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  • Writer's pictureDr. Maura Ferguson

Why 'supportive psychotherapy' isn't enough.

Should psychotherapy always feel comfortable? Best practices in therapy.

People who care about me tell me when spinach is in my teeth, even if it is uncomfortable or they think it may be embarrassing. I want to hear the painful and uncomfortable truths. It is a sign of closeness and caring to tell someone something they could benefit from knowing might be a moment. A therapeutic relationship can allow a person to know themselves better, including the emotional or mental versions of having spinach in their teeth that no one else has been able to help them see.

Ideally, individual or couple therapy has ways of challenging us around uncomfortable truths, although usually on a larger scale than having spinach in our teeth. The reasons that people reach out to start therapy are remarkably diverse. Some people feel that they generally feel good and functioning very well and then experience a specific event that throws them off balance. Still, many of the people seeking help with mental health are people with longstanding difficulties relating to other people, find themself repeating the same patterns and unable to free themself from falling into the same rut they have revisited over and over again. They struggle with their close relationships, their bosses, and their colleagues; they feel chronically lonely or misunderstood and feel that they swing between feeling depressed, numb, anxious, etc.

Many of us learn about therapy from watching films and television; those depictions vary but generally show a therapist listening, nodding, empathizing and validating a patient or client.

An empathic person who listens to a person and validates their feelings can have benefits, particularly for people who have never had the experience of genuinely being listened to and attuned to. However, a supportive approach to therapy only goes so far. It may not foster the growth and transformation that people seek, may lead to stagnation in treatment, or worse, can reinforce a person's existing maladaptive patterns.

Ideally, therapy involves more than just supportive or challenging interventions. Most of us appreciate that, at times, people who care about us may see things differently and help us to think through something rather than merely agreeing with everything we say. I always appreciate people telling me I have spinach in my teeth rather than hesitating to tell me something they think might make me momentarily uncomfortable.

Although agreement and sameness can be temporarily comfortable, they may not be accurate: they may represent a type of avoidance rather than engaging with someone and reflecting back to them something difficult that they may benefit from knowing. Seasoned and experienced therapists are skilled at helping people understand the patterns they repeat and their role in these patterns without blaming, attacking, or shaming the patient. 

Some more concrete examples include:

If a patient discloses that their family members are not speaking to them and that they binge on alcohol several nights per week - a therapist who colludes would agree with the patient that all their family members are jerks who are out to get them. A skilled clinician would work with this patient to help them understand their need to cope through their use of alcohol, facilitate their understanding of how their drinking affects their relationships and ability to manage their lives and help them find the appropriate resources to address any physiological dependence on substances while exploring appropriate and sustainable coping skills. This example is relatively straightforward, but there are also far more subtle issues present in therapy that can be colluded with or challenged. 

When a therapist colludes with a patient, they align themselves with the patient's perspective, avoiