
In early models of psychotherapy, the process of termination was viewed

as critical for cementing the gains that had been made during the therapy.
If a person had overcome anxiety or depression or had learned to undo some
self-reproach, the process of terminating with the therapist was seen as cru
cial to strengthen these gains. The self-actualization of termination showed
that the patient was able to function independently rather than being de
pendent on the therapist. Patients were expected to mostly lead the way to
ward their termination from therapy, much as young adults would leave
their parents. The act of successful termination was seen in and of itself as
the final act of maturation from the psychotherapeutic process. In fact, ther
apists would intentionally avoid saying “Come back if you need me in the
future” during termination, because this could potentially be seen as imply
ing unresolved dependency needs in the patient. In summary, psychother
apy was seen as incomplete without a successful termination.
Early in the evolution of supportive psychotherapy, patients were only
referred for this technique when they were too ill to undergo the rigors of
exploratory or psychoanalytic therapy. This included patients with primi
tive personality disorders or major mental illnesses. Patients with these con
ditions were seen as having major mental defects causing their symptoms as
opposed to having neurotic defenses. With this perspective, the idea that a
patient might need 18 years of therapy is not strange at all, because the men
tal illness is seen as a defect in functioning that will likely always require
professional help. Using medical illness as an example, one might compare
treatment of an infection with treatment of insulin-dependent diabetes.
One would expect the infection would “clear up” with treatment and the
patient would then return to his or her usual level of medical stability. With
insulin-dependent diabetes, the patient is seen as having a chronic medical
illness requiring lifelong treatment. Nobody would have the illusion that the
diabetes would be “cured” and no longer require treatment. Some patients
needing supportive psychotherapy fit this perspective, that of having a
chronic mental illness that will likely require lifelong treatment. For these pa
tients, there is no need to have a termination process in order to “complete”
their therapy. Thus, supportive psychotherapy can be viewed as a sustaining
process and not a time-limited treatment. If the patient at some point then
wants to discontinue psychotherapy, there’s no problem with wishing them
well and saying, “The door is always open, and I’m here if you need me in the
future.”
Supportive psychotherapy has evolved to now include a wider variety of
patients, including high-functioning people without major psychological
impairments. The range of sessions can be from 1 to 1,000, and there’s no
Termination 125
longer a preconceived notion that a termination process is necessary to

complete the therapy. There can be periods of intense psychotherapeutic
work, followed by a hiatus without therapy, then continuing sessions on an
“as-needed” basis. All combinations are acceptable.
A situation frequently encountered with termination is when the therapist
and patient have a great therapeutic alliance but therapy must be termi
nated because one of them is leaving. This is a yearly occurrence for psychi
atric residents and social work interns completing their training. For most
patients who have enjoyed a good therapeutic alliance, terminating with the
therapist is a very hard thing to do. There is often a belief that the relation
ship is special in ways that will never be recreated. There’s a certain truth to
this point of view, because relationships of any type are never entirely re
producible and even the same relationship changes over time. It’s very
important for the therapist to acknowledge the specialness of the relation
ship and not diminish it, especially as there is a reality to this point of view
from the patient’s perspective. The therapist should validate the unique and
healing aspects of the therapy they’ve shared while at the same time help to
induce a positive cognitive framework for starting with a new therapist. For
example:
PATIENT (dealing with impending termination): But I like you, I don’t want
to start again with someone else, you have been so good for me.
THERAPIST: Well, don’t worry, I’m sure you will do just as well with the new
therapist, just give it some time. Think positively!
In this example, the response by the therapist is invalidating the deep

