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SECOND
EDITION SECOND EDITION
Once reserved for use with severely impaired patients, support-

Clinical Manual of
Supportive Psychotherapy
Clinical Manual of
ive therapy has come to be recognized as the treatment of
choice for many patients, and supportive techniques underlie many other
Supportive
psychotherapies. As a result, in the 25 years since the first edition of Clinical
Manual of Supportive Psychotherapy was published, the academic literature
covering both specific populations and technical issues has mushroomed.
The authors of this revised volume—practicing mental health clinicians—
have undertaken a thorough review of the available literature to present up-
dated and new chapters, case vignettes, tables, and resources that reflect
best practices.
Psychotherapy
In these pages, readers will find an introduction to the principles and tech-
niques of supportive psychotherapy, as well a description of its application to
specific mental disorders, including new chapters on co-occurring disorders
and anxiety.
This updated and greatly expanded edition also features supportive ther-
apy with medically ill and older patients, as well as discussion of practicing
in correctional and detention centers and the special needs of therapists
in public institutions, community and family involvement, and medication
adherence and therapy interactions. A discussion of ethics, augmented with
guidance on cultural and religious sensitivity, completes the manual.
Peter N. Novalis, M.D., Ph.D., is a psychiatrist in private practice in

Las Vegas, Nevada.
Virginia Singer, D.N.P., PMHNP-BC, CARN-AP, is a psychiatric

nurse practitioner in private practice in Las Vegas, Nevada.
Novalis
Roger Peele, M.D., DLFAPA, is Chief Psychiatrist for Montgomery Singer
County, Maryland.
Peele
Peter N. Novalis, M.D., Ph.D.

Virginia Singer, D.N.P.
Cover design: Tammy J. Cordova
Cover image: © AlexGreenArt
Used under license from Shutterstock
Roger Peele, M.D., DLFAPA
Clinical Manual of
Supportive
Psychotherapy
Second Edition
Clinical Manual of
Supportive
Psychotherapy
Second Edition

Virginia Singer, D.N.P., PMHNP-BC, CARN-AP
Note: The authors have worked to ensure that all information in this book is accurate
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 standards may change.
Moreover, specific situations may require a specific therapeutic response not included
in this book. For these reasons and because human and mechanical errors sometimes
occur, we recommend that readers follow the advice of physicians 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/
specialdiscounts for more information.
Copyright © 2020 American Psychiatric Association Publishing
ALL RIGHTS RESERVED
Second Edition
Manufactured in the United States of America on acid-free paper
23 22 21 20 19 5 4 3 2 1
American Psychiatric Association Publishing
800 Maine Avenue SW
Suite 900
Washington, DC 20024-2812
www.appi.org
Library of Congress Cataloging-in-Publication Data
Names: Novalis, Peter N., author. | Singer, Virginia, author. | Peele, Roger, author. | American
Psychiatric Association Publishing, issuing body.
Title: Clinical manual of supportive psychotherapy / Peter N. Novalis, Virginia Singer, Roger Peele.
Description: Second edition. | Washington, D.C. : American Psychiatric Association Publishing,
[2020] | Includes bibliographical references and index.
Identifiers: LCCN 2019020721 (print) | ISBN 9781615371655 (paperback ; alk. paper) | ISBN
9781615372737 (ebook)
Subjects: MESH: Psychotherapy—methods | Professional-Patient Relations | Psychotherapeutic
Processes
Classification: LCC RC489.S86 (print) | LCC RC489.S86 (ebook) | NLM WM 420 | DDC
616.89/14—dc23
LC record available at https://lccn.loc.gov/2019020721
LC ebook record available at https://lccn.loc.gov/2019981117
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
Contents
Introduction to the Second Edition . . . . . . . . . . xvii
Introduction to the First Edition . . . . . . . . . . . . . xix
Notes on Usage. . . . . . . . . . . . . . . . . . . . . . . . . . . xxi
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . xxiii
PART I
Principles
1 The Basis for Supportive Psychotherapy. . . . . . . 3
What Is Supportive Psychotherapy? . . . . . . . . . . . . . . . 3
Rule Books and Clinical Manuals. . . . . . . . . . . . . . . . . . 3
Supportive Psychotherapy as an Eclectic Therapy . . . . 5
How Effective Is Supportive Psychotherapy?. . . . . . . . . 8
Can Supportive Psychotherapy Be Harmful?. . . . . . . . . 9
Core Supportive Techniques . . . . . . . . . . . . . . . . . . . . 10
Goals of Supportive Psychotherapy . . . . . . . . . . . . . . . 11
Evidence for Effectiveness . . . . . . . . . . . . . . . . . . . . . . 13
Historical Background to Supportive Psychotherapy . . 17
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2 The Supportive Relationship . . . . . . . . . . . . . . . . 29
The Concept of Support . . . . . . . . . . . . . . . . . . . . . . . . 30
The Working Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Transference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Managed Transference . . . . . . . . . . . . . . . . . . . . . . . . 36
Psychotic Transference . . . . . . . . . . . . . . . . . . . . . . . . 37
Institutional Transference . . . . . . . . . . . . . . . . . . . . . . . 38
Managing Dependency and Entitlement . . . . . . . . . . . 39
Countertransference. . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Burnout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3 Principles of Supportive Technique:

Explanatory Techniques . . . . . . . . . . . . . . . . . . . 49
Spectrum of Explanatory Techniques . . . . . . . . . . . . . 49
Fundamental Concepts in Supportive Technique . . . . 52
Reassurance and Enhancement of Self-Esteem . . . . . 59
Explanatory Techniques. . . . . . . . . . . . . . . . . . . . . . . . 62
Principles of Supportive Interpretation . . . . . . . . . . . . . 69
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
4 Principles of Supportive Technique:

Directive Interventions . . . . . . . . . . . . . . . . . . . . . 85
Suggestion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Advice and Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Explicit Direction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Limit Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Control of Affects and Impulses . . . . . . . . . . . . . . . . . . 92
Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Social Skills Training . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Work and Work Skills . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Scheduling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Cognitive Restructuring and Behavioral and
Experiential Learning . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Modeling and Identification With the Therapist . . . . . 102
Homework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Diversions, Substitutes, and
Paradoxical Interventions . . . . . . . . . . . . . . . . . . . . . . 103
Reinforcement of Desirable Behaviors. . . . . . . . . . . . 104
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
5 Managing the Therapy . . . . . . . . . . . . . . . . . . . . 109

Selection of Patients for Supportive Psychotherapy . . 109
Treatment Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Phases of Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Changing Modes of Therapy . . . . . . . . . . . . . . . . . . . 127
Directing the Content . . . . . . . . . . . . . . . . . . . . . . . . . 128
Curveballs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Excavating “Hidden Issues” . . . . . . . . . . . . . . . . . . . . 133
Judging the Effectiveness of Interventions. . . . . . . . . 136
Management and Feedback: A Session Dialogue . . . 137
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
PART II
Diagnostic Applications
6 Schizophrenia and Hallucinations . . . . . . . . . . 147
Diagnostic Considerations . . . . . . . . . . . . . . . . . . . . . 147
Supportive Psychotherapy in Schizophrenia . . . . . . . 148
Natural Course of Schizophrenia . . . . . . . . . . . . . . . . 151
Response to Special Symptoms . . . . . . . . . . . . . . . . 156
Integration of Medications With Therapy . . . . . . . . . . 169
Difficulties in Supportive Psychotherapy With
Patients With Schizophrenia . . . . . . . . . . . . . . . . . . . 173
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
7 Mood Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . 183

Depressed States. . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Primary Techniques and Emphases in
Treatment of Depressed States . . . . . . . . . . . . . . . . . 194
The Depressed Patient in Remission . . . . . . . . . . . . . 198
Dysthymic Conditions and Dysphoric States . . . . . . . 198
Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Addressing Comorbid Illnesses and
Personality Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
8 Anxiety Disorders and Related Disorders . . . . 213

Victor Chavira, Ph.D.
General Principles and Techniques . . . . . . . . . . . . . . 214
Specific Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
9 Co-occurring Disorders . . . . . . . . . . . . . . . . . . . 235

Confounding Effects of Substance Use on
Making a Mental Health Diagnosis. . . . . . . . . . . . . . . 238
Addiction and Substance Abuse Terminology . . . . . . 239
Substance Use Disorders and
the Practice of Confrontation . . . . . . . . . . . . . . . . . . . 239
Supportive Groups: Alternatives to 12-Steps . . . . . . . 240
Goals and Objectives of Supportive Psychotherapy
for Individuals With Co-occurring Disorders . . . . . . . . 241
Schizophrenia and Substance Use Disorder . . . . . . . 241
Substance Use Disorders Co-occurring With
Mood and Anxiety Disorders . . . . . . . . . . . . . . . . . . . 243
Cocaine Use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Relapse and Relapse Prevention Strategies for
the Therapist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
10 Personality Disorders. . . . . . . . . . . . . . . . . . . . . 251

The Six Personality Disorders for
Which There Is the Strongest Evidence
Under the Dimensional Model . . . . . . . . . . . . . . . . . . 254
Other Personality Disorders Not as
Well Supported Under Dimensional Models. . . . . . . . 261
Tips for Managing a Therapeutic Process . . . . . . . . . 269
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
11 Crisis Management and Suicidality. . . . . . . . . . 275

Overview of Supportive Therapy for
Individuals in Crisis. . . . . . . . . . . . . . . . . . . . . . . . . . . 276
History and Development of
Time-Limited Crisis Support . . . . . . . . . . . . . . . . . . . . 277
The Supportive Therapy Patient in Crisis. . . . . . . . . . 278
Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Bereavement, Grief, and Mourning . . . . . . . . . . . . . . 288
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
PART III
Interactions and
Special Settings
12 The Medically Ill Patient . . . . . . . . . . . . . . . . . . . 299
General Considerations of Support in
Acute and Chronic Illness. . . . . . . . . . . . . . . . . . . . . . 300
Differences Between Supportive Therapy and
Psychiatric Consultation . . . . . . . . . . . . . . . . . . . . . . . 301
Personality Types and Reactions to Illness . . . . . . . . 302
Supportive Therapy in Life-Threatening Illness . . . . . 307
Medical Illness Causing Disfigurement . . . . . . . . . . . 312
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
13 The Older Patient . . . . . . . . . . . . . . . . . . . . . . . . 319

Mental Health and Aging . . . . . . . . . . . . . . . . . . . . . . 319
Barriers to Mental Health Care for Older Adults. . . . . 320
Geriatric Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . 323
Depression and Suicide Among the Elderly . . . . . . . . 327
Supportive Psychotherapy in Dementia . . . . . . . . . . . 328
Death and Dying. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
14 Special Populations . . . . . . . . . . . . . . . . . . . . . . 333

Individuals in Jails, Prisons, and Detention Centers . . 334
Individuals With Intellectual Disabilities . . . . . . . . . . . 345
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
15 Community and Family Involvement . . . . . . . . 353
Inside Interfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
External Interfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
Family Matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
Peer Group Support . . . . . . . . . . . . . . . . . . . . . . . . . . 372
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
16 Medication-Therapy Interactions and

Medication Adherence . . . . . . . . . . . . . . . . . . . . 377
Medication-Therapy Interactions . . . . . . . . . . . . . . . . 377
Adherence to Medications . . . . . . . . . . . . . . . . . . . . . 383
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
17 Ethical and Cultural Awareness in

Supportive Psychotherapy . . . . . . . . . . . . . . . . 395
Ethical Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
Cultural Sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Seven Permissive Guidelines. . . . . . . . . . . . . . . . . . . 400
Seven Limiting Guidelines . . . . . . . . . . . . . . . . . . . . . 408
Women’s Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
List of Tables
Table 1–1 Repertory of a typical supportive
psychotherapist . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Table 1–2 Goals of supportive psychotherapy . . . . . . . . . . . . 12
Table 2–1 Desirable elements of a supportive relationship . . 32
Table 2–2 Elements of a supportive relationship that
must be carefully controlled if present . . . . . . . . . . 33
Table 2–3 Nonsupportive elements in a relationship . . . . . . . 34
Table 2–4 Elements of the managed transference. . . . . . . . . 36
Table 2–5 Causes of countertransference . . . . . . . . . . . . . . . 41
Table 2–6 Avoiding countertransference burnout. . . . . . . . . . 45
Table 3–1 Major techniques of supportive psychotherapy:
explanatory techniques . . . . . . . . . . . . . . . . . . . . . 50
Table 3–2 Techniques of supportive psychotherapy that
are for limited or occasional use . . . . . . . . . . . . . . 51
Table 3–3 Psychological defenses:
a convenient classification. . . . . . . . . . . . . . . . . . . 55
Table 3–4 Coping behaviors in a sample of
86 outpatients with schizophrenia . . . . . . . . . . . . . 60
Table 3–5 A metaphorical look at interpretations as doors . . 72
Table 3–6 Guidelines for handling dreams in
supportive psychotherapy . . . . . . . . . . . . . . . . . . . 79
Table 4–1 Major techniques of supportive psychotherapy:
directive interventions . . . . . . . . . . . . . . . . . . . . . . 86
Table 4–2 The many faces of direction in dealing with
a patient considering leaving a job . . . . . . . . . . . . 89
Table 4–3 Important social skills to consider in therapy . . . . . 96
Table 4–4 Typical cognitive errors leading to
depression or anxiety . . . . . . . . . . . . . . . . . . . . . . 99
Table 4–5 Typical automatic thoughts and images . . . . . . . 100
Table 4–6 Some major assumptions that are
usually maladaptive . . . . . . . . . . . . . . . . . . . . . . . 101
Table 5–1 Diagnostic indications for
supportive psychotherapy . . . . . . . . . . . . . . . . . . 111
Table 5–2 Patient selection for
long-term supportive psychotherapy . . . . . . . . . . 114
Table 5–3 Patient selection for
short-term supportive psychotherapy . . . . . . . . . 115
Table 5–4 Exclusion criteria for supportive psychotherapy . . 116
Table 5–5 The opening agenda . . . . . . . . . . . . . . . . . . . . . . 119
Table 5–6 Causes of therapeutic slowdown. . . . . . . . . . . . . 126
Table 5–7 Hidden issues . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Table 6–1 Therapeutic advantages of the real relationship . . . 153
Table 6–2 Benefits of therapist-family cooperation . . . . . . . 156
Table 6–3 Therapeutic responses to hallucinations . . . . . . . 160
Table 6–4 Therapeutic responses to delusions . . . . . . . . . . 163
Table 6–5 Levels of therapeutic response to
ideas of reference . . . . . . . . . . . . . . . . . . . . . . . . 165
Table 6–6 Therapeutic responses to depression in
schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Table 6–7 Approaches to talking about medications in
supportive psychotherapy . . . . . . . . . . . . . . . . . . 174
Table 6–8 Risks of using supportive therapy in
schizophrenia and strategies for
minimizing these risks . . . . . . . . . . . . . . . . . . . . . 176
Table 7–1 Supportive psychotherapy approaches to
disorders with affective components . . . . . . . . . . 185
Table 7–2 Supportive strategies for depression . . . . . . . . . . 187
Table 7–3 Comparison of supportive therapy with
other therapies for depression. . . . . . . . . . . . . . . 189
Table 7–4 Patient selection for four therapies:
psychodynamic, cognitive,
interpersonal, and supportive . . . . . . . . . . . . . . . 193
Table 7–5 Agenda for treatment of
the acutely manic patient. . . . . . . . . . . . . . . . . . . 205
Table 8–1 Therapeutic strategies for anxiety disorders . . . . 214
Table 8–2 Therapeutic techniques for specific disorders . . . 215
Table 9–1 Goals and objectives for treating patients with
co-occurring disorders . . . . . . . . . . . . . . . . . . . . . 242
Table 9–2 Supportive psychotherapeutic approach to
substance abuse in patients with schizophrenia . . 243
Table 9–3 Supportive psychotherapeutic approach to
alcohol use disorder in patients with
anxiety disorders . . . . . . . . . . . . . . . . . . . . . . . . . 245
Table 10–1 Basics of supportive therapy for
the histrionic personality . . . . . . . . . . . . . . . . . . . 268
Table 11–1 Risk factors and warning signs of suicide . . . . . . 283
Table 11–2 Therapeutic agenda for the suicidal or
previously suicidal patient . . . . . . . . . . . . . . . . . . 285
Table 11–3 Supportive agenda for grief . . . . . . . . . . . . . . . . . 290
Table 12–1 Typical reactions to serious medical illness. . . . . 303
Table 12–2 Stages of adaptation to medical illness . . . . . . . . 305
Table 12–3 Therapeutic techniques for personality styles . . . 308
Table 12–4 Therapist do’s and don’ts in medical illness . . . . 313
Table 13–1 Some adaptational responses in older patients. . 321
Table 13–2 Adaptations of technique for older patients . . . . . 324
Table 14–1 Giving advice in special settings . . . . . . . . . . . . . 339
Table 14–2 Activities of psychotherapists in
correctional or residential settings . . . . . . . . . . . . 343
Table 15–1 Some common functions of therapy and
case management . . . . . . . . . . . . . . . . . . . . . . . . 356
Table 15–2 Goals of the family psychoeducational
approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Table 15–3 Stages in family management of
psychiatric illness. . . . . . . . . . . . . . . . . . . . . . . . . 369
Table 15–4 Benefits from therapist-family interaction . . . . . . 373
Table 16–1 Meanings, messages, and effects of
medication from the patient’s perspective . . . . . . 378
Table 16–2 Guidelines for discussing medication
with the patient . . . . . . . . . . . . . . . . . . . . . . . . . . 380
Table 16–3 The therapist-prescriber split . . . . . . . . . . . . . . . . 381
Table 16–4 Ways to improve adherence . . . . . . . . . . . . . . . . 385
Table 17–1 Sources of professional ethics codes . . . . . . . . . 398
Table 17–2 Examples of important ethical rules derived
from the many professional codes. . . . . . . . . . . . 399
Table 17–3 Attitudes that may lead to ethical abandonment . . 416
Table 17–4 Attitudes that may lead to ethical infringement . . 417
Introduction to the
Second Edition
It has been a generation since the Clinical Manual of Supportive Psychotherapy

saw the light of day. Since then, we have had the privilege of training psychi
atry residents and student therapists using this manual, with the knowledge
that it has remained effective and accurate even with the background that was
available 25 years ago.
One of our original authors, Dr. Rojcewicz, did not participate in the writ
ing of this edition, but his wise and incisive contributions to the first edition can
still be found in many spots, especially covering historical issues and schizo
phrenia. However, we have been much pleased that we now have an advanced
practice nurse, Virginia Singer, D.N.P., PMHNP-BC, CARN-AP, as a major
contributor, and a special chapter on anxiety disorders from our clinical psy
chologist colleague, Victor Chavira, Ph.D. Therefore, much of the material
you see is new or revised, including many new clinical vignettes, but we have
also kept many of the “good old parts,” as valid now as in the past.
No longer do therapists treat supportive psychotherapy like a stepchild of
psychoanalysis or reserve its use for severely impaired psychiatric inpatients
who supposedly cannot achieve insight into their unconscious mental pro
cesses. Supportive therapy has been recognized as one of the principal psycho
therapies required in training for psychiatry residents. Supportive techniques
also underlie most other psychotherapies, so that support is found not only in
the eponymous therapy but in the other enumerated “psychotherapies” that
xvii
xviii Clinical Manual of Supportive Psychotherapy
continue to proliferate (although some of the 400 have become moribund or

“proscribed” rather than “prescribed”).
To be sure, through the years much has changed and much remains the
same. What remains the same is the basic organization of the book, which
starts with describing the techniques and then applies the therapy to specific
mental disorders and, in the last two parts, special adaptations and interactions
and special settings. The academic literature on supportive psychotherapy has
mushroomed, and we found hundreds of articles covering both specific pop
ulations and technical issues. As was true in the past, we are all practicing clini
cians and not academic researchers, but we have tried to reference the relevant
literature for those inclined to read further.
Surprisingly, and one of the reasons you are seeing a new edition of our book,
there is an absence of any recent textbook on the subject other than the well
known primer Learning Supportive Psychotherapy, also from American Psychi
atric Association Publishing. Although the authors of that text use extended
case presentations and discussions of technique, we have tried to maintain our
goal of using both a technique- and a disease-oriented presentation, and have
continued to use brief vignettes to illustrate important points. We have stream
lined the section on technique to make room for new chapters on co-occur
ring disorders; special considerations for therapy with residential populations,
including detention and corrections, and with intellectually disabled patients;
and guidance regarding use of supportive psychotherapy in community settings
(which incorporates our previous chapters on working with families and case
management). Finally, as in 1993, we end with a discussion of ethics, broad
ened to reference organizational ethics in psychology and counseling, and aug
mented with guidance on cultural and religious sensitivity. So in our opinion,
that last chapter is a “must read,” but you can pick and choose your diagnoses
and settings in the middle of the book.
We are pleased to bring you this new edition.

Virginia Singer, D.N.P., PMHNP-BC, CARN-AP
Introduction to the First Edition
This book, the Clinical Manual of Supportive Psychotherapy, has been written
to fill what we believe is a significant gap in the otherwise plentiful literature
on psychotherapy. It is addressed to a wide audience, including residents in
psychiatry and nonpsychiatric physicians, as well as more experienced psychi
atrists and psychotherapists who would like a comprehensive guide to the spe
cific modality of supportive psychotherapy. This is the type of therapy most
often prescribed for persons in crisis or with chronic mental or physical illness,
but we believe in, and have tried to document, its wider applicability. We have
tried to produce a text that would also be appropriate for novice psychothera
pists who are beginning to apply their theoretical knowledge of psychiatric di
agnosis to real patients.
While offering a comprehensive and self-contained manual, we have taken
pains to refer readers to other resources and current research when needed. For
convenience, references have been attached to chapters, but the project was al
ways conceived as a unitary one.
The principles of Part I progressively develop the background and tech
niques of supportive psychotherapy, dividing the latter into explanatory and
directive interventions. The applications of Part II represent various modifica
tions and adaptations of supportive psychotherapy to major psychiatric and
patient populations. In this part we have presented a consistent approach to
supportive psychotherapy but have also given attention to identifying guidelines
for distinguishing patients who will benefit most appropriately from support
ive work. The interactions of Part III cover significant issues that arise in sup
portive work: the interplay between medication, therapy, and compliance; the
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xx Clinical Manual of Supportive Psychotherapy
relationships between therapist, patient, family, and other members of the treat
ment team; and the interactions between technique and values that generate
ethical problems.
As in all finite projects, many topics (especially those germane to psycho
therapy as a whole) have been passed over lightly or excluded to conserve both
space and the supportive focus of the enterprise. Individual treatment is the over
riding emphasis. The chapter on family issues covers the most vital issues for
an individual therapist but does not presume to offer a complete guide to the
diverse field of family therapy. Group treatments could be applied to most of
the problems encountered here, but they are mentioned only when it is especially
important not to neglect them. Cultural, racial, sexual, and socioeconomic issues
in therapy, as well as the multiple problems of public sector psychotherapy,
have also not been given their due. Despite these necessary omissions, we believe
we have offered the reader the most comprehensive text yet available on the ap
plication of supportive psychotherapy to specific patient populations and di
agnostic groups, showing in each case how basic principles must be modified to
meet individual needs.
Each of us practices psychiatry in the public sector. We have had extensive
experience with both public clinic and private practice patients, and both groups
are represented in the cases given here. Both the clinical and theoretical ma
terials were also field-tested by each of us in different courses that over the last
few years were presented to first- and second-year psychiatry residents; master’s
or doctoral-level therapists in psychology, nursing, social work, education, and
art therapy; and pastoral counselors. Lastly, the material developed for this book
was presented in a course primarily for psychiatrists at the annual meeting of
the American Psychiatric Association in 1992. We are most grateful for the com
ments we received. And, of course, we are indebted to our patients, who taught
us much about how to teach them; and our significant others, who have helped
to bring this project to fruition, even though our original estimate of the work
required was off by a factor of 10.

Stephen J. Rojcewicz Jr., M.D.
Roger Peele, M.D.
Notes on Usage
I n the first edition, we used mostly third-person sentences like “The therapist
should do this” rather than “You should do this.” We also used the somewhat
epicene construction “he or she” to avoid sexism, but in retrospect we think
that these stylistic decisions impaired readability and made the materials some
what formal and distant from the reader, that is, YOU. Since this is indeed a
clinical manual of instructions, it does seem more appropriate now to address
the reader more often in the second person, and we have alternated the “he”
and “she” examples to achieve balance without “conjunction dysfunction.”
There are also some folks who remind us that there is a difference between
“supportive psychotherapy” and “supportive therapy,” the latter being a rubric
that covers many nonpsychological treatments such as pet therapy or nutrition
being supportive therapies for cancer treatment. We understand the differ
ence, but we shall lapse into “supportive therapy” for stylistic reasons, and in the
context of this book, it is simply a shortened form of “supportive psychother
apy.” Many other writers in the field use “supportive therapy” in the same man
ner. Our prequel article title “What Supports Supportive Therapy?” had a
much better ring to it than the longer version of the term. It is available online,
so we apologize if it attracts an occasional pet therapist or dietitian.
xxi
Acknowledgments
Dr. Novalis acknowledges the help of and dedicates this book to Carol Novalis,
who is a family educator and teacher in her own right. She reviewed and edited
the entire manuscript several times and wrote substantial portions of the chapters
on family and community involvement and intellectually disabled popula
tions, and sections on active listening and ethics. She was offered a co-author
ship, and even a portion of the royalties, but she graciously declined. But she
will not be allowed to decline this appreciation for a lifetime of friendship,
love, and marriage.
Dr. Singer acknowledges the help of and dedicates this book to Donald
Singer, for his love, encouragement, and support, which kept her motivated;
and for his endless trips to the office supply store for paper and ink. And for
taking Blinky to the dog park while she worked.
xxiii
PA R T I
Principles
1
The Basis for Supportive
Psychotherapy
What Is Supportive Psychotherapy?
Supportive therapy is a type or mode of psychotherapy. A psychotherapy, in turn,
is a collection of rules or techniques used to conduct mental health treatment,
having a relevant set of goals, between a professionally trained person known
as a therapist and a recipient or subject of the therapy known as the client or pa
tient. Of course, there are therapies involving couples or groups. Supportive
group psychotherapy is indeed an important modality of treatment, and we
shall make some mention of it—but coverage of group therapy is not the focus
of this book.
Rule Books and Clinical Manuals

You might compare a psychotherapy to a serious game or any organized activity
of which you may think. To learn the game, you might ask, “Who are the play
ers?” and “Where is it played (on a board, etc.)? How long does a game last?
What are the rules? Where is the rule book? Who starts the game and what are
they allowed to do? What goals do the players seek to reach? What does it take
to win the game? Is there a prize for winning a game? What skills do serious
players have that help them to win games? What are the penalties for people
who don’t play by the rules?” And of course, in the field of psychotherapy, there
are many books that set out the rules of the relevant “game” one is learning.
3
4 Clinical Manual of Supportive Psychotherapy
In fact, you are reading a rule book for psychotherapy. Many therapies have
been codified into manuals that give fairly detailed instructions on how to
perform the therapy and how to develop a therapeutic relationship (or work
ing alliance) with the patient, respond to the patient’s questions or behaviors,
develop goals and a treatment plan, manage difficult issues and emotions, pe
riodically measure the effectiveness of the therapy, move the therapy through
phases of treatment, and eventually terminate the therapy.
This clinical manual does do all those things but in a laissez-faire manner,
which gives the therapist a considerable amount of leeway in performing the
therapy. Therapy manuals that are more directive and present highly structured
advice do abound in the psychotherapy field and do exist for supportive psy
chotherapy. A much referenced one by Luborsky (1984) is a free-standing book
as well but also contains instruments to create goals of the therapy, monitor its ef
fectiveness, and so on. The book is still readily available, and at least two manual
ized versions are posted online for treatment of marijuana and cocaine use
disorders. That manual is still used by researchers, and an update of such studies
may be found (Leichsenring and Leibing 2007). The authors of the learning se
ries mentioned in our introduction (Winston et al. 2012) also used a manualized
treatment. (A brief but complete treatment manual for time-limited, short-term
supportive individual therapy can be found in Piper et al. 2002.) However, our
conceptualization of supportive psychotherapy is somewhat different from these
manualized versions, for reasons we make clear in the next few chapters.
So-called manualized therapies have an important role to play in training
and research, because they enable head-to-head comparisons of the effective
ness of different therapies in differing populations, and so on. However, it is
still debatable whether one should conduct one’s therapy with patients using a
strict treatment protocol or manual. It could certainly be boring to do so and
would not allow for the eclecticism that we figure is central to supportive ther
apy. Once more, there is considerable research and debate on the place of highly
manualized treatments versus looser and unstructured treatment protocols.
Until recently, the very mention of psychotherapy suggested a particular
mode of psychotherapy known as psychodynamic psychotherapy, itself being an
outgrowth of Sigmund Freud’s (and others’) psychoanalytic therapy and theory.
However, supportive psychotherapy historically was conducted to an extent
thousands of years ago by the ancient Greeks and was simply overshadowed by
the Freudian-era focus of treatment on making the unconscious conscious.
The Basis for Supportive Psychotherapy 5
It is helpful to define supportive therapy both by its collection of tech

niques and by its goals of treatment. For example, we have already suggested
that supportive therapy does not have the goal of making unconscious pro
cesses conscious. Although some researchers prefer to define the therapy with
its techniques, you cannot do only that. For example, Freud might have en
couraged ventilation of emotions to assist someone in interpreting her dream.
A supportive psychotherapist might also encourage ventilation to reduce a pa
tient’s anger, a very different goal. Perhaps the best way to clarify this is to de
fine not the supportive therapy but the supportive therapist, as a therapist who
uses the techniques of supportive therapy in a supportive therapeutic alliance
with the patient to meet the aims of supportive therapy.
To explain and elucidate what supportive psychotherapy is, we will be dis
cussing the goals, techniques, and patient-therapist relationship that charac
terize supportive psychotherapy: the goals of supportive therapy (see Table 1–2
later in this chapter), the techniques of supportive therapy (see Tables 3–1, 3–2,
and 4–1), and the components of a supportive patient-therapist relationship
(see Tables 2–1 and 2–2).
We will spend our first five chapters describing and teaching these tech
niques and goals, with the caveat that supportive psychotherapy as we conceive
and teach it is an eclectic therapy that does not limit itself to just the techniques
and goals of the therapy in those tables. Whether or not you consider the add
ons from other techniques, supportive therapy is by no means simple or sim
plistic, and it does require exacting and complex skills of its practitioners. For
the very reason that supportive therapy is indicated—such as for patients in cri
sis, in psychotic decompensation, or with low level of social functioning—its
provision often taxes the clinician’s abilities to offer empathy, understanding,
and benevolent direction. Thus, it is ironic that trainees on inpatient units are
often given the most impaired patients to treat, and those who are most in need
of support, even before they have completed a basic course in psychotherapy.
Supportive Psychotherapy as
an Eclectic Therapy
Many psychotherapists consider themselves “eclectic,” either informally or in
a certain technical sense, which we will discuss later. Nontechnically, eclectic
refers to using different methods or drawing selectively from different sources,
and the word presumes a positive connotation. Eclectic therapists use a reper
tory of techniques drawn from different sources, such as supportive, cogni
tive-behavioral, psychodynamic, interpersonal, and humanistic.
In the first edition of our book, we advocated for supportive psychotherapy
as an eclectic therapy that draws on empirically supported methods. To avoid
a misunderstanding, we would correct this slightly now to emphasize that sup
portive psychotherapy does have its own group of distinctive techniques, but
that supportive psychotherapists should feel free to supplement their repertory
with techniques from other psychotherapies. In our previous edition, the main
source of techniques external to supportive psychotherapy was cognitive ther
apy. The other “external” set of techniques referred to were those of psychody
namic psychotherapy, which we said were used infrequently in supportive work
but still had their place.
In looking at resources to expand your repertory of techniques, you will find
many that present collections of techniques from various therapies, listing
“the best” exportable techniques. You might wonder, however, how it is pos
sible to be eclectic at all. Doesn’t that require embracing incompatible theories
of personality, mind, or behavior? We think there is considerable controversy
over that question and no simple answer. Thus, if you are a strict behaviorist and
do not believe in unconscious mental processes, you might find it difficult to
use psychodynamic techniques. But what is it that you must accept to endorse
some of the methods of dialectical behavior therapy, interpersonal psycho
therapy, or mentalization therapy? Each of these therapies does have an un
derlying “fundamental belief.” For example, a proponent of mentalization
therapy may believe that failure to mentalize leads to the impulsive and self
destructive behaviors of borderline personality. In the first edition of our book,
which was written before mentalization was developed, we referred to failure
to self-soothe as one of the defects of borderline personality and suggested
some of the therapeutic techniques developed under that assumption. We also
hoped that supportive psychotherapy could utilize empirically validated tech
niques (which predated the current focus on what are called evidence-based
methods), which were relatively atheoretical (e.g., those that simply worked
without making the user feel bound to accept a deep scientific theory of hu
man behavior as the justification for the use of that therapy). Some therapies
such as eye movement desensitization reprocessing, or EMDR, are being used
because the therapists believe they work even though they are not entirely sure
of the reason why they work or the supposed reason they work (i.e., the re
programming of rapid eye movements from dreaming). Similarly, there is a
group of the aforementioned eclectic theorists who describe and advocate a
“transtheoretical” approach to therapy.
We wish we had space to elaborate, but that will be left to you. Use your ac
ademic resources and talk to your teachers, mentors, and colleagues to find out
how they arrived at their own orientations to doing psychotherapy. There are
specific resources designed to help you develop a personal theoretical orienta
tion to psychotherapy. For example, Halibur and Vess Halibur (2015) sum
marize six major schools of thought and discuss some different meanings of
eclecticism. (By the way, these are the psychodynamic, behavioral, humanis
tic, pragmatic, constructivist, and family approaches.) Another reference pro
vides a primer of techniques that are categorized as belonging to nine different
theoretical orientations (Erford 2015). For example, most therapists are famil
iar with reframing, thought stopping, guided imagery, and journaling. Some
therapists feel comfortable switching theories, and others find that paradoxi
cal but feel comfortable switching techniques. We urge you to learn from such
guidebooks and from your patients as you find out what works and does not
work so well, building your own library of techniques and putting aside the
ones you do not find useful.
Although we have mentioned supportive therapy as existing for 2,000
years, when it was discussed by the psychoanalytic therapists, it frequently ob
tained the character of being a subset of a full set of psychoanalytic techniques,
used with the most impaired patients who were not suitable for psychoanaly
sis. Clearly, this is not how we or other advocates of supportive psychotherapy
conceive of it. In fact, as we mentioned, some supportive techniques are com
mon to most forms of psychotherapy, including psychoanalytic. Therefore,
supportive psychotherapy is more like the keystone in all psychotherapies, and
without it the structure would collapse. (And continuing the analogy, you can
build some very different arches having the same keystone.) Other writers de
scribe it similarly as a base of the letter Y, illustrating common competencies
and techniques in teaching psychotherapy (Plakun et al. 2009).
Therefore, as a guide for your own future development, we outline the
repertory of a typical supportive psychotherapist in Table 1–1.
Table 1–1. Repertory of a typical supportive psychotherapist
• Occasional techniques that might be useful but presume other theories of the
mind and interpretations (e.g., dream interpretation)
• Isolated techniques that the therapist has found effective (e.g., the empty chair
technique borrowed from Gestalt therapy)
• Frequently used techniques without theoretical assumptions (e.g., journaling,
thought stopping, guided imagery, progressive muscle relaxation)
• Core techniques of supportive psychotherapy
• Therapist’s favorite techniques but from other psychotherapies (e.g., inter
personal, mentalization-based, emotion-focused, Rogerian, motivational
interviewing)
• Techniques from cognitive-behavioral therapy
• Techniques from psychodynamic therapy
• Techniques from psychoanalytic therapy
• Techniques from humanistic therapy
• Techniques from family therapy
How Effective Is Supportive Psychotherapy?

The effectiveness of supportive psychotherapy was well established 25 years
ago, but the number of positive studies and applications to mental diagnoses
has proliferated since then. However, there are still some problems and issues
in documenting the effectiveness in specific studies. One problem is the “tradi
tional” use of supportive psychotherapy as a control or comparator in psycho
therapy studies conducted by researchers with the desire to prove the effective
ness of some other type of therapy. This has resulted in some negative studies
as well as many surprisingly positive outcomes for supportive psychotherapy.
Supportive psychotherapy also ends up being a “pseudo placebo” in some stud
ies, sometimes even by being outrageously unsupportive or negative. How
ever, we emphasize that the evidence that supports supportive psychotherapy
has grown tremendously in the past 25 years.
Can Supportive Psychotherapy Be Harmful?

Therapists also wonder if they should warn their patients that therapy could
be harmful to them, and there are indeed ethical obligations from the major
professional organizations to do just that in obtaining a formal consent to be
gin therapy. Reassuringly, many researchers on effectiveness also looked in this
direction and concluded that historically there are relatively few “therapies”
that have proven to be outright harmful (Wampold and Imel 2015). One ex
ample was CISD, or critical incident stress debriefing, and in a similar vein the
use of certain grief counseling in subjects undergoing normal bereavement
reactions. Also, familiar to all therapists with some years of experience were
certain therapies uncovering memories of childhood abuse, which later was
shown to not possibly have occurred.
A much-discussed study (Schermuly-Haupt et al. 2018), however, dis
cussed the negative outcomes in cognitive psychotherapy. Based on a survey of
cognitive therapists, it was thought that about a quarter of their patients had
negative side effects from the therapy, such as worsening condition and family
stress. However, it was not implied that therapy was not itself a worthwhile de
cision for a person seeking help. Given that the survey was sent to experienced
and presumably ethical therapists, the risks of psychotherapy are much more
likely to be enhanced with inexperienced or unethical therapists, and anyone
who has practiced in the field knows that from having reengaged with patients
from such therapists. Therefore, therapy could certainly end up being mini
mally or marginally effective and hence a waste of time and money and pos
sibly a cause of lost opportunities to get better faster. A good comparison, in
our opinion, is with a highly effective, low-risk surgical procedure such as an
appendectomy or cholecystectomy. You are usually much better off having
such a procedure than not. Then there are moderate benefit–moderate risk
surgeries such as back surgery and finally dangerous surgeries such as brain an
eurysm repairs. However, we think that psychotherapy is analogous to the first
group.
It would also be wrong, we think, to use supportive therapy when there is a
more effective therapy available that the therapist is skilled to perform or for
which the therapist can make a referral. For example, if a patient with fear of fly
ing really seems to need exposure therapy and the therapist does not do that, the
patient would need a referral. So we hope that none of our readers will end up do
ing ineffective or ineffectual therapy when something clearly better is possible.
In the history of psychotherapy effectiveness research going back as far as
1936 and the work of Saul Rosenzweig, however, there has been a major the
ory that many therapies are equally effective, presumably because of nonspe
cific factors in their psychotherapeutic methods (see Duncan 2002). This has
been called the “dodo bird effect,” after a fictional race in Chapter 3 of Lewis
Carroll’s Alice’s Adventures in Wonderland (an analogy to politics), in which the
Dodo claims that “everyone has won, and all must have prizes.” (A thorough
yet fairly brief history of both sides of the issue may be found in Wikipedia
[2019].) In the last few decades, however, we have seen some therapies that do
seem to rise a cut above the pack, such as cognitive-behavioral therapy. So
when we propose the use of supportive therapy for specific diagnoses in this
book, we are careful to note the limitations on patient selections and techniques,
and do make mention of some of the other therapies.
We all wish, as do major authors in the field, that supportive psychother
apy will continue its development as an evidence-based treatment (Hellerstein
and Markowitz 2008).
Core Supportive Techniques

Definition and the Place of Theories and Concepts
The supportive psychotherapist plays an active and directive role in helping
the patient to improve his social functioning and coping skills. The emphasis
is on improving behavior and subjective feelings rather than achieving insight
or self-understanding. We believe there is a core of supportive techniques in
many of the hundreds of psychotherapies, most of which provide patients
with support, improve defenses, reduce anxiety, and so forth.
Supportive psychotherapy also differs from most other psychotherapies in
its epistemological basis to the extent that it does not require a deeply theo
retical concept or theory of the mind. Thus, a good definition of supportive
psychotherapy is as follows:
Supportive psychotherapy is a form of psychotherapy that uses techniques that

are empirically and/or evidence based—that is, techniques that have been ob
served to work—to achieve the following aims: 1) promote a supportive therapist

patient relationship; 2) enhance the patient’s strengths, coping skills, and ca
pacity to use environmental supports; 3) reduce the patient’s subjective dis
tress and behavioral dysfunctions; 4) achieve for the patient the greatest practical
degree of independence from his or her psychiatric illnesses; and 5) foster the
greatest possible degree of autonomy in treatment decisions for the patient.
Supportive Therapy Is Empirically Based and Patient

Driven (Rather Than Theory Guided)
The therapist’s activity at any point in the therapy is determined by the patient’s
current state and the therapist’s selection from a repertory of proven tech
niques without theoretical bias. In addition, the supportive psychotherapist
may change techniques as the therapy proceeds, based on observations of what
is effective with given symptoms of the patient’s illness. Concepts such as
transference and defense mechanisms are frequently invoked, but theories as to
the supposed cause of the patient’s disorder are not required. Even those ther
apists committed to certain theories can use supportive psychotherapy prin
ciples at those times when they determine that any single theory is inadequate
to explain the complexity of behavior or to form the basis for intervention.
Supportive psychotherapy is, to use a term defined by Beitman et al. (1989),
technically eclectic, in that it does not presuppose a particular theory of psy
chopathology; it can draw as needed from particular schools of psychotherapy,
including psychodynamic, cognitive-behavioral, interpersonal, and experien
tial. It is also eclectic in that it may address different symptoms with potentially
different therapeutic methods (Kramer 1989).
Goals of Supportive Psychotherapy

Potential goals of supportive psychotherapy, based on our definition, are pre
sented in Table 1–2. These goals can be divided into those that are frequently
chosen and those that are usually given less emphasis. Specific goals are reached
by the therapist’s active selection of priorities and emphases on the content of
therapy sessions. Some of these goals (e.g., strengthening defenses) may even
appear contradictory to reciprocal goals (weakening defenses), but this is a
matter of relative emphasis and selection of particular defenses, as will be de
scribed later in our chapters on technique.
Table 1–2. Goals of supportive psychotherapy
Frequent goals Infrequent goals
Reducing behavioral dysfunctions Enhancing insight and self-understanding

Reducing subjective mental distress Exploring interpersonal experiences
Supporting and enhancing the Exploring inner experiences
patient’s strengths and coping
Understanding childhood determinants
skills, and his or her capacity to use
of adult personality
environmental supports
Resolving intrapsychic conflicts
Maximizing treatment autonomy
Restructuring personality
Achieving maximum possible
independence from psychiatric
illness
Examples
Resolving acute crises—for example, bereavement, trauma, disaster, suicide
attempt, and crises associated with medical illness
Promoting adherence to treatment plans
Decreasing inappropriate behavior
Decreasing dysphoric thought processes and content
Improving coping skills
Improving social skills
Resolving external conflicts
Preventing relapse, deterioration, or hospitalization
Enhancing self-esteem
Improving reality testing (of patient, others, and the world)
Strengthening healthy defenses
Weakening maladaptive defenses
Maximizing family and social support
In a patient-driven, symptom-focused, or empirical therapy, you must ad

dress the treatment with the relative goals in mind. A patient who is experienc
ing a psychotic breakdown probably needs to be asked about his medication;
no therapist of any school would wait for the patient to bring up the topic, if
ever he did. Similarly, the high-functioning executive brought in by her family
for depression requires a directive interview with attention to suicidal intent.
She may benefit from long-term characterological change, but that is not the
most important goal of therapy at this moment.
Supportive psychotherapy is often described in negative terms as a therapy
suited for patients who cannot benefit from, afford, or engage in the time
consuming, long-term psychodynamic forms of therapy. This negative ap
proach toward definition does not do justice to the fact that supportive ther
apy is probably a preferred mode of treatment for the majority of mentally ill
persons (Dewald 1971). However, the negative bias against supportive ther
apy is an intellectual one that assumes that treatment with psychoanalytic
methods is perhaps more interesting or rewarding to the clinician. Such bias is
reflective more of the lack of knowledge of supportive therapy and of how to
conduct it.
Supportive therapy does not presuppose low function, psychosis, or chronic
mental illness, although these characteristics are likely to make it a preferred
mode of treatment. The methods and goals of supportive therapy are equally
applicable to high-functioning patients in crisis or with limited access to more
intense therapies. It is not a linguistic accident that supportive therapy has de
veloped along a parallel track as part of the biopsychosocial treatment of be
reaved, suicidal, or traumatized patients as well as of acutely, chronically, or
terminally medically ill patients, regardless of their preexisting psychopathol
ogy, if any. For these reasons, such supportive interventions are included in the
spectrum of topics in this manual, for these constitute the same form of treat
ment and not just disparate ones with the same name.
Evidence for Effectiveness

Traditionally, supportive psychotherapy has been considered the treatment of
choice (often in conjunction with medication) for patients in crisis or for
those with very chronic medical or psychiatric illnesses. Many studies, how
ever, including some with surprising or counterintuitive outcomes, have es

tablished the wide applicability and efficacy of supportive psychotherapy. As
we said even in the first edition of this book, it is not even possible to discuss
all the positive studies that have been published. However, as in the past, we
will emphasize the groundbreaking studies with the addition of some more re
cent research. (Note: More recent studies are often given in the diagnosis
specific chapters of the book.)
In the Boston Psychotherapy Study (Gunderson et al. 1984), a sample of 95
persons with schizophrenia were treated with either a reality-adaptive, support
ive (RAS) form of psychotherapy or an exploratory, insight-oriented (EIO) type.
Two-year outcomes showed minimal differences in only 3 of 10 areas of assess
ment, with RAS treatment slightly superior in reducing hospitalizations and
improving occupational function, and EIO treatment modestly superior in
improving ego functioning. Given the cost of hospitalization, the RAS treat
ment was clearly more cost-effective, pending the development of specific
treatment strategies for patients. One review of outcome studies (Krauss and
Slavinsky 1982, pp. 230–232) emphasized the generally positive results but
noted that the stimulation of group settings could worsen symptoms, espe
cially in unmedicated patients. In addition, the provision of group socializa
tion in clinic settings may be a substitute for community activities that does
not aid in the patient’s adjustment in the community. (For additional discus
sion, see Goldberg et al. 1977; Hogarty et al. 1974, 1979.)
A later study of first-episode psychosis also reported positive findings
(Rosenbaum et al. 2005). However, the most comprehensive analysis of sup
portive psychotherapy has since been reported by the Cochrane Collaborative
and is readily available (Buckley et al. 2015). There are actually three down
loadable documents, consisting of a brief summary, a moderate-sized report
(150 pages), and a detailed analysis of individual studies (250 pages). The Col
laborative’s conclusions are that the quality of evidence is poor for reasons we
suggested earlier in the chapter: that supportive therapy is often used as a con
trol condition, weak comparator, and so on, and in studies with the purpose of
proving the superiority of other types of psychotherapy. So the greatest benefit
is actually found in their analysis of individual studies showing which ones re
port a positive trend for supportive psychotherapy.
Supportive psychotherapy was shown to be as effective as behavior therapy
in the treatment of phobias (Klein et al. 1983; Zitrin et al. 1978). A subsequent
study (Barrowclough et al. 2001) found that its effectiveness was broadly equal
to that of cognitive-behavioral therapy for several anxiety disorders.
The usefulness of supportive psychotherapy in depression was established in
the National Institute of Mental Health’s Treatment of Depression Collaborative
Research Program (Elkin et al. 1989), which compared the effectiveness of four
16-week treatment conditions, two of which utilized a clinical management
(CM) component that was described as approximating a “minimal supportive
therapy” because it included support, encouragement, and direct advice along
with medication management and a review of the patient’s condition. For a se
verely depressed subgroup of patients, the imipramine-CM treatment was supe
rior to (in order of lessening superiority) interpersonal psychotherapy, cognitive
psychotherapy, and placebo CM. For a less depressed subgroup, no other treat
ment was more effective than the placebo-CM condition. This study attested
not only to the therapeutic efficacy of medication combined with supportive
psychotherapy but also, as the authors themselves suggested, to the effectiveness
of supportive therapy alone for less severely depressed patients. Although there
was no isolated placebo treatment, for ethical reasons, Elkin et al. (1989) sug
gested (on the basis of previous placebo-alone studies) that placebo and CM
combined would be a more effective treatment than placebo alone.
In addition, a review of 26 articles, most of them studies of supportive
type therapies for depression and related problems, concluded that “there is
evidence to suggest that the group of therapies often referred to as supportive
are effective, and equally as effective as selected other therapies, in the treatment
of adult depression” (Jacobs and Reupert 2014, p. 2). The therapies identified
in this article include many with methods and techniques more limited than
those of the therapy we advocate in this book (e.g., supportive and nondirec
tive counseling).
Many other studies have been conducted in various types of depression
and different samples such as adolescents assigned to cognitive, family, or sup
portive psychotherapy (Renaud et al. 1998), and supportive psychotherapy
was found to be superior for mild depression but not as much for severe. As for
bipolar disorder, both supportive therapy and mentalization-based therapy
were found to be effective in treatment (Meyer and Hautzinger 2012).
We previously mentioned the availability of treatment manuals for sub
stance abuse and mentioned Luborsky’s (1984) supportive-expressive psycho
therapy. It should be pointed out that supportive therapy for cocaine abusers
was found to be effective but was not the superior treatment in a large National
Institute on Drug Abuse study of 400 patients and four treatment arms (Crits-
Christoph et al. 1997).
Studies involving medical conditions abound. One of the earlier controlled
studies was that of Mumford et al. (1982), which showed multiple benefits in
patients receiving ancillary supportive psychotherapy after myocardial infarc
tions and surgery (e.g., increased adherence, increased speed of recovery, fewer
complications and days in hospital). Sjödin et al. (1986) reported a controlled
study of patients with peptic ulcer disease showing favorable results in those who
had supportive psychotherapy added to their medical treatment. (For newer
references, see Chapter 12, “The Medically Ill Patient.”)
Quite fascinating and still worth emphasizing are the results of the Men
ninger Foundation’s Psychotherapy Research Project, a long-term (1956–1972)
naturalistic study of expressive and supportive psychoanalytic psychotherapy
with 42 patients. The initial findings in this complex study showed that “the
modality of treatment by itself did not have significant effect on the outcome;
however, successful supportive treatments require a higher skill in the therapist
than the expressive treatments” (Burstein et al. 1972, p. 79). A major variable
that did correlate positively with treatment outcome was ego strength. Based on
the finding that patients with initially low ego strength benefited more from
expressive than supportive treatments, Kernberg (1984) was led in his inter
pretation of the study to prescribe a somewhat limited role for supportive psy
chotherapy in the treatment of severe personality disorders. In sharp contrast,
subsequent analysis by Wallerstein (1989) led the latter to draw what might
seem (to some) to be radical conclusions:
• Treatment results for both methods tended to converge rather than diverge.
• All courses of treatment embodied a greater number of supportive elements
than originally intended, and these elements accounted for more of the
changes than was anticipated.
• The changes (regardless of the treatments used to achieve them) “often
seemed quite indistinguishable from each other and equally represented
structural change in personality functioning” (Wallerstein 1989, p. 205).
It is the last statement, which argues for the effectiveness of supportive

psychotherapy in producing long-term personality change, that shows most
clearly the ability of supportive psychotherapy to achieve one of the treatment

goals often ascribed to psychoanalysis alone. (For additional discussion, see
the original data, Wallerstein’s arguments, and his monograph based on the
Menninger project [Wallerstein 1986].) More recently, Kernberg (2018) has
addressed the role of supportive psychotherapy in treating severe personality
disorders, given that the resources for more psychodynamic treatments are not
available (e.g., are too expensive or time consuming, or trained therapists are
not available to perform them).
Other studies on use of supportive psychotherapy in treating personality
disorders have also been reported. Brief supportive psychotherapy was found
equally effective as short-term dynamic psychotherapy in high-functioning
outpatients with personality disorder (Hellerstein et al. 1998). General equiv
alences were found between transference-focused therapy, supportive psy
chotherapy, and dialectical behavior therapy in outpatients with borderline
personality disorder (Clarkin et al. 2007), and supportive-expressive psycho
therapy was found to be as effective as psychodynamic therapy in outpatients
with Cluster C personality disorders (avoidant, dependent, obsessive-compul
sive) (Vinnars et al. 2005). Both mentalization-based and supportive psycho
therapy were found to be highly effective in treating patients with borderline
personality disorder (Jørgensen et al. 2013), and mentalization-based treat
ment and a fairly minimal therapeutic method called structured clinical man
agement were both found to be effective in treating borderline personality
disorder (Bateman and Fonagy 2009). And supportive psychotherapy has been
found to be as effective in treating bipolar disorder as cognitive-behavioral
therapy (Pedersen 2018).
Historical Background to
Supportive Psychotherapy
Supportive psychotherapy has a long and varied history dating back to the an
cient Greeks, who conceived of methods of treating the mentally ill humanely
as well as the more specific approaches of counseling and support for persons
in crisis (Ducey and Simon 1975).
Various methods of dealing with the irrational in man can be found in
Plato, Aristotle, Hippocrates, and other classical authors (Dodds 1951). Many
of these techniques (e.g., emotional catharsis, education) have direct applica

