Supportive Evidence: Brief Supportive Psychotherapy as Active Control and Clinical Intervention

“Supportive psychotherapy” is a hoary term with many definitions, most of them pejorative. The term originated as a description of the lesser therapy offered to patients who could not tolerate psychoanalysis: in effect, a “second-class” therapy for “second-class” patients (1). From a psychoanalytic vantage, supportive therapy encompasses any noninterpretative talking therapy, including cognitive-behavioral therapy (CBT) (2), interpersonal psychotherapy (IPT) (3), and some psychodynamic psychotherapies (4–7). Supportive therapy has been variously viewed as hand-holding, unqualified positive regard, and an attempt to strengthen organizing defenses. Although it has been characterized as the most common psychotherapy in everyday practice (8) (admittedly predating the dominance of CBT), what the term actually means in community treatment is vague.

Supportive psychotherapy has appeared in clinical research trials, again usually in a disadvantageous role. A longstanding conundrum in psychotherapy research is what constitutes an appropriate psychotherapy placebo (9, 10). None has been satisfactory; no true analogue to the pharmacological pill placebo exists, embodying both treatment credibility and inert ingredient. A waiting list as the control condition essentially disappoints the patient, who enrolls in treatment only to be told there will be no treatment, but to return for more symptom ratings months hence. Beating no treatment is easy: a waiting list may even be a “nocebo” (11).

One option frequently chosen as a less active comparator has been supportive psychotherapy. In comparative psychotherapy trials, even with independent evaluators blinded to treatment type assessing patients, the investigator’s favored treatment tends to have an advantage unless study design and researcher allegiance are carefully balanced. This has too rarely occurred (12). Supportive therapy, lacking the bells and whistles of more elaborate, manualized therapies, has often been used as an unmanualized, poorly characterized comparison condition. Researchers have too often employed the same therapists to conduct both their favored treatment and the supportive therapy comparison, claiming this design controls for “therapist factors,” while ignoring the glaring problem that therapists may be hired for superior skill in and allegiance to the researcher’s preferred treatment. One research group (13) candidly admitted, “All [study therapists] were CBT-oriented therapists, and this may have biased the treatment in favor of CBT, as the therapists were requested to use [supportive therapy] methods they judged as noneffective.”

Despite these handicaps, supportive therapy has generally fared well in trials, generating the feared “dead heat” outcome: the favored treatment benefits patients yet performs no better than does the ignoble control. Under the circumstances, we can conclude that this relatively unloved therapy has potency.

In the early 1990s, Dr. Michael Sacks and I, with input from Drs. Allen Frances and Lawrence Jacobsberg, manualized a nondirective, affect-focused, common-factors brief supportive psychotherapy (BSP) as a comparison condition in a randomized controlled trial (RCT) for treatment of depression among HIV-positive patients at Cornell University Medical College (14). Unwilling to offer pill placebo to patients with depression and a then deeply stigmatizing, lethal, and essentially untreatable medical illness, we sought to provide a relatively constrained, affect-focused control condition for comparison with IPT and pharmacotherapy for depression. BSP has since been studied in other RCTs.

BSP (15) is time limited. Patients set the agenda. Therapists pursue affect, encouraging patients to recognize and tolerate feelings, particularly negative affects such as anger, disappointment, and anxiety. Unlike IPT (3), BSP includes no overt attempt to encourage the patient to explore options for expressing that affect to change relationships. Rather, it is anticipated that the patient, once comfortable with the feelings, may spontaneously express them. Relatively unstructured, without homework or exposure exercises, BSP facilitates psychotherapy common factors inherent in all effective therapies, such as encouraging affective arousal, helping patients feel understood, and offering optimism for improvement (15, 16).

Methods

All BSP studies were included in the current review. As part of a team that received many requests for the BSP manual over years, I had some connection to all these studies; the manual was provided only for studies whose investigators showed willingness to treat BSP as a serious comparator. In undertaking this review, I knew the results would be generally positive and anticipated finding large effect sizes for pre- to posttreatment BSP symptom change. In accordance with Cohen (17), a small effect size was defined as d=0.2, medium as d=0.5, and a large effect size as d=0.8.

Results

Nine studies have used BSP as a time-limited comparator; eight of them (14, 18–24) have been published (Table 1).