feelings of impending loss by the patient and is also possibly inaccurate
with the prediction of doing “just as well” with the new therapist. The new
therapist might be terrible, or may be a great therapist who doesn’t “click”
with the patient, or any number of other things that might make the next
therapy go poorly. The upbeat nature of the response is an empathic failure
on the part of the therapist because it misses the boat with the feelings of
forthcoming loss. The therapist does recommend giving the new therapy
“some time,” which is a good idea because there are likely to be some grow
ing pains with starting with a new therapist. This forecasting of rough road,
however, is embedded in the greater context of unfounded optimism, which
makes it less effective.
Let’s try this again:
PATIENT: But I like you, I don’t want to start again with someone else, you
have been so good for me.
THERAPIST: Yes, we’ve worked well together, it has been a very rewarding
experience for me too. I’ve witnessed your growth in so many ways.
I can understand your reluctance to start with a new therapist. That
makes sense to me. At the same time, you must remember that you’ve
been 50% of why we have worked so well together. You’re half of this
winning formula. You can take what you have learned and bring it to
the new therapeutic relationship.
PATIENT: I hear you, but I’m not looking forward to it. I’ve had other ther
apists before, and you’ve been the best. I just don’t want to change.
THERAPIST: I’m sure it will feel weird at first working with someone differ
ent. We’ve developed such a good rhythm, it likely will feel awkward
at first with a new therapist, kind of like throwing a ball with your
left hand. Just give it some time. Remember that you’re a different
person now than you were before we worked together. You’re better
at this. Every relationship is different. Who knows, you might learn
things with the new therapist you weren’t able to with me.
In this second example, the therapist acknowledges the pain of loss and
the unique healing experience the patient has felt. The therapist also pre
pares the patient for the “letdown” of feelings they will likely feel by starting
with someone new. Finally, the therapist opens the door for the possibility
that the new therapy experience will allow growth in ways that they have
not had in the current therapeutic relationship.
When psychotherapists are aware they will be leaving their practice, they
must decide when to tell their patients. If life circumstances are such that
therapists know well ahead of time when they’re leaving, they can tell their
patients early enough to allow sufficient time to process the termination.
Processing the termination includes allowing the patient ample opportunity to
express his or her feelings about it, reviewing what has been helpful or not
helpful with the therapy, and preparing the patient for either transfer to an
other therapist or termination of therapy altogether. There is no exact for
mula for when to inform the patient about an impending termination.
Usually the longer a patient has been in the psychotherapy, the greater num
ber of sessions should be allowed to process the termination. For example,
if a patient has been attending supportive psychotherapy on a biweekly ba
sis for 10 years, I would announce the termination at least several months
prior to allow ample processing.
Termination should not be viewed as a “separate” process from the therapy.
In fact, for many patients with significant losses in their lives, undergoing
termination with a nurturant psychotherapist becomes an opportunity for
a corrective emotional experience. The longer one lives, the more one ac
cumulates losses in life. Losses can become traumatic and for many are a
substantial underpinning to their psychological suffering. Termination with
Termination 127
a therapist can bring these issues into sharp focus. In supportive psychother
apy, helping patients cope with loss includes a balance of shoring up their
strengths and coping mechanisms while also helping them experience the
pain of the loss in a tolerable way. Getting patients to talk about what was
good about the therapy, what allowed them to grow, and what they liked
about the therapist, as well as what their disappointments were, can be ben
eficial. Talking with the therapist “live” about their impending loss of the
therapist can be powerfully healing as a corrective emotional experience for
prior losses.
There are many different ways a patient can leave therapy, and sometimes
these are more interruptions in therapy than they are terminations. When
the therapist has had a sustained or meaningful therapy with the patient,
sudden wishes by the patient to discontinue therapy should be evaluated care
fully. Often something in the psychotherapy has touched on an important
issue, and the patient might be leaving therapy to avoid the pain of looking
at it further. Just as often, a patient might want to leave therapy because of
hurt or anger toward the therapist. It’s very important for the therapist to
question the intention to leave therapy in these circumstances because they
represent ripe opportunities for further healing. The therapist can urge the
patient to continue for at least a few more sessions to examine what they
have accomplished and also to look closely at the desire to terminate. Some
times having an opportunity for at least one “closure” session will reveal very
important material that allows significant further growth for the patient. In
some circumstances when the patient is very hurt or angry, he or she might
not agree to this. When patients who have undergone a substantial psycho
therapy suddenly will no longer meet with me, I have sometimes offered
them one last closure session pro bono so that I can learn from their feedback.
This has led to significant insights for the patient as well as for me on some
occasions.
Case Example: Premature Termination 1

Abe was a handsome and successful young entrepreneur with a rich social
life; however, he often felt empty and depressed despite his accomplish
ments. He finally decided to undergo psychotherapy at the urging of his
girlfriend. He generally liked the therapist, although he was often critical of
her and felt she was “very cliché” with her questions. After several months
of psychotherapy, the therapist asked Abe some exploratory questions
about his mother. He quit therapy after this, telling his girlfriend, “It was
so Freudian it was right out of a movie...so tell me about your mother...
sheesh!” The therapist called Abe after learning that he had cancelled all
scheduled sessions and urged him to attend one final closure session (at the
time of her call, she had no idea why Abe suddenly quit psychotherapy).
Abe was reluctant to do this, but the therapist gently convinced him that it
might be useful to have one last session to wrap up what they had learned
together. During the termination session, Abe told the therapist how much
he disliked her cliché questions, especially about his mother. He was defen
sive when talking about his mother and painted a picture of her that was
overly good and one dimensional. The therapist recognized that Abe had
significant issues with his mother and also that he was too sensitive at this
time to examine these in therapy. She let Abe know that in the future it
might be useful for him to look at his relationship with his mother; how
ever, she offered to avoid the topic in the short term. Abe accepted this and
decided to continue in psychotherapy. In paradoxical fashion, Abe eventually
began to bring up issues with his mother in subsequent sessions. It turns out
that Abe had underwent neglect and cruelty with his mother, and examin
ing this proved very helpful for him in the context of his chronic depression.
He ended up attending psychotherapy for several years with good results.
Case Example: Premature Termination 2

A psychiatry resident was doing psychotherapy with a depressed young
man who was conflicted about accepting his homosexuality. They had been
working together for about a year and had an excellent therapeutic alliance,
something the patient had not felt in prior psychotherapies (different ther
apists). The patient was often suicidal, and the resident felt he had em
ployed extraordinary efforts to keep him alive as well as to keep him engaged
in treatment. The resident was gay but had never discussed this with his pa
tient. One weekend the psychiatry resident went to a gay bar and while
dancing with another man saw his patient there. They did not have eye
contact and did not approach each other; however, the resident was “sure”
he had been seen. The patient cancelled his next psychotherapy session and
did not reschedule any further sessions. The resident called the patient to
schedule an appointment, and the patient agreed to resume psychotherapy
(the phone call was brief; they did not discuss anything that had happened).
The patient did not show up for the rescheduled appointment. The psychi
atry resident discussed the case under supervision and identified a number
of personal issues he strongly shared with this patient, especially with his
own depression and coming out journey (not yet completed). He felt his
shared issues with the patient had allowed a particularly strong therapeutic
alliance, and he was extremely hurt that his patient had quit therapy. The res
ident recognized that both transference and countertransference feelings
were involved with the premature termination as well as his response to it.
He agreed that the reason his patient had quit therapy was likely important
for them both to understand; however, he felt he had already “given too
much of himself” and was too “burned out” to try and coach the patient into
returning. He was able to examine his needs to be valued and liked by the
patient and see that this contributed to his current inability to reach out fur
ther. The supervisor and resident agreed that he should continue to work
Termination 129
on his own issues of depression and sexuality, both for his own life journey
as well as to become a better psychotherapist.
Situations sometimes arise in which a therapist leaves and has anxiety that
the options for his or her patient to continue psychotherapy are suboptimal.
This is a common occurrence and understandable, for when the therapeutic
alliance is good, most therapists feel that their connection with their patients
is special. Their connection is most certainly special and nonreproducible
because each relationship is unique. This countertransference becomes
problematic, however, if the therapist believes he or she is the “only one”
who can treat this patient. In these situations, a therapist will sometimes al
low a patient to maintain contact after termination, by phone, email, social
media, or other correspondence. This is usually not a good idea because it
can interfere with the patient forming a good alliance with the new thera
pist. It also becomes legally risky because the departed therapist can be held
liable for suicidal or other dangerous behavior that a former patient has re
vealed to them in a posttherapy conversation. Even though they have offi
cially terminated with the patient, the therapist is still maintaining a
therapeutic relationship by virtue of his or her correspondence. A better op
tion for the departing therapist is to allow some feedback from the patient
on how the patient is doing, but not as a correspondence. An example of
this would be for the patient to send a letter to the new professional address
of the departed therapist with the agreement that it would be an update on
how the patient is doing rather than a correspondence. In other words, the
therapist and patient would have agreed beforehand that the therapist
would not be returning any communication. This arena of feedback after
termination is still wrought with problematic transference/countertransfer
ence possibilities, and the best option remains a “clean break.”
Case Example
Allison was a young computer programmer who struggled with borderline
personality disorder. She had had several psychotherapy experiences that
were quite unsuccessful and one that was traumatic (therapist had tried to
seduce her). She finally found a therapist, Anthony, with whom she “clicked”
and enjoyed a good working relationship for several years. When Anthony
told her that he was moving to another state and would need to terminate
therapy, she was devastated. Anthony was proud of the work they had accom
plished together and was aware how unique their therapeutic alliance had
been. He knew how fragile she was and also of her prior traumatic therapy
experience. He helped her find a new therapist; however, he also felt guilty
for leaving her. She had asked if they could “stay in contact,” and he agreed
to allow email correspondence as long as she would refrain from discussing
clinical issues. He believed the email communication would “soften the blow”
of their termination.
Within a month after he moved, Anthony began receiving emails from
Allison. At first, they were somewhat neutral updates on how she was doing
at work and at home. Eventually, she began to email him about her dissat
isfaction with her new therapist, her worsening suicidality, and her hope
lessness. He urged Allison to continue working with her new therapist and
attempted to set limits on the content of the emails by asking her to discuss
her problems only with the new therapist. He again specified that he was
not able to help her with her clinical matters. She continued to email him
with even more details about her woes, made some suicidal threats, and in
formed him she was quitting with the new therapist. Anthony felt trapped
and anxious that he was responsible for her situation. He eventually in
formed her that he would no longer respond to her emails because he was not
her clinical provider any longer, and he strongly urged her to remain in treat
ment. Anthony received one final email from Allison where she detailed
how she felt badly hurt and abandoned by him. She told him that she re
gretted having put faith in him, and that she would never trust a therapist
again. She also said he would “never hear from her again.” Anthony felt ter
rible about the situation and contacted the new therapist to make sure that
Allison was safe. The new therapist did a welfare check on Allison and as
sumed responsibility for follow up with her. Anthony brought the case to
supervision and explored his role in how it had evolved.
The most difficult aspect of termination with a successful, positive psy

chotherapy, for both patient and therapist, is to acknowledge the sadness of
the situation and allow the grief it entails. To put this in perspective, I need
to discuss what might seem like a bit of a detour...to talk about death. In
his landmark book The Denial of Death, psychoanalyst Ernest Becker argues
that much of the energy in our lives is spent to avoid the anxiety and despair
associated with death.1 Nobody can look death in the face with complete
serenity. In this point of view, we work hard, both consciously and uncon
sciously, to decrease the anxiety associated with death. Some might even
view the writing of a book as an attempt to ease the finality of death by liv
ing forever through the life of the book (hmm, interesting...). Death is
hard, and loss reminds us of death, especially loss of love and intimacy. Ter
mination from a good therapeutic relationship is like that, when looked full
in the face. As we’ve discussed previously in this book, psychotherapy can
occupy some of the most intimate moments of a person’s life. This is true
for both patient and therapist. I’ve shared tears with patients during termi
nation multiple times over. What becomes vitally important in sharing this
sadness with patients is to remind them that we all internalize the people
who have been important to us. We carry parts of them with us throughout
Termination 131
our lives. In fact, we actually cannot be separated once someone has had a
lasting positive impact. Patients will often tell their therapists, “I think about
what you would say,” when they encounter situations outside of the therapy
hour. This internalization of the therapist is an excellent way to remind pa
tients that even though the physical appointments have come to an end, the
good things discovered and shared in the therapy never will.
I’m actually sad to bring an ending to this book. I’ve enjoyed writing
this book, sharing my insights and knowledge of psychotherapy with you,
and I’ve imagined you reading it as I wrote each sentence. I put myself into
it, in a personal way, hoping to open the door for you to enter the wonderful
healing world of psychotherapy. For some patients the time spent in psy
chotherapy is among the most intimate of their lives. We’re privileged to be
a part of this world and to help people in ways that will profoundly change
their lives. I hope this book has changed you, and I hope your journey will
be as fulfilling as mine has been.
1. In the case of Allison (patient) and Anthony (therapist) discussed in this
chapter, what transference and countertransference phenomena might
have been involved in the evolution of events?
2. Under what circumstances would a continued relationship with a patient
and therapist be OK after they had formally terminated treatment?
Reference
1. Becker E: The Denial of Death. New York, Free Press, 1973
Index
Page numbers printed in boldface type refer to tables.
Acceptance, 58
confrontation of, 25
ACE-IQ. See Adverse Childhood explaining, 73–75
Experiences International Ques case example of, 74–75
tionnaire influence of human behavior on
ACEs. See Adverse childhood experi supportive psychotherapy,
ences
16
Acting out, 14, 15