bility to supportive psychotherapy. For example, Gorgias, the Sicilian Greek
sophist of fifth century B.C.E., and Antiphon, an Athenian Greek sophist of
approximately the same era, both had reputations for curing certain illnesses
through verbal methods (Lain Entralgo 1970). Gorgias was the brother of the
physician Herodicus of Leontini but did not identify himself as a physician.
The Platonic dialogue Gorgias, in which Socrates debates the aged Gorgias, il
lustrates the latter’s reputation for persuading patients to take their medicine
when physicians themselves could not so persuade them. (It appears that some
issues remain cogent, even after 2,500 years.) In this dialogue, Plato has Gorgias
say: “I have often, along with my brother and with other physicians, visited
one of the patients who refused to drink his medicines or submit to the surgeon’s
knife or cautery, and when the doctor was unable to persuade them, I did, by
no other art but rhetoric” (Hamilton and Cairns 1961, p. 239). An elaborate
discussion of this example ensues. Included in the argument of Socrates is the
conclusion that the person who uses verbal methods to cure must also know
medicine.
Additional elements of supportive psychotherapy technique can be found
in Greek tragedy and the Asclepian temple healing procedure (Gorelick
1987). Further examples can be cited for philosophers such as Cicero or me
dieval physician-philosophers such as Avicenna (Shafii 1972). Indeed, the var
ious components of supportive psychotherapy in use for many centuries have
often been the province of philosophers, poets, political leaders (Williman
and Kvarnes 1984), religious practitioners (Finucane 1973), and indigenous
healers, rather than a part of the armamentarium of the medical profession.
The first systematic organization of these principles as part of the overall
field of medicine was put forth by the German physician Johann Christian Reil
(1759–1813), who was also the first to use the word psychiatry. His 1803 book,
Rhapsodien über die Anwendung der psychischen Curmethode auf Geisteszerrüt
tungen (“Rhapsodies on the Application of the Psychic Cure Method to Men
tal Disorders”), outlined a complete method of psychotherapy for the
treatment of mental disorders (Reil 1803, cited by Ellenberger 1970). Reil
emphasized security, stimulation, and comfort accomplished through talking,
rest, appropriate physical work, massage, music, education, occupational
therapy, art therapy, and even a form of psychodrama. Based on the system
atization of his ideas and their integration into a comprehensive view of men
tal disorders and medical treatment, such that verbal methods are part of a
total treatment plan, Reil has been called the founder of rational psycho
therapy (Colp 1989), and perhaps he may also be considered the modern-day
founder of supportive psychotherapy.
Most psychotherapies, and especially supportive psychotherapy, have a
humanitarian thrust. Philippe Pinel’s (1745–1826) unchaining of the psychi
atrically ill of Bicêtre in 1792 and of the Hôpital Salpêtrière in Paris in 1794
is generally regarded as the beginning of the modern era of humanitarian treat
ment. This action, frequently depicted dramatically in art, is often seen as the
beginning of the medical model of mental illness (Van den Berg 1987). It was
not merely this decision but his development of treatment guidelines (includ
ing productive activities for the mentally ill) that established Pinel’s place in
history.
In the United States, this current of reform was continued by the founder of
American psychiatry, Benjamin Rush, a signer of the Declaration of Indepen
dence. In addition to his many biological treatment innovations, Rush coun
seled direct advice, educational efforts, healthy employment or productive
activities, and temperance—approaches that can be seen as forerunners of sup
portive psychotherapy (Rush 1809/1972).
In a more modern context, Freud, who had himself elaborated and then
abandoned the use of direct suggestion and hypnosis in lieu of associative psy
choanalytic technique, predicted that “the large-scale application of our the
ory will compel us to alloy the pure gold of analysis freely with the copper of
direct suggestion” (Freud 1919[1918]/1955, p. 168). Subsequently, supportive
psychotherapy was defined by a succession of clinicians with respect to its dif
ferences from psychoanalytic technique. Alexander and French (1946), in a re
action to nondirective analytic technique, conceived the notion of the “corrective
emotional experience,” which was tailored to provide the missing components
of a patient’s nurturing and a relearning of assumptions about interpersonal
relationships. Their work spawned lines of development in behavioral thera
pies and focused brief psychotherapy.
The focused, limited, and non-insight-oriented aspects of Alexander and
French’s method were developed further by Gill (1951), who proposed that
the usual interpretations of defenses could not be applied to patients with low
ego strength, who risked regression and could not handle the anxiety. Such
patients needed differential support of behaviors that expressed adaptive de
fenses. A similar conception of supportive interventions, derived by Draper et

al. (1968) from Heinz Hartmann’s “regressive adaptation” (Hartmann 1958),
defined “adaptive psychiatry” as a technique to mobilize ego strengths so that
the patient remained functional. A key tenet of Draper et al.’s treatment was to
support psychological defenses—even overt, pathological ones such as para
noid delusions. This formulation of supportive therapy concerned its role in
the strengthening and inculcation of a patient’s individual coping and social
ization skills.
And here are some additional views of supportive psychotherapy:
• Knight (1954) describes it as a “superficial psychotherapy” that utilizes in

spiration, reassurance, suggestion, persuasion, counseling, reeducation,
and other techniques for patients who are too psychologically fragile, in
flexible, or defensive for exploratory devices.
• Bloch (1979) stresses sustenance and maintenance rather than suppres
sion and repression as the focus of supportive psychotherapy.
• Werman (1984) sees supportive psychotherapy as a substitutive form of
treatment that supplies the patient with those psychological functions that
he or she either lacks entirely or possesses insufficiently.
• Wallerstein (1988), following Gill (1951), defines supportive psychother
apy as one that strengthens defenses and represses selected symptoms
(in favor of exploring others), using means other than interpretation or
insight to achieve these goals.
• Pinsker and Rosenthal (1992) describe individual supportive psychotherapy
as “a dyadic treatment characterized by use of direct measures to amelio
rate symptoms and to maintain, restore, or improve self-esteem, adaptive
skills, and psychological function. To the extent necessary to accomplish
these objectives, treatment may utilize examination of relationships, real
or transferential, and both past and current patterns of emotional response
or behavior” (p. 21).
Rockland (1989, pp. 22–39), in his excellent review, has traced the devel
opment of supportive psychotherapy, the key points of which are as follows. In
1912, Ernest Jones wrote that suggestion depends on the patient’s positive trans
ference to the healer. Edward Glover, in 1931, developed the concept of “in
exact” interpretations.
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nothing produced by the sculptors, painters, and ornamentists who
were employed on the decoration of those great buildings which
even the Jewish prophets could not help admiring, while they abused
the princes who built them and the gods to whom they were
consecrated. The earliest Greek travellers, such as Herodotus and
Ctesias, only saw the ruins of these magnificent structures and of
their rich adornment of enamels, frescoes, and sculptured figures;
and yet how great was their wonder! We can hardly reflect without
emotion upon what we have lost in great works in stone and metal
carried out in the style of which certain fragments from Tello and a
few terra-cotta statuettes give us some faint idea.[230]
Fig. 111.—The Caillou Michaux, obverse. Drawn by Saint-Elme Gautier.

Fig. 112.—The Caillou Michaux, reverse. Drawn by Saint-Elme Gautier.
That such works did once exist we are told by the Greek
historians. Herodotus, after having described the temple of Bel and
the sanctuary on its summit in which no image of the deity was set
up, goes on, “In this temple at Babylon there is another sanctuary
lower down, where a great seated statue of Zeus may be seen.[231]
Near this statue there is a large table of gold, the throne and its
steps are of the same material. The whole, according to the
Chaldæans, is worth eight hundred talents of gold ... at one time the
sacred inclosure also contained a statue of massive gold twelve
cubits high. I did not see it. I content myself with repeating what the
Chaldæans told me about it. Darius, the son of Hystaspes, formed a
project to carry it off, but he did not dare to execute it. Xerxes, the
son of Darius, caused the priest to be put to death by whom the
enterprise was opposed, and took possession of the statue.” We
here have the evidence of an eye-witness. The seated statue of Bel,
without being of the colossal size ascribed by the Chaldæans to the
image destroyed by Darius, must yet, if we may judge from the
expression of Herodotus, have been larger than nature. We may
gather some notion as to its pose and general appearance from
certain figures carved upon the cylinders (Fig. 40), just as, in
Greece, the more famous and venerable of her religious statues
were reproduced upon coins and gems. As to this Babylonian statue,
the one doubt we have relates to the value put upon it by the
Chaldæans. Had the statue and its surroundings really been of
massive gold, would the Persians have spared it when the other was
overthrown and broken up? It is possible that in spite of the
historian’s assertion the work he describes was only gilded bronze.
And as for the image twelve cubits high, we may express the
same doubts. Ctesias seems to have received better information as
to how these figures were made than Herodotus, and, through
Diodorus, he tells us that they consisted of metal plates beaten into
shape with the hammer.[232] Whether Ctesias or his informants did
or did not exaggerate their true dimensions (Diodorus speaks of a
Bel forty feet high), or whether these figures were of gold or gilded
brass, is of comparatively slight importance; we are interested chiefly
in the information he gives as to the method of fabrication. Ever
since the discovery of the Balawat gates proved to what a height the
student art of Assyria carried the manipulation of metal by the
repoussé process, we have had no difficulty in believing that the
sculptors of Babylon in the time of Nebuchadnezzar could build up
images of colossal size and fine decorative effect by means of
plaques united with rivets. If we may believe the rest of Diodorus’s
description, the Chaldæan artists combined the glory of gold and
silver with the purity of ivory and the bright and varied colours of
precious stones. And all this we see good reason to admit when we
have examined at the British Museum those ivories in which lapis
lazuli and other substances of the same kind even now fill up the
hollows of the design, while the field still glitters here and there with
some last fragments of the gold with which it was once incrusted.
The skilful workmen who discovered the secret of this kind of
mosaic, may very well have learnt to combine these beautiful
materials so well that the statues upon which they were used would
even have rivalled the chryselephantine masterpieces of Phidias; in
richness and harmony of tones, at least, if not in nobility and purity of
form.
§ 6. Assyrian Sculpture.
Assyrian sculpture is far from leading us into the remote centuries

