A recent article published in the journal Global Psychiatry advocates for “back to basics” psychotherapy that prioritizes emotional expression. Against the potential of “exposure” based therapies such as CBT to become too intellectual, technically heavy and emotionally drained, psychiatrist John Markowitz explores the clinical effectiveness and importance of supportive psychotherapy brief.
“People get carried away with the bells and whistles, but sometimes it’s the basics that count. Psychotherapists, like their patients, are uncomfortable with strong emotions and may avoid them. Yet focusing on the strong emotions is at the heart of psychotherapy, and that’s what good therapy, and especially good supportive psychotherapy, should do,” says Markowitz.
Despite the growing influence of cognitive behavioral therapies (CBT), some practitioners still believe in the therapeutic efficacy of person-centered or humanistic approaches, even criticizing CBT’s status as the “gold standard”.
Person-centered or humanistic forms of therapy tend to emphasize the client’s autonomy and dignity, the therapeutic relationship, emotional expression, and validation, essentially acting as a benevolent guide for the client’s self-exploration.
This article, by psychiatrist John Markowitz, argues for a return to these core therapeutic values and practices. Markowitz reviews the evidence for the effectiveness of Brief Supportive Psychotherapy (BSP) and states that more “heavy technique” approaches such as CBT can drain the emotion from therapy.
According to Markowitz, out of nine randomized controlled therapeutic trials that have been done over the years, seven have found that “BSP worked as well as the preferred treatments,” despite being a mostly used “underdog comparison condition.” to evaluate other approaches. These trials examined the therapeutic effectiveness of mood and anxiety disorders, including depression.
The two studies where BSP did not perform as well as the preferred treatments were always a “credible, almost missed second.” Accordingly, Markowitz argues that BSP should be included in treatment guidelines for depression.
Explaining the principles of BSP, Markowitz states that it is grounded in the search for common factors and shares similarities with other forms of “supportive” psychotherapy, such as person-centered and humanistic therapies, which were at once the most common form of therapy. Carl Rogers and Jerome Frank are considered important figures in this line.
Research on common factors suggests that five different “essential” elements tend to explain the success of therapy:
- Affective/emotional awakening
- Feel understood by the therapist and develop a therapeutic alliance
- Provide a framework of understanding, as well as a therapeutic ritual
- Be optimistic about improvement
- Encourage experiences of “success”
In particular, Markowitz believes that psychotherapy should return to the meaning of emotion. He advocates for the importance of therapies that focus on emotional regulation and expression.
In terms of therapeutic technique, this approach is simple but profound and more difficult to practice than to understand. It involves active listening, normalizing and validating difficult emotions such as anger, and encouraging emotional expression. The therapeutic goal is to help individuals become more comfortable with and tolerate strong emotions.
The underlying belief is that it can improve quality of life and reverse tendencies that can exacerbate things like depression – for example, people with anxiety and depression “frequently avoid interpersonal confrontations, have trouble assert their wishes and find it hard to say no”.
Through normalizing and encouraging emotional expression in therapy, individuals can become more comfortable expressing and asserting themselves.
“Affect”-based approaches such as BSP can be contrasted with “exposure”-based approaches such as CBT, which Markowitz says can sometimes be problematic:
“A danger with more fanciful, technique-heavy psychotherapies is that they can become mechanical, intellectualized, affect-drained exercises. One of the reasons for the rise of so-called ‘third wave’ cognitive behavioral therapies has was the recognition of the weakening of affect by exposure-based treatments.”
“There are other affect-focused treatments, including interpersonal psychotherapy, well-conducted psychodynamic psychotherapies, and mentalizing-based therapies. The BSP is the refined core of these approaches. It lacks and needs no bells and whistles. It just sticks to feelings.
By letting the patient lead and focusing on their emotions, they maximize patient autonomy. The therapist assigns no duties and applies no structure beyond affective focus. A transportable, disseminating, low-cost, affect-focused intervention deserves a second look.
Markowitz, JC (2022). In support of supportive psychotherapy. World Psychiatry, 21(1), 59-60. (Link)