meaning of, 21
Adverse childhood experiences

normalizing, 75
(ACEs), 94
pattern of, 76
Adverse Childhood Experiences

Borderline personality disorder
International Questionnaire
(BPD), 105–113
(ACE-IQ), 94
case example of, 112–113
Agoraphobia, 8
“push-pull” response, 106–107
Alcohol and other drug abuse

treatment of patients with, 106
(AODA), 113–118
Boundaries, maintenance of, 37–38
BPD. See Borderline personality
consequences of, 116
disorder
integrated treatment, 113–114

Breathing techniques, 81
relapses, 115
Bullying, 66
Alcoholics Anonymous, 117
Alexander, Franz, 4–6

Case examples
as disciple of Freud, 4
of alcohol and other drug abuse,
on flexibility, 5–6
116–117
Anorexia nervosa, randomized con of angry transference, 49–50
trolled study of, 8
of behavior of the therapist, 35–36,
Anticipatory guidance, 82
41–43
of borderline personality disorder,
Becker, Ernest, 130
112–113
Behavior
of comparing pain, 87–88
adaptive, 21
of confrontation, 76–77
case example of the therapist,
of coping skills, 81–83
35–36, 41–43 of countertransference, 61–67
133
Case examples (continued) skills, 80–83
of denial, 57–58 case examples of, 81–83
for developing a psychodynamic of therapist, 43–44
formulation, 18–20
Corrective emotional experience, 5
of encouragement, 78
Countertransference, 47–68
of erotic transference, 53–54, 62

case examples of, 61–67
of explaining behavior, 74–75

denial, 57–58
of feedback after termination,

erotic, 62
129–130
description of, 47
of hope, 78–79
feedback to patient and, 64–65
of metaphor, 80
interaction with transference, 55
of positive transference, 48
“red” of, 59
of posttraumatic stress disorder,

stages of, 57–59
96–100 supervision of therapist and, 62–67
of premature therapy termination, for therapists, 108
127–129
therapist’s coping methods of,
of repair of transference, 51–52

57–58
of schizophrenia, 120
“wounded healer” example of,
of trauma, 94–99
55–56
CDC. See Centers for Disease Control
and Prevention Defense mechanisms
Centers for Disease Control and Pre descriptions of, 15
vention (CDC), 93–94 Freud’s description of, 13–14
Childhood, bio-social-cultural envi higher-order, 14
ronment of, 3
primitive, 14
Child Protective Services, 94

Delusions, 119
Cognitive-behavioral skills, 8
Denial, 14, 15
Cognitive-behavioral therapy
as gold standard for therapy,

Displacement, 14, 15
x–xi
Dissociation, 14, 15
supportive psychotherapy as con

trol condition in studies of, Ego, Freud and, 3
8–9 Embracement, 58–59
techniques, 81
EMDR. See Eye movement desensiti
Cognitive restructuring, 81
zation and reprocessing
Communication, 88. See also Thera Empathy, 18–20
peutic alliance definition of, 22
Confrontation, 75–77 of therapist, 22

Encouragement, 77–78
Consciousness, Freud and, 2
case example of, 78
Conversion, 14, 15
Exposure and response prevention, 81
Coping
Eye movement desensitization and
of patient, 33–34 reprocessing (EMDR), 99–100

Index 135
Fantasy, 14, 15
Listening, 69–70
“Feelings journal,” 88
Love
Flexibility, of therapist, 22–23
Fluphenazine, for treatment of suicide

Mantra, 84
attempts, 25
Menninger Institute, 7
Frankl, Victor, existential model of, 16

Menninger Psychotherapy Research
Free association, Freud and, 3

Project, 7
Freud, Sigmund, 2–4

Metaphors, 79–80, 107–108, 109, 115
defense mechanisms, 13–14 case example of, 80
development of principles of psy trauma and, 100
chodynamics in human func Mindfulness meditation, 81
tioning, 3
Models“continuous interpersonal
development of topographical and

capability improvement model,”
structural theories of the

23
mind, 2
ego psychology model of Heinz
Kohut, 16
Gender discrimination, 18
existential model of Victor Frankl,
Grief, 8–9
16
Guilt, 35, 114–115

of psychotherapy, 124
Motivational assessment, 8
Hallucinations, 119
Hope, 78–79
Neuroses, description of, 4

Nurturance
D.W. Winnicott and, 24
Id, 2–3
of therapist, 22–23
Idealization, 14, 15
Imipramine, for treatment of phobias, 8

Pain
Insight
Alexander and, 5
comparison of, 87–88
Freud and, 5
Patient
personality and, 4
“burnout,” 117–118
Intellectualization, 14, 15
consultation, 89
Interpersonal deficits, 9
coping plans, 33–34
Interpretation, 74
feedback to, 64–65
Introjection, 14, 15
first session with, 28–31
positive experience with prior ther

Jung, Carl, 56
apy, 30–31
self-esteem of, 35
Kohut, Heinz, ego psychology model

well-being of, 33
of, 16
working relationship between ther
apist and, 21–22
“Lending ego,” 82
working with a “difficult” patient,
Libidinal principle, 2
73
Personality, 2–3
Rationalization, 14, 15
insight and, 4
Reaction formation, 14, 15
structural change of, 7

Reassurance, 78
Pleasure principle, 2
Reframing, 81
Plussing, 70–73
Regression, 14, 15
examples of, 71
Relapse prevention, 8
unempathic, 71–73
Relationships. See also Therapeutic
PMR. See Progressive muscle relaxation

alliance; Therapist
Posttraumatic stress disorder (PTSD), 92
unhealthy, 14

Reluctant acceptance, 58
secondary, 102
Repetition compulsion, 14–15
transgenerational, 101–102
Repression, 13–14
treatment of, 95–96

Role transitions, 9
Preconsciousness, Freud and, 2
Progressive muscle relaxation (PMR),

SAMHSA. See Substance Abuse and
81
Mental Health Services Adminis
Projection, 14, 15
tration
Projective identification, 107
Schizophrenia, 118–120
Psychoanalysis
case example of, 120
description of, 4
description of, 119
development of supportive psycho symptoms of, 119
therapy from, 6
Secondary PTSD, 102
Psychoanalytic psychotherapy, evolu Self-soothing, 83–86
tion of, 7
Psychodynamics
Splitting, 14, 15
definition of, 17
Storytelling, 88
Freud’s development of principles

Sublimation, 14, 15
of, 3
Substance Abuse and Mental Health
Psychoeducation, 8
Services Administration
Psychotherapy
(SAMHSA), 93–94
description of, 5
Suicidal ideation, 38
early models of, 124

Suicide
pacing of, 36
attempts, 25
as “talking cure,” x, 4
threat of, 109
trainees in, 32
Superego, Freud and, 3
understanding, x
Supportive psychotherapy. See also
PTSD. See Posttraumatic stress Therapeutic alliance; Therapist
disorder
Puryear, Dr. Douglas, 70

creative opportunities, 88–89
Pythia, 1
descriptions of, 7
development from psychoanalysis,
Race, 18, 101

6
Rape, 98–99
evolution of, 124–125
Index 137
friendly vs. being friend, 32

coping methods of, 43–44
growth of, x
countertransference, 57–58
history and evolution of, 1–11

countertransference of, 108
influence of human behavior and,

“draining” session and, 44
16
empathy of, 22
for management of schizophrenia,

ethics of, 45
119
flexibility of, 5–6, 22–23
nonspecific, 9
goals of, 50
psychodynamic, xi
inappropriate disclosure example
case example for developing a of, 42–43
psychodynamic formula limitations of, 23
tion, 18–20 mental health of, 43
formulation of, 17–18, 25–26

nondirective questions, 29–30
recognition of, 6
nurturance and, 22–23
strategies and techniques, 69–90

office environment of, 27–28
termination, 123–131
personal information disclosure
validation of, 8
about, 39–40
Suppression, 13
psychoanalysis of, 56
Sympathy, definition of, 22

public information knowledge
about, 39–40
Termination, 123–131 qualities of, 37
case examples safe supervision of, 60–61
of premature termination, stress in, 105
127–129
techniques of, 34
examples of, 125–126

time management of, 38
feedback after, 129–130

trust and, 60
processing, 126
working relationship between
Therapeutic alliance. See also Support patient and, 21–22

ive psychotherapy
Transference, 47–68. See also Uncon
during first session, 31
sciousness
psychodynamics and, 13–24

Alexander and, 4–5
for successful supportive therapy,

case examples of
33
angry, 49–50
as working relationship between

erotic, 53–54
therapist and patient, 21–22

positive, 48
Therapist
psychotic, 54–55
acting out, 57
repair of, 51–52
as “anchor” of therapeutic alliance,

description of, 4, 47
43
erotic, 52
appropriate disclosure example of,

interaction with countertransfer
41–42
ence, 55
behavior of, 27–46

love and, 52
case examples of, 35–36, 41–43

psychotic, 54
Transgenerational PTSD, 101–102

Unconsciousness. See also Transference
Transitional object, 111

Freud and, 2, 47
Trauma, 91–104
avoidance of trauma-related emo Well-being, of patient, 33
tions, 97
Werman, David, 10

WHO. See World Health Organization
“epicenter” of, 100–101

Winnicott, D.W., 24
metaphors and, 100

Working through, 85
“ripple effects” of, 101–102

World Health Organization (WHO), 94
severe, 91
Writing, 88–89
severity of, 93
“feelings journal,” 88
“A
concise, readable, and very experience-near guide to
supportive psychotherapy. Full of clinical examples
DOING SUPPORTIVE PSYCHOTHERAPY

and discussion questions, this book could be used by
trainees in any mental health field.”
Deborah L. Cabaniss, M.D., Associate Director, Residency

Training, Professor of Clinical Psychiatry, Columbia University,
Department of Psychiatry
“T
his book is an essential tool for any learners and profes-
sionals looking to forge meaningful, impactful therapeu-
tic relationships with their patients—even for clinicians
not intending to ‘do psychotherapy.’ Through engaging case ex-
amples, this book will teach the reader how to make relatively
quick sense of the complex life histories that our patients bring
to us, and how to truly allow patients to feel heard using spe-
cific techniques. The high-yield, practical pearls that Dr. Batta-
glia provides promise to form the basis for effective interactions
with your patients on a daily basis. In a nutshell, this book will
optimize the likelihood that your patients would answer ‘yes’ to
DOING
the question ‘Does your provider understand you?’ If you have
time for one quick, enjoyable read in the next month that will
immediately benefit your patients, it should be this.”
Claudia L. Reardon, M.D., Associate Professor, University

Health Services, University of Wisconsin School of Medicine and SUPPORTIVE
PSYCHOTHERAPY
Public Health, Department of Psychiatry
ABOUT THE AUTHOR

John Battaglia, M.D., is Clinical Adjunct Associate
Professor of Psychiatry at the University of Wisconsin
School of Medicine and Public Health, and Medical Direc-
tor of the Program of Assertive Community Treatment in
Madison, Wisconsin.
Battaglia
Cover design: Tammy J. Cordova

Cover image: © lolloj
Used under license from Shutterstock

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“A

concise, readable, and very experience-near guide to

DOING SUPPORTIVE PSYCHOTHERAPY

Deborah L. Cabaniss, M.D., Associate Director, Residency

Claudia L. Reardon, M.D., Associate Professor, University

ABOUT THE AUTHOR

John Battaglia, M.D.

Cover design: Tammy J. Cordova

John Battaglia, M.D.

University of Wisconsin School of Medicine and Public Health

Medical Director, Program of Assertive Community Treatment

Preface: Why This Book? . . . . . . . . . . . . . . . . . . ix

1 A Brief History and Evolution of

the Therapeutic Alliance . . . . . . . . . . . . . . . . . . .13

3 Getting Started and

the Behavior of the Therapist. . . . . . . . . . . . . . 27

4 Transference and Countertransference. . . . . . 47

5 Strategies and Techniques . . . . . . . . . . . . . . . . 69

7 Special Populations: Borderline Personality

Disorder, Substance Use Disorders, and

Why This Book?

Over my 30 years of teaching psychotherapy,

notwithstanding. I find that patients and therapists alike, however, struggle

I’ve been blessed with many who have shaped

For those directly involved in providing me with helpful feedback on

I’m going to tell you a story about a man

ceptions and their psychological functioning. In addition to this process of

tance of the therapeutic relationship (between patient and psychoanalyst) as

In addition to the original decision as to the particular sort of strategy to be

various techniques in a flexible manner, shifting tactics to fit the particular

These modifications proposed by Alexander were a dramatic shift from

As supportive types of psychotherapy began to take hold, there was a

Considered a simple-minded endeavor that one can practice without train­

If it is supportive, it cannot be psychotherapy; if it is psychotherapy, it can­

By necessity, psychoanalysis itself had undergone some transformation

disputes, role transitions, and interpersonal deficits. The patient’s identi­

Supportive psychotherapy has become the subject of research on therapy in

City, NY, Anchor Books, 1974

2. Alexander F, French TM: Psychoanalytic Theory: Principles and Applica­

3. Wallerstein RS: Psychoanalysis and psychotherapy: an historical perspective.

5. Crown S: Supportive psychotherapy: a contradiction in terms? Br J Psychiatry

To do good supportive psychotherapy,

ory of it from reaching our conscious awareness. Defense mechanisms are

TABLE 2–1. Defense mechanisms

Defense mechanism Description

Denial Not acknowledging the feeling

Intellectualization Avoiding the feelings by thinking intellectually

It’s useful to think of defense mechanisms not as “good” or “bad” but,

We now have more data for the psychodynamic formulation as more

alliance is the central element of healing in the therapy relationship.3 Main­

who are seeking controlled substances will undergo psychotherapy with a

chotherapy, and a tool for continuous hypothesis testing as therapy proceeds.

Behavior of the Therapist

I can distinctly remember how excited I was

goal is to make your patients feel comfortable. Lighting should be mid­

derstood, they’re likely to continue in psychotherapy. In a funny kind of way,

difficult to talk because he or she is feeling intense emotions, or alternatively,

As we discussed in the prior chapter, a good therapeutic alliance is the

been educated to expect “after-shocks” of emotions and have coping methods

In this example, Isabel has been traumatized by an event in her child­

therapist is to get her talking about it in a marginalized way, to begin the

act to ensure his or her safety (fortunately, this is an uncommon occurrence

RACHEL: Everything seems surreal being back here. It’s so differ­

Considered a simple-minded endeavor that one can practice without train

If it is supportive, it cannot be psychotherapy; if it is psychotherapy, it can

disputes, role transitions, and interpersonal deficits. The patient’s identi

2. Alexander F, French TM: Psychoanalytic Theory: Principles and Applica

alliance is the central element of healing in the therapy relationship.3 Main

goal is to make your patients feel comfortable. Lighting should be mid

In this example, Isabel has been traumatized by an event in her child

RACHEL: Everything seems surreal being back here. It’s so differ

In this example, the therapist decided to disclose his personal experi

therapist violates the ethical professional boundary by having a romantic re

THERAPIST (allowing positive transference): Thanks, James, I appre

knock me down. You’re trying to control my life. You’re jeal

2. Barr A: An investigation into the extent to which psychological wounds in

a mental note to bring it up later in the session in order to avoid interrup

In this example, the therapist gave a reasonable plussing response, be

In this example, the therapist asks “help me understand” instead of ask

In this example, Stuart accepts a confrontation through the use of meta

The most powerful soothing experiences in supportive psychotherapy oc

tentions, and this is encouraged. Sometimes writing in this fashion pro

Despite a large number of studies on psychotherapy for PTSD, the ev

supportive psychotherapy is to establish safety measures and coping meth

highly traumatic events to be recalled without experiencing the marked dis

chotherapy with people affected by transgenerational PTSD, it’s vitally im