BSP for HIV-Positive Patients With Depression

Markowitz et al. (14) developed BSP for a National Institute of Mental Health (NIMH)–funded RCT comparing 16 weeks of IPT, CBT, imipramine plus BSP, and BSP alone for 101 patients with HIV and with depression diagnosed according to DSM-III criteria. HIV was then a lethal, stigmatizing, sexually and intravenously transmitted infection decimating gay and substance-using communities. Detectable by blood test but lacking effective treatment, HIV devastated the immune system, killing many young adults. Infected individuals developed previously rare cancers, such as Kaposi’s sarcoma, opportunistic infections like pneumocystis pneumonia, and a cadaverous wasting syndrome. So frightening was the epidemic that many thought its victims should have depression: who would want to sicken and die young, disfigured by a stigmatizing illness?

Study patients were young (mean±SD=37±7 years); most were male (85%), gay or bisexual (80%) in a highly sexually stigmatized era, and White (58%). Eighty-four percent had known of their HIV-positive status for ≥1 year, 71% for >2 years. Mean CD4 count was 280±222 cells/mm³ (normal range 500–1,200 cells/mm³), indicating immunosuppression. Although most patients did not have acute medical illness at presentation, some needed medical hospitalization and several died during the 16-week study.

Participants in all four treatment groups improved (Table 2) on the primary outcome measure, the 24-item Hamilton Depression Rating Scale (HAM-D) (25); score ranges are 0–7, euthymic; 8–12, mildly depressed; 13–19, moderately depressed; ≥20, severely depressed. BSP, delivered by one of two experienced psychiatric social workers at the Cornell Payne Whitney Clinic, lowered HAM-D scores from 21.3 (severe) to 15.5 (moderate) over 16 weeks. This was a meaningful change for chronically stressed patients facing illness and premature death. Overall, BSP alone was less efficacious than IPT, which focuses on life adversity (which patients surely had) in relationship to depression, or imipramine, which patients received combined with BSP. It was, however, equipotent with CBT delivered by psychologists supervised by a Beck Institute–credentialed expert (14). In this baptism by fire, BSP had a creditable outcome (d=0.78). The investigators, therapists, and many of the patients were impressed.

BSP for “Pure” Dysthymic Disorder

Chronic depression is less treatment-responsive than acute depression. We adapted BSP slightly for a 16-week RCT treating 96 patients who met DSM-IV criteria for “pure” dysthymia (i.e., patients with dysthymia who had not met major depression criteria within the past 6 months). This NIMH-funded study (18) compared IPT, BSP, sertraline, and sertraline plus IPT, with BSP again the underdog. Dr. Sacks again supervised experienced therapists who had conducted at least two pilot cases.

All treatments helped patients, with large effect sizes (d>1.00) observed. Pharmacotherapy had the greatest benefit (Table 3). Response rates, defined as ≥50% reduction from baseline HAM-D score, were 58% for sertraline, 57% for combined IPT-sertraline, 35% for IPT, and 31% for BSP. In this study, pharmacotherapy clearly outperformed psychotherapy, but BSP fared as well as better-proven IPT, yielding considerable antidepressant improvement over 16 weeks.

BSP Versus IPT for Chronic Depression With Secondary Alcohol Abuse

A parallel pilot RCT compared 16 weekly sessions of BSP (N=12) with IPT (N=14) for patients with dysthymia and co-occurring alcohol abuse disorder. More than half of the patients met DSM-IV Axis II personality disorder criteria. We hypothesized that this underpowered trial would have larger effect sizes for IPT in ameliorating both depression and alcohol use. In fact, IPT had a large effect size for depression (d=1.15) and BSP had a moderate one (d=0.77); for percentage of days alcohol abstinent, BSP had a moderate (d=0.54) and IPT a small (d=0.21) effect size (19). HAM-D scores fell from 22.9±5.8 to 16.4±5.8 in the BSP group and from 19.9±5.1 to 13.3±6.3 in the IPT group, both significant within-group improvements. Most patients stopped drinking. In another dead heat, both treatments showed similar benefits.

