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Ethical Boundaries in Balancing the Power Dynamic in the Therapeutic Relationship
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Section 21
Supportive Techniques

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Several factors help differentiate the highly expressive therapies, which we will divide into psychoanalytically oriented expressive psychotherapy or psychoanalysis, as opposed to the purely supportive, middle-of-the-road,supportive-expressive psychotherapy.

Ethics - Psychoanalysis and Psychoanalytically Oriented Expressive Therapy
Psychoanalysis is not the most frequently indicated modality of treatment in working with adult survivors of physical, sexual, or emotional abuse in childhood. However, the clinician trained and skilled in the psychoanalytic field may identify patients with a history compatible with trauma who could benefit from an analytic approach. At times, this particular patient population presents an atypical manifestation of the trauma in combination with other psychological conflicts that may be related to the trauma itself but have been internalized, disguised to such a degree that only a highly expressive therapeutic process can facilitate their uncovering. In fact, as we have pointed out, Freud’s initial thinking about the origin of the neurotic conflict was embedded in a theory of trauma during the childhood.

Panic Episodes
Ms. B. came to the office seeking help for panic episodes that were increasing, which several other therapists had unsuccessfully tried to help her control. She was a bright, educated, young college graduate who experienced episodes of depression but who had always been able to meet the responsibilities of her job. Her internal turmoil grew worse in spite of supportive therapy and medication prescribed by other therapists and reached a climax when she suddenly became suicidal. Following a brief hospitalization and upon completion of a battery of projective psychological testing, a past traumatic event was suspected. On further exploration in individual therapy, she was able painfully and slowly to recover early memories of sexual abuse she suffered from her father. She was repeatedly sexually molested and fondled from age 3 to age 5 as recalled in her expressive therapy.

Ms. B. has been in supportive-expressive psychoanalytically oriented psychotherapy with a frequency of two to three times per week. She is also considered a candidate for psychoanalysis, as she has shown an increased interest in pursuing her therapy on a more intense and frequent basis. Not only is she interested in symptom relief, but she wishes to have a more in-depth understanding of the impact of the trauma on her overall psychological functioning and to improve the quality of her life. Her psychological curiosity constitutes a desirable rationale for psychoanalytic treatment that goes beyond the working-through of the trauma.

Neutral analyst
Merton Gill defines psychoanalysis as “that technique which, employed by a neutral analyst, results in the development of the regressive transference neurosis and the ultimate resolution of this neurosis by techniques of interpretation alone.”

The aspects of the analyst’s neutrality, the intensive use of the transference, and the use of interpretation are clearly the most important ingredients of a psychoanalytic process. Ticho, in “Differences between Psychoanalysis and Psychotherapy,” identifies other aspects pertinent to our patients not included in Gill’s definition:

1. “The goal of psychoanalysis is to obtain a thorough personality change in the patient”; the “overall goal of psychotherapy is the resolution of symptoms and the attainment of some degree of behavioral change.”

2. Countertransference (in analysis) “is much easier to control because of the neutrality and relative inactivity of the analyst.”

3. “The fact that the analyst does not gratify infantile longings . . . but instead interprets them . . . is by necessity experienced by the patient as frustration.”

4. Psychoanalysis “cannot be limited ahead of time. Psychotherapy may be limited for a variety of reasons.”

5. The area of investigation “of psychotherapy is limited while in psychoanalysis . . . is unlimited”.

Psychoanalytically oriented therapy and psychoanalysis have specific indications for the treatment of trauma victims, provided that the patient is not in the acute phase of the trauma where other interventions could, perhaps, be more effective.

Ethics - The Supportive Psychotherapies
As we have discussed, there is a continuum from psychoanalysis, the most highly expressive therapy, at one extreme, to the supportive (whether brief, focused or long-term) psychotherapy at the other end of the psychodynamic spectrum.

Freud was the first to use a supportive (and brief) approach. As early as 1906, Freud successfully treated the right-arm paralysis of the conductor Bruno Walter in six sessions, using a combination of direct advice, suggestion, and ego support.

