The choice between supportive and insight psychotherapy

For more than a decade I’ve taught a seminar in dynamic psychotherapy to psychiatry residents. One tricky issue that arises every year is the apparent choice between conducting a “supportive” psychotherapy, versus an “analytic” or “insight-oriented” one. I developed a sailing analogy to clarify this issue, and to teach an important point about it.

Most patients appreciate emotionally comforting support. Many seek a therapist who will provide a listening ear, who won’t judge them negatively, who will encourage them and praise their successes, and who will offer solace and kind words in the face of setbacks. However, many critics charge that such support requires no special training — other than learning to listen, no small feat perhaps — and can be offered by teachers, relatives, clergy, counselors, and many others. Supportive therapy is sometimes derided as “buying a friend.”  Indeed, friends often offer support of this type.

Dynamic psychotherapy, originally derived from Freudian psychoanalysis, strives for something else. Freudian analysts are stereotyped as cold, painstakingly “neutral,” and anything but supportive. While this caricature exaggerates reality, it nicely illustrates the contrast between “support” and “insight.” In this type of therapy the patient is left to grapple with his or her own thoughts and feelings. These are brought into the light of consciousness by the therapist, but not softened or eased by emotional support. The aim of such therapy is not to help the patient feel better in the moment, but to lead to deep self-knowledge and the ability to accept one’s own feelings as they are. Critics sometimes claim that such therapy doesn’t really help or that it’s unnecessarily harsh, but no one calls it “buying a friend.” It isn’t all that friendly.

Psychiatry trainees learning about psychotherapy are usually told to aim for as much “insight-oriented therapy” as the patient can tolerate, and as much “supportive therapy” as the patient needs. In other words, insight is really the goal, but if a patient can’t tolerate the process to get there, add support as needed. Even presented this way, trainees often cubbyhole patients into “support cases” and “insight cases,” as though these are permanent categories, like blood type.

My sailing analogy aims to break down this sharp (and artificial) categorization. The aims of insight and support are fluid, and change moment by moment within a given therapy.

If you’ve ever been sailing — or windsurfing, which was my original version of this comparison — you appreciate the trade-off between stability and forward motion. Let the sail billow loosely and the boat floats quietly in the water. It is very stable but it doesn’t go anywhere. Tighten the sail to catch the wind, and the boat starts to move. However, in doing so it also leans over. It feels less stable, and in extreme cases threatens to capsize. Although I’m not much of a sailor, and even less of a windsurfer, I was struck by the kinesthetic reality of this moment-to-moment trade-off. At every moment, one chooses how tightly to trim the sail, and thus how much stability to trade away for forward progress.

In dynamic therapy, the therapist chooses how much anxiety to allow (or invoke). Minimize anxiety by avoiding painful topics and providing ample emotional support, and the boat of therapy sits stable but motionless in the water. The therapy is comfortable but does not go anywhere. Introduce some anxiety by gently confronting the patient, or simply by not offering as much support, and the boat of therapy starts to move. However, it also becomes less stable, and in extreme cases may threaten to capsize. The job of the therapist, the sailor in this scenario, is to adjust the sail at every moment, such that anxiety and stability are in balance: Enough stability that the patient can trust the process, enough anxiety to propel the therapy forward.

The sailing analogy can be extended by noting that some boats are inherently more stable.  They can withstand more sail pressure and go faster, while others are more easily capsized and need to be sailed more carefully. Likewise, some patients are more resilient, some more fragile. Also, external stressors in a patient’s life are like a strong gusty wind blowing over the water. In such conditions a boat will move ahead even if the sail is loose. Tightening the sail in such conditions is more apt to upset the boat.  This parallels therapy in the face of severe external stressors or trauma, when a lighter, more supportive touch is needed.  Conversely, in calm conditions a boat can be sailed more aggressively. Likewise, a person notdealing with severe current stressors can bear more anxiety imposed by the therapy itself, which may allow more fundamental change to occur.

The main point is that patients don’t come stamped with “support” or “insight” on their foreheads. Everyone is on a continuum between the two and benefits by both. Moreover, everyone moves along this continuum on a moment-by-moment basis, the result of a complex interplay of defenses, the topics being discussed, and the relationship between the two parties. A sensitive therapist recognizes this and tailors the therapy accordingly.

Steven Reidbord is a psychiatrist who blogs at Reidbord’s Reflections.

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