REVAMP Study: BSP Versus Cognitive Behavioral Analysis System of Psychotherapy (CBASP) for Augmenting Antidepressant Nonresponse in Chronic Depression

An eight-site clinical research consortium conducted an NIMH-funded prospective RCT of patients who met DSM-IV criteria for treatment-resistant chronic depression. Patients participated in an open-label, 12-week aggressive antidepressant medication trial that followed a medication treatment algorithm. Patients not remitting (HAM-D improvement ≤60% and score >8) were randomly assigned to a second 12 weeks of sequential pharmacotherapy alone, to pharmacotherapy plus CBASP (26)—a therapy reputedly specific to chronic depression—or to pharmacotherapy plus BSP (20). Because this study followed a previous CBASP and pharmacotherapy trial (27), CBASP therapists were seasoned and CBASP-allegiant. BSP therapists were chosen as a seeming afterthought, with some therapists previously trained only in, and allegiant to, CBT (28). Unused to affect-focused therapy, they may well have felt initially disappointed by their assignment.

Of 808 patients with chronic depression entering the medication-only phase, 491 who met criteria for nonresponse or partial response were randomly assigned to the three treatment arms. Investigators hoped that psychotherapy would augment the medication algorithm for these patients with difficult-to-treat diagnoses. Results of this ambitious trial were disappointing. In the second phase, mean HAM-D scores fell for first-round nonresponders, from 25.9 to 17.7, and for partial responders, from 15.2 to 9.9. The three treatment arms showed no statistically significant differences on any measure, not differing whatsoever in rates of remission (15%), partial response (23%), nonresponse (63%), or HAM-D change (20). Thus, for patients with highly chronic, treatment-resistant depression, another round of medication alone had limited benefit, and adding adjunctive CBASP or BSP to the medication regimen provided no further benefit. BSP did no worse than CBASP, the favored treatment delivered by more experienced psychotherapists.

One interesting outcome was that some previously hardcore CBT therapists assigned to BSP found it a novel, broadening clinical training experience and reported that they would incorporate BSP into their practices (29). BSP attuned them to the importance of affect (30) and patient autonomy. Therapists further reported that many patients in the BSP group savored the opportunity to talk about their feelings and to feel listened to in a previously unprecedented fashion.

Supportive Psychotherapy Versus CBASP for Chronic Depression

In another large, multisite RCT, Schramm and colleagues (21), at multiple German centers, randomly assigned 268 patients to CBASP (N=137) or to supportive psychotherapy (N=131) that was based on the BSP manual as sole treatments for chronic depression. Patients received 20 weekly treatment sessions, followed by eight monthly booster sessions. Chronic depression is usually an indication for combining psychotherapy and medication (18, 31), so this treatment approach was atypical.

HAM-D scores fell for both treatment groups from severely to moderately depressed ranges: scores in the CBASP group were 27.2±5.5 at baseline, 17.2±10.0 at week 20, and 14.0±9.7 at week 48; scores in the supportive therapy group were 27.1±5.7, 20.4±9.7, and 16.5±9.6, respectively. Between-treatment differences on the HAM-D, although small (indeed, nearing the assay sensitivity level of the HAM-D) (25), slightly but consistently favored CBASP, with statistically significant differences at 20 weeks (p=0.03) and 48 weeks (p=0.01) in this large trial. Patients were, however, more likely to meet response criteria of ≥50% HAM-D improvement (39% versus 24%) and remission (22% versus 13%) with CBASP than with supportive therapy (21). Supportive therapy, with a large effect size (d=0.84), finished a reasonably close second in this trial of difficult-to-treat, unmedicated chronic depression.

BSP Versus IPT for Infertility-Related Depression

Koszycki and colleagues (22), in Ottawa, conducted a novel pilot RCT for women struggling with infertility, a personal and interpersonal stressor often associated with depression. Women with infertility difficulties who met DSM-IV criteria for at least moderate major depression were randomly assigned to 12 weekly sessions of BSP (N=16) or IPT (N=15). Most of the women had experienced depression for a year prior to study entry. Both therapies were associated with large effect sizes (d>0.90) for improvement, with no difference on the Montgomery-Åsberg Depression Rating Scale (MADRS) (32), although response rates (MADRS improvement ≥50%) favored IPT, 80% versus 63%. Improvement persisted at the 6-month follow-up for both treatments.

BSP Versus IPT for Mothers With Depression

Swartz and colleagues (23), in Pittsburgh, conducted a fascinating RCT of mothers with depression whose children were receiving treatment for psychological distress. Children of mothers with depression rarely improve unless their mothers receive effective treatment. This NIMH-funded study randomly assigned mothers with depression who had children (ages 7–18) with internalizing disorders to nine sessions of BSP (N=83) or IPT (N=85). Patients in both conditions improved (along with their children), with no between-group differences, large effect sizes (d=2.0 for BSP), and no statistically significant between-group difference, although the comparison actually slightly favored BSP (H. Swartz, personal communication, Sept. 2, 2021) (Table 1). Children of BSP-treated mothers required more outpatient visits and were more likely to receive antidepressant medication than children whose mothers received IPT. For both treatments, children’s symptom improvement temporally trailed maternal improvement (23). The results of this trial can be considered another dead heat, with BSP performing credibly, helping two generations of patients.

BSP Versus IPT for Depression With Panic Spectrum Symptoms

Cyranowski and colleagues, in Pittsburgh, adapted IPT for major depression with comorbid panic spectrum symptoms (IPT-PS), adding CBT features to the IPT approach. Comorbid anxiety symptoms diminish antidepressant intervention response (33). Building on a successful IPT-PS open-label trial (34), this NIMH-funded pilot RCT compared BSP with IPT-PS. Twenty-six patients were assigned to BSP, 24 to IPT-PS (J. Cyranowski, personal communication, July 2021). Patients in both treatments achieved meaningful improvement, with no between-treatment differences. The study results remain unpublished. This trial provides another example of a BSP dead dead-heat that effectively killed further development for the competing, potentially promising treatment.

BSP Versus IPT for Social Anxiety Disorder

BSP has been studied principally, but not exclusively, for treating depression. In an ongoing RCT (NIMH R-01-MH-123691), Dr. Robin Aupperle and colleagues in Tulsa are comparing BSP with behavioral activation and exposure therapy for patients who report both anxiety and depressive symptoms. Previously, Lipsitz and colleagues (24) compared 14 weeks of BSP (N=34) with IPT (N=36) for patients with social anxiety disorder. The same therapists conducted both therapies, a situation (12) that may have contaminated the treatment techniques (35). Both conditions showed similar improvement, with Liebowitz Social Anxiety Scale (LSAS) (36) scores decreasing from 64.5 to 49.8 in the BSP group and from 67.7 to 46.9 in the IPT group. LSAS scores range from 0 to 144, with higher scores indicating greater social anxiety. A total score of 0–29 indicates minimal social anxiety; 30–49, mild; 50–64, moderate; 65–79, marked; and ≥80, severe social anxiety.

In summary, this supposed “second-class” treatment, compared with “first-class” treatments, has not come off as second rate. In the nine studies, BSP generally equaled the favored treatments despite presumed researcher allegiance (12). Compared with IPT, BSP was less efficacious once (for HIV-comorbid depression) and had comparable results six times, although the two affect-focused treatments are clearly distinguishable (37). Versus CBASP, BSP was less effective once and comparable once. In a single trial, it equaled CBT. In nearly every trial with available data, BSP produced large improvement effect sizes (d=0.77–1.01 for depression; d=0.62 for social anxiety).

Discussion

BSP is an active treatment. It has never had the luxury of an open trial, nor comparison to a waiting list or other weak comparator, which might have yielded dramatic effect sizes. Still, its pre- to posttreatment effect sizes have been large. Targeted disorders have included chronic depression, which has low placebo response and relatively low response rates to active treatments. Thus, BSP has always faced strong, proven competition, treating difficult disorders, yet generally has held its own. BSP has been champion of the dead heat noninferior outcome.

BSP did not show advantages over fancier or more targeted therapies, but it generally matched them. This review was limited in that it included only nine trials, four of which were underpowered pilot studies. Nonetheless, BSP never performed poorly, despite treating difficult, chronic conditions against tough competitors. This outcome concords with the general psychotherapy research assertion that psychotherapy common factors, the use of which BSP exemplifies, account for at least half of treatment outcome, making it difficult to show differences between well-conducted active psychotherapies (38).

BSP is not the only research-tested supportive psychotherapy. In what constitutes perhaps the first real psychotherapy study (in the 1950s), the prediagnostic Menninger Project compared psychoanalysis, expressive psychoanalytic psychotherapy, and supportive psychoanalytic psychotherapy in the treatment of 42 patients. Results indicated the potency of the least favored supportive psychotherapy approach and the difficulty in separating it from expressive psychotherapy (39). Wallerstein (39) concluded, “The supportive aspects of all psychotherapy . . . must be specified more respectfully in all its forms than it has been in the psychodynamic literature.”

The largest (N=134) psychotherapy RCT for patients with comorbid major depression and breast cancer (40) compared 12 sessions of cognitive-behavioral problem-solving therapy, IPT, and a time-limited supportive psychotherapy. Supportive therapy was defined as “an active treatment that uses techniques such as clarification, suggestions, praise, reassurance, normalization, and rehearsal and anticipation to promote a supportive patient-therapist relationship, enhance the patient’s strengths and ability to use environmental supports, reduce distress and behavioral dysfunction, and maximize autonomy” (40). This approach was derived from the supportive psychotherapies of Pinsker (5) and Novalis et al. (7), not the BSP manual. Supportive therapy was the presumed control condition for two more active interventions. In fact, HAM-D scores fell from 19 to 12 across treatments—another dead heat (40).

Similarly, a year-long RCT comparing Kernberg’s transference-focused psychodynamic psychotherapy, dialectical behavioral therapy (DBT), and dynamic supportive psychotherapy based on the approach of Rockland (4) for 90 patients with borderline personality disorder found that all treatments equally improved depression, anxiety, global functioning, and social adjustment (41). In secondary analyses, supportive therapy was less likely than the competitors to reduce suicidality but was more likely than DBT to improve anger symptoms. Transference-focused therapy and supportive therapy both reduced impulsivity (41)—yet another dead heat, wherein supportive therapy matched brand-name psychotherapies.

Rosenthal and colleagues (42) looked at pilot findings using an unspecified (perhaps Pinsker’s) supportive psychotherapy, finding interpersonal improvement among the 60% of the 20 patients with cluster C personality disorder who completed the 40-session treatment. Luborsky (6) wrote the first manual of supportive and expressive psychotherapy, which has since been tested in several trials, with sometimes promising outcomes (43).

It is unclear how BSP compares to these other supportive therapies in efficacy. The current review ignored numerous sham studies that offered “supportive therapy” as a loose, nonmanualized control condition for favored psychotherapies or in which the therapists skilled in the favored therapy—which they daily practiced and believed in—also conducted the afterthought “supportive therapy” control condition (12).

In a meta-analysis of 31 studies, including some BSP trials, Cuijpers and colleagues (44) found that various forms of “nondirective supportive therapy” effectively treated depression among adults, with no differences relative to other psychotherapies when the analysis was controlled for researcher allegiance. The meta-analysis (44) concluded that nondirective supportive therapy “has a considerable effect on symptoms of depression.”

This finding returns us to the longstanding research question of what constitutes an appropriate psychotherapy control. Some have been too weak: waiting lists are inadequate and perhaps unethical for diagnoses having effective treatments. “Treatment as usual” is highly variable and not replicable. By contrast, a treatment as active as BSP is a killer control, knocking out budding therapies of potential promise. Unfortunately, dead-heat trials derail further exploration of potentially valuable therapies. As funding for psychotherapy research has always been scarce, even in more generous times (45), any experimental treatment that cannot beat the control condition loses funding. One negative trial means game over. Thus, BSP ended IPT as a treatment for dysthymia and for depression-panic spectrum and, for a time, CBASP.

Hence, it may be premature to use BSP as a comparative condition in phase II psychotherapy treatment development (i.e., for therapies that are just beginning to be evaluated). Rather, BSP should be reserved as an active comparator to more rigorously tested therapies that have already shown promise against weaker competition. Exactly what that weaker competition should be remains an unsolved question.

So BSP works. Focusing on stripped-down psychotherapy common factors makes BSP a powerful comparator, daring investigators to demonstrate that their treatments can exceed those common factors. Studies suggest a 10%–15% advantage for specialized therapies in specialized circumstances, but at least 50% of psychotherapy outcome derives from common factors (38).

Beyond the science, why does BSP matter? It defines a skillful, elemental psychotherapeutic approach. Therapists we have trained (24, 46), and many patients they have treated, begin unsure of what they are encountering. By the end, they are generally impressed. BSP, its manual finally published (15), may have a role in clinical practice, providing therapists with an organized, controlled template for evoking emotion and honing their affect focus both in supportive and other forms of psychotherapy.

Conclusions

BSP may have been maligned by the weak reputation of supportive psychotherapy. In fact, this manualized treatment has proven, under duress, a potent time-limited common factors psychotherapy for depression and possibly for anxiety disorders. In research settings, it should be considered not a psychotherapy placebo control condition but a vigorous comparator. For training and clinical purposes, the BSP therapeutic approach helpfully defines and demonstrates the elements and potency of a common-factors treatment.