from which some of the Chaldæan works must date. It had no period
of infancy or childish effort. The Semites of the north were the pupils
of their southern brothers, from whom they obtained an art already
mature. The oldest known Assyrian monument dates from the reign
of Tiglath-Pileser I., or about the end of the twelfth century b.c.; it is a
bas-relief chiselled upon a rock near the sources of the Tigris, about
fifty miles north of Diarbekir and near the village of Korkhar. It
represents the king standing upright, his right hand extended and his
left holding a sceptre; at present, however, we only know it by the
very poor sketch given by Professor Rawlinson.[233] It is almost the
only monument extant from the time when the capital of the
monarchy was on the site now known as Kaleh-Shergat. One other
may be named, the female torso in the British Museum, to which we
have already referred;[234] on it the name of Assurbilkala, who
succeeded Tiglath-Pileser I., may be read.
The monumental history of Assyria really begins two centuries
later, with the great buildings erected by Assurnazirpal at Calah
(Nimroud), his favourite residence. Assyrian art then reached a level
that, speaking generally, it never surpassed. In the following
centuries it innovated, it became more complex and certainly more
refined, but it produced nothing essentially nobler than certain
Nimroud bas-reliefs, in which the king is seated among his great
officers or before his gods, and always in the attitude of prayer and
sacrifice. We have already given several examples of these reliefs
(Vol. I. Fig. 4, and above, Figs. 15 and 64); we may here add one
more (Fig. 113). Leaning on his bow with his left hand, the king,
richly dressed, lifts in his right the patera whose contents he is about
to pour as a libation to the deity. Facing him stands a gigantic
eunuch, who waves over his master’s head one of those fly-flappers
that, with the parasol, have always been among the insignia of
Oriental royalty (see Plate X.).
These figures are rather short in their proportions, and the
muscular development of their arms, which alone are bare, is
violently exaggerated, but yet as a whole the work has a certain
grandeur and nobility. The lines are well balanced. Both the king and
his attendant seem fully impressed with the gravity of the rite over
which they are busy. There is dignity in their attitudes, but no
stiffness; their gestures are easy and expressive without being too
much accented. In our engraving we have only been able to include
the two isolated figures, in the original there are several more all
occupied over the same rite. Even the British Museum has only a
few fragments from these vast compositions. For those who saw
them in their original completeness, well lighted and distributed in
their right order along the walls of spacious saloons, they must have
seemed majestic enough.
In his palace decorations the Assyrian artist set himself to free his
figures from all unnecessary surroundings and to simplify his theme
as much as he could. But we must make a distinction between those
reliefs that may be called historical, such as the pictures of battles
and sieges, and those in which the king is shown in the
accomplishment of some duty belonging to his position, and part of
his daily or periodical routine. It is to the latter class that the most
carefully-executed works belong. In these no particular locality is
specified; like that of the Panathenaic procession, it is left
undetermined, and the mind of the spectator is silently invited to fill it
in for himself. Those who frequented the palace were accustomed to
see the king upon his throne, or traversing the wide quadrangle, or
pouring libations on the altar that stood in front of the temple; so that
they had no difficulty in imagining all that the sculptor had left unsaid.
In the hunting pictures the same method was followed with but little
modification. A flat surface suggesting the unbroken expanse of the
desert, was the only indication of a locus in quo.
Fig. 113.—Assurnazirpal offering a libation. Height 7 feet 8
inches. British Museum.
Drawn by Saint-Elme Gautier.
It would have been difficult, or rather impossible, to adhere to
such a rule in those reliefs in which the actual incidents of military
expeditions were retraced. In them the sculptor thought it necessary
to insert such details as would permit the various episodes
commemorated to be identified. One of the simplest means of
insuring the desired result was to render not only buildings, such as
castles and fortified towns, but also the natural features of the scene,
with the greatest possible truth. This the Assyrian artist did, as a rule,
with excellent judgment. Thus, if an action or campaign had been
fought in a mountainous country, he made use of a kind of lattice-
work or reticulation, which every spectator thoroughly understood
(see Vol. I. Figs. 39 and 43); if among forests, he introduced
numerous trees among his figures. He made little attempt to
distinguish between one kind of tree and another, but in most cases
employed forms as conventional as that by which he indicated hills
(Fig. 114).
Fig. 114.—Tree on a river bank;

from Layard.
One of the chief merits and most striking features of Assyrian
sculpture is, then, its power of selection, its rejection of all that is
superfluous, its comprehension, in fact, of the true spirit and special
conditions of the art. The field has none of those encumbering
accessories which, under the pretext of furnishing and defining, only
serve, so to speak, to take away air and elbow-room from the
figures. When certain complementary features are required to make
the subject clear, the sculptor introduces them, but he never gives
more than is strictly necessary. He never gives way to the temptation
to exaggerate such details, or treats them as if they had an interest
and importance of their own. Such sobriety found its reward. His
work no doubt remained faulty in many respects and inferior to that
of his Egyptian forerunner, still more to that of his Greek successor;
but yet it had an air of frankness, of pride and dignity, to which the
more complex and superficially more skilful compositions of the
following epoch too seldom attained.
The good qualities of this early Assyrian school are no less
conspicuous in the colossal figures with which the doorways of
palaces and temples were decorated. The head of the winged bull
has nowhere a more lofty expression or one more full of dignity than
at Nimroud (see below, Fig. 133). The chisels of these northern
artists never created anything more bold, energetic, and lifelike than
the figures from the small temple built by Assurnazirpal (Vol. I. Fig.
188); we need only mention the colossal lion in the British Museum
(Plate VIII.) and the grimacing demon whom a beneficent god seems
to be expelling from the sanctuary in spite of his threats and grinning
teeth.[235]
And yet this art which is so masterly in some respects is very
primitive and naïve in others. We cannot help being amazed, for
instance, at the wide band of wedges that the scribe has been
allowed to cut across all the lines and contours left by the sculptor.
This proceeding is to be explained, of course, by the essentially
historical and anecdotic character of Assyrian art, but nevertheless it
betrays the contempt for æsthetic effect which is one of the
characteristics of archaic art in Assyria. This feature is by no means
without importance, and Sir Henry Layard seems to us to have been
ill advised in deliberately suppressing it. In his otherwise faithful
reproductions of the best preserved among the bas-reliefs of
Assurnazirpal he has everywhere left out the continuous band of
inscription which runs across them at about two-thirds of their height.
By such a proceeding he has sensibly modified their decorative
value.[236]
We must be on our guard against attributing such primitive
simplicity to inexperience in the use of the chisel. In the finest works
of later years that instrument was never wielded with more assured
skill than in the delicate carvings in which the embroidery on the
royal robes are reproduced. We have already put several of these
motives before our readers; in Fig. 115 we give a last exquisite
morsel. It shows a winged lion with the head of a woman, and a king
or priest who holds one of her paws in his left hand, while with his
right he seems to threaten her with a mace.
Fig. 115.—Detail from the royal robe of Assurnazirpal; from Layard.

Such dexterity as this is not to be seen in works in the round (see
Fig. 60). But with the reign of Assurnazirpal commences another
series of royal monuments in which the artist, not being compelled to
quit work in relief, felt himself more at home. We refer to those
round-headed steles on which the standing figure of the king is
relieved against a flat ground bordered by a raised edge. An
inscription is engraved sometimes upon the bed of the relief,
sometimes on the reverse of the stele. An effigy of Assurnazirpal
belonging to this class is now in the British Museum. It was
discovered still standing in the entrance to one of the temples built
by that sovereign on the platform of Calah. Before the stele there
was an altar similar to that shown on page 256 of our first volume.
This altar is also in the British Museum.[237] From the existence of
these steles it has been concluded, with no little probability, that the
Assyrian kings, or at least some of them, received divine honours
after their deaths. We have chosen that of Samas-vul II. for
reproduction, on account of its good condition (Fig. 116). It differs but
little from the stele of Assurnazirpal. High up in the field and in front
of the head may be noticed symbols like those on the land marks
(see Figs. 111, 112, and 143). The king’s right hand is raised in the
attitude of adoration. In his left he holds a sceptre, with a ball of ivory
or metal at one end and a tassel at the other. These steles must
have been set up in great numbers. We find them represented in the
reliefs (Vol. I. Figs. 42 and 112, and Plate XII.) and upon cylinders
(ib. Fig. 69). They were raised as a sign of annexation in conquered
countries, and an invocation engraved upon the stone put them
under the protection of the Assyrian gods, who were charged with
the punishment of any who might lay hands upon them.[238]
In the British Museum there are fragments of a sculptured obelisk
on which the wars and hunts of Assurnazirpal are figured. It is taller
than that of his son Shalmaneser II., being nearly ten feet high, but
as the material is a soft limestone, it is in far worse preservation; we
only mention it to show that Assyrian art was in possession of all its
resources in the time of this king.
Under none of the princes who reigned at Calah did sculpture
show any sensible change of style; but yet, perhaps, in certain
passages of the Balawat gates we may recognize the first signs of a
tendency that was to become strongly marked under the Sargonids.
The field of the relief there contains a far greater number of
picturesque and explanatory details than the great bas-reliefs of
Nimroud. The campaigns and victories of Shalmaneser II. was the
theme put before the sculptor. In order to do it justice he had to carry
the spectator into countries of various aspects, and to give their true
character to military struggles whose conditions were incessantly
changing. He did not think success was to be attained by confining
himself to figuring the cities and fortresses besieged and taken by
the Assyrian army; he introduced features for the purpose of
determining the seat of war. Such accessories were better placed
among figures on a small scale than among those surpassing or
even approaching life size; and without knowing exactly why, the
artist seems to have been warned of this by a secret and delicate
instinct. These strips of bronze are ten inches high; each is divided
into two horizontal divisions by a narrow band of rosettes, which is
also repeated at the top and bottom of each strip. The figures are on
an average about three and a half inches high (see Fig. 117 and
Plate XII.).
Fig. 116.—Stele of Samas-vul II. Height
7 feet 2 inches. British Museum.
Drawn by Saint-Elme Gautier.
PLATE XII
FROM THE BALAWAT GATES