What does supportive therapy support? Many trauma victims can make very good use of a variety of supportive measures. Various mental structures need support at different points during treatment. These may include ego support to encourage the patient’s executive function, id support to encourage the therapeutic use of the patient’s dormant assertive-aggressive capacity, or superego support to facilitate control and regulation of impulses and self-esteem. The therapist should be aware of what aspect of the mental structure is being supported or is in need of supportive interventions in order not to lose sight of the therapeutic goals when using this approach.

A variety of technical interventions are currently used in supportive and supportive-expressive psychotherapies, such as clarification and confrontation, which are insight-producing approaches. Non-insight-producing interventions include suggestion, advice, direct recommendations, persuasion, reassurance, educational or instructional intervention, and encouraging or prohibiting specific types of behaviors. In general, these non-insight­producing interventions are avoided in the more expressive modalities of therapy.

Whether the chosen treatment modality is supportive or expressive, short- or long-term, and whether the patient is psychologically minded or not, there are therapeutic barriers to be dealt with and crossed for the therapeutic process to move forward. Very frequently these barriers are present at the outset. Usually, they are related to the mistrust generated by the internalized past and the poor quality of object relationships, which continues to exercise control over the patient’s feelings and behavior. The patient/therapist relationship is a caldron where the vicissitudes of the patient’s past object relationships are played out. Fears of rejection or of being taken advantage of, fears of exploitation and renewed victimization are in the forefront of the beginning of any therapeutic process.

There are always two types of patient/therapist relationships. The real, uninterpreted relationship, which is like any other relationship, and the transferential relationship, which is dominated by fantasies and expectations on the part of the patient and usually evolves into the so-called transference neurosis. The latter may become a therapeutic barrier when it results in a transference resistance. With either type, in working with trauma victims, there will always be a need on the part of the patient to discharge built-up anger and rage generated by the insult to his or her self-integrity and the self-fragmentation that usually follow such a severe injury.

Techniques used to facilitate the discharge of emotions include (1) exploring feelings in connection with the trauma; (2) helping the patient to identify specific feelings connected with the abuse and to attach the emotion to a specific situation; (3) helping the patient abreact or discharge the feeling; (4) encouraging the patient to verbalize the affective reaction, which leads to a working-through of the traumatic experience and a resolution of the symptoms that brought the patient to therapy. In other words, the ego is no longer being attacked from inside, obviating the need for defensive operation and leading to a decrease in symptoms and behavioral problems. Whether a supportive approach works better than an expressive approach will be determined only by the patient’s character and capacity to work in therapy and by the therapist’s ability to uncover all the factors about the evaluation process. Either way, the goal is the same, that is, a resolution of the trauma, an increase in the patient’s level of functioning, and an overall improvement in the patient’s quality of life.
Christiane Brems

Brems, C. PhD. (2000). "Dealing with Challenges in Psychotherapy and Counseling." Brooks and Cloe, New York.

Peer-Reviewed Journal Article References:
Ahn, L. H., & Kivlighan, D. M., Jr. (2021). Working alliance, therapist expressive skills, and client outcome in psychodynamic therapy. Journal of Counseling Psychology. Advance online publication.

Hill, C. E., Lu, Y., Gerstenblith, J. A., Kline, K. V., Wang, R. J., & Zhu, X. (2020). Facilitating client collaboration and insight through interpretations and probes for insight in psychodynamic psychotherapy: A case study of one client with three successive therapists. Psychotherapy, 57(2), 263–272.

Leibovich, L., Front, O., McCarthy, K. S., & Zilcha-Mano, S. (2020). How do supportive techniques bring about therapeutic change: The role of therapeutic alliance as a potential mediator. Psychotherapy57(2), 151–159.

Leibovich, L., Nof, A., Auerbach-Barber, S., & Zilcha-Mano, S. (2018). A practical clinical suggestion for strengthening the alliance based on a supportive–expressive framework. Psychotherapy55(3), 231–240.

Zlotnick, E., Strauss, A. Y., Ellis, P., Abargil, M., Tishby, O., & Huppert, J. D. (2020). Reevaluating ruptures and repairs in alliance: Between- and within-session processes in cognitive–behavioral therapy and short-term psychodynamic psychotherapy. Journal of Consulting and Clinical Psychology, 88(9), 859–869. 

What two types of therapist-patient relationships need to be balanced regarding supportive versus excessive therapeutic relationships? To select and enter your answer go to Ethics CE Test.

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