British Museum
Our Plate XII. is an exact copy from a part of the band marked B
in the provisional numeration adopted by Dr. Birch.[239] According to
the inscription upon it this part of the work commemorates a sacrifice
offered by Shalmaneser on the borders of the Lake Van, in Armenia.
The figure of the king is not included in our plate, but it contains all
the sacred vessels of which he made use for the ceremony.
Beginning on the left we find a sort of great candelabrum, a three-
legged altar, and two standards upon tripods. Must these be
accepted as military ensigns of the same class as that shown in Fig.
46 or as religious emblems of the sun and moon? The question is
hardly one for us to discuss. Next comes a stele raised upon a rock,
or perhaps carved upon its surface. Other reliefs of the same series
show us that Shalmaneser erected these steles in every country he
conquered. Further to the right we see soldiers throwing into the lake
the limbs of the animals sacrificed. This must be an offering to the
deity of its waters, perhaps to Anou, who was believed to reside in
rivers and lakes as well as in the sea. The denizens of the lake seize
upon the morsels thus put in their way; among them we may
recognize a large fish, a tortoise, and a quadruped, that may
perhaps be an otter.[240]
In the lower division we see the Assyrian army on the march. On
the right Mr. Pinches recognizes a fortified camp in which horses
were left for flight in case of defeat. There is, indeed, one of these
fortified walls shown in projection, of which we have already spoken,
but the horse is placed upon a clearly indicated arch. What is this
arch doing in the middle of the camp? We ask ourselves whether this
circular structure may not be intended to represent a fortified tête-de-
pont. It is abundantly proved that the Assyrians and Chaldæans
made great use of the vault. Why should they not have employed it
for bridges elsewhere than at Babylon? and wherever there were
bridges on the great roads and near their own frontiers what could
be more natural than to defend them by works flanked, like this, with
towers? The horse would then be about to cross the bridge, and his
introduction would be explained simply by the sculptor’s desire to
give all possible clearness to a representation which could never be
complete. He seems to advance with some precaution as if the floor
of the bridge, which is indicated merely by a straight line, was made
of tree trunks or roughly squared planks badly joined. We offer this
hypothesis for what it may be worth. Next come two archers, and
then chariots. The ground must be difficult, for not only does the
driver support his horses with a tightened rein, but a man on foot
walks in front and holds them by the head.
We find a scene entirely similar but still better treated in the upper
division of another plaque (see Fig. 117).[241] Here we may see that
the chariots are progressing not without difficulty and even danger, in
the very bed of a torrent. The movement of the men who lead the
horses is well understood and skilfully rendered; we feel how
carefully they have to conduct their advance among the blocks of
stone that encumber the bed of the stream and the tumbling water
that conceals the nature of the ground. In the lower division we are
presented with one of those scenes that are so common in Assyrian
reliefs. The king in his royal robes appears on the left; a line of
prisoners guarded by archers approach him and beg for mercy, while
the foremost among them “kiss the dust beneath his feet,” to use an
oriental expression in its most literal sense.
Fig. 117.—Two fragments from the Balawat gates. British Museum. Drawn by
Saint-Elme Gautier.
We should have been willing, had it been possible, to make
further extracts from this curious series of reliefs; to have shown,
here naked prisoners defiling under the eyes of the conqueror, there
Assyrian archers shooting at the heaped-up heads of their slain
enemies. But we have perforce been content with giving, by a few
carefully chosen examples, a fair idea of the work that intervened
between the sculptors of Assurnazirpal and those of the Sargonids.
It is probable that the scheme of this vast composition was due to
a single mind; from one end to the other there is an obvious similarity
of thought and style. But several different hands must have been
employed upon its execution, which is far from being of equal merit
throughout. It is on examining the original that we are struck by these
inequalities. Thus, in some of the long rows of captives the handling
is timid and without meaning, while in others it has all the firmness
and decision of the best among the alabaster or limestone reliefs;
the muscular forms, the action of the calf and knee, are well
understood and frankly reproduced. The passages we have chosen
for illustration are among the best in this respect. Taking them all in
all these bronze reliefs are among the works that do most honour to
Assyrian art.
The only monument that has come down to us from the reign of
Vulush III., the successor of Samas-vul, is a statue, or rather a pair
of statues, of Nebo; the better of the two is reproduced in Fig. 15 of
our first volume. These sacred images are of very slight merit from
an art point of view; we should hardly have referred to them but for
their votive inscriptions. From these we learn that they were
consecrated in the Temple of Nebo by the prefect of Calah in order
to bespeak the protection of that god for the king. But the latter is not
named alone; the faithful subject says that he offers these idols “for
his master Vulush and his mistress Sammouramit.”
In this latter name it is difficult not to recognize the Semiramis of
the Greeks, and we are led to ask ourselves whether the queen of
Vulush may not have afforded a prototype for that legendary
princess. This association of a female name with that of the king is
almost without parallel either in Chaldæa or Assyria. In royal
documents, as well as in those of a more private character, there is
no more mention of the royal wives than if they did not exist. Only
one explanation can be given of the apparent anomaly, and that is
that Sammouramit, for reasons that may be easily guessed, enjoyed
a quite exceptional position. It was in those days that, from one reign
to another, the princes of Calah attempted to complete the
subjugation of Chaldæa. It may have happened that in order to put
an end to a state of never-ending rebellion, Vulush married the
heiress of some powerful and popular family of the lower country,
and, that he might be looked upon as the legitimate ruler of Babylon,
joined her name with his in the royal style and title. This hypothesis
finds some confirmation in what Herodotus tells us about Semiramis.
She was, he says, queen of Babylon five generations before Nitocris,
which would be about a century and a half. He adds that she caused
the quays of the Euphrates to be built.[242] This takes us back to
rather beyond the middle of the eighth century b.c., that is very near
to the date which Assyrian chronology would fix for the reign of
Vulush (810–781). As the last representative of the old national
dynasty, this Semiramis, associated as she was in the exercise, or at
least in the show, of sovereign power both in Assyria and Chaldæa,
would not be forgotten by her countrymen, and the population of
Babylon would be especially likely to magnify the part she had
played. There is nothing fabulous in the tradition as Herodotus gives
it, although it may, perhaps, go beyond the truth here and there.
Ctesias, however, goes much farther. He brings together and
amplifies tales which had already received many additions in the half
century that separated him from Herodotus, and he thus creates the
type of that Semiramis, the wife of Ninus and the conqueror of all
Asia, who so long held an undeserved place in ancient history.[243]
The last Calah prince who has left us anything is Tiglath-Pileser
II. (745–727). We have already described how his palace was
destroyed by Esarhaddon, who employed its materials for his own
purposes.[244] At the British Museum there are a few fragments
which have been recognized by their inscriptions as belonging to his
work (Vol. I. Fig. 26)[245]; they are quite similar to those of his
immediate predecessors.
With the new dynasty founded by Sargon at the end of the eighth
century taste changed fast enough. In those bas-reliefs in the
Khorsabad palace which represent that king’s campaigns, many
details are treated in a spirit very different from that of former days.
Trees, for instance, are no longer abstract signs standing for no one
kind of vegetation more than another; the sculptor begins to notice
their distinguishing features and to give their proper physiognomy to
the different countries overrun by the Assyrians. But these landscape
backgrounds are not to be found in all the bas-reliefs of Khorsabad.
[246]
The art of Sargon was an art of transition. While on the one hand
it endeavoured to open up new ground, on the other it travelled on
the old ways and followed many of the ancient errors; it had a
marked predilection for figures larger than nature, and bas-reliefs
treating of royal pageants and processions remind us by the
simplicity of their conception of those of Assurnazirpal. We have
already given many fragments (Vol I. Figs. 22–24, and 29), and now
we give another, a vizier and a eunuch standing before the king in
the characteristic attitude of respect (Fig. 118). The inscription which
cut the figures of Assurnazirpal so awkwardly in two has
disappeared; the proportions have gained in slenderness, and the
muscular development, though still strongly marked, has lost some
of its exaggeration. All this shows progress, and yet on the whole the
Louvre relief is less happy in its effect than the best of the Nimroud
sculptures in the British Museum. The execution is neither so firm
nor so frank; the relief is much higher and the modelling a little heavy
and bulbous in consequence. This result may also be caused to
some extent by the nature of the material, which is a softer alabaster
than was employed, so far as we know, in any other part of Assyria.
At Nimroud a fine limestone was chiefly used.
We shall be contented with mentioning the stele of Sargon, found
near Larnaca, in Cyprus, in 1845. It is most important as an historical
monument; it proves that, as a sequel to his Syrian conquests, the
terror of Sargon’s name was so widespread that even the inhabitants
of the islands thought it prudent to declare themselves his vassals,
and to set up his image as a sign of homage rendered and
allegiance sworn. But the stone is now too much broken to be of any
great interest as a work of art.[247]
The artistic masterpiece of this epoch is the bronze lion figured in
our Plate XI. It had been suggested that its use was to hold down the
cords of a tent or the lower edge of tapestries, a purpose for which
the weight of the bronze and the ring fixed in its back make it well
suited. This idea had to be abandoned, however, when a whole
series of similar figures marked with the name of Sennacherib was
found. Their execution was hardly equal to that of the lion we have
figured, but their general characteristics were the same, and they
had rings on their backs.[248]
These lions are sixteen in number; they form a series in which
the size of the animal becomes steadily smaller with each example;
the largest is a foot long, the smallest hardly more than an inch. The
decrease seems to follow a certain rule, but rust has affected them
too greatly for it to be easy to base any metrological calculation upon
their weight. But all doubt as to their use is removed by the
inscriptions in cuneiform and in ancient Aramaic characters with
which several of them are engraved. The Aramaic inscriptions all
begin with the word mine; then comes a figure indicating the number
of mines, or of subdivisions of the mine that the weight represents;
finally, there is the name of some personage, who may perhaps have
been a magistrate charged with the regulation and verification of
weights.
Fig. 118.—Bas-relief from Khorsabad. Height 9 feet 5
inches. Louvre.
With the accession of Sennacherib, a sensible change comes
over the aspect of the reliefs. What until now has been the exception
becomes the rule. On almost every slab we find a complex and
carefully treated landscape background. The artist is not satisfied
with indicating the differences between conifers, cypresses, and
pines (Vol. I. Figs, 41–43), palms (ib. Figs. 30 and 34; and above,

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Clinical Manual of Supportive

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Peter N. Novalis, M.D., Ph.D.

Peter N. Novalis, M.D., Ph.D.

Introduction to the First Edition . . . . . . . . . . . . . xix

Notes on Usage. . . . . . . . . . . . . . . . . . . . . . . . . . . xxi

3 Principles of Supportive Technique:

4 Principles of Supportive Technique:

5 Managing the Therapy . . . . . . . . . . . . . . . . . . . . 109

7 Mood Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . 183

8 Anxiety Disorders and Related Disorders . . . . 213

9 Co-occurring Disorders . . . . . . . . . . . . . . . . . . . 235

10 Personality Disorders. . . . . . . . . . . . . . . . . . . . . 251

11 Crisis Management and Suicidality. . . . . . . . . . 275

13 The Older Patient . . . . . . . . . . . . . . . . . . . . . . . . 319

14 Special Populations . . . . . . . . . . . . . . . . . . . . . . 333

16 Medication-Therapy Interactions and

17 Ethical and Cultural Awareness in

It has been a generation since the Clinical Manual of Supportive Psychotherapy

continue to proliferate (although some of the 400 have become moribund or

Peter N. Novalis, M.D., Ph.D.

Peter N. Novalis, M.D., Ph.D.

Rule Books and Clinical Manuals

It is helpful to define supportive therapy both by its collection of tech­

Table 1–1. Repertory of a typical supportive psychotherapist

How Effective Is Supportive Psychotherapy?

Can Supportive Psychotherapy Be Harmful?

Core Supportive Techniques

Supportive psychotherapy is a form of psychotherapy that uses techniques that

served to work—to achieve the following aims: 1) promote a supportive therapist­

Supportive Therapy Is Empirically Based and Patient

Goals of Supportive Psychotherapy

Table 1–2. Goals of supportive psychotherapy

Frequent goals Infrequent goals

Reducing behavioral dysfunctions Enhancing insight and self-understanding

In a patient-driven, symptom-focused, or empirical therapy, you must ad­

Evidence for Effectiveness

ever, including some with surprising or counterintuitive outcomes, have es­

It is the last statement, which argues for the effectiveness of supportive

clearly the ability of supportive psychotherapy to achieve one of the treatment

of these techniques (e.g., emotional catharsis, education) have direct applica­

fenses. A similar conception of supportive interventions, derived by Draper et

• Knight (1954) describes it as a “superficial psychotherapy” that utilizes in­

Fig. 111.—The Caillou Michaux, obverse. Drawn by Saint-Elme Gautier.

Assyrian sculpture is far from leading us into the remote centuries

Fig. 114.—Tree on a river bank;

Fig. 115.—Detail from the royal robe of Assurnazirpal; from Layard.

FROM THE BALAWAT GATES

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• Knight (1954) describes it as a “superficial psychotherapy” that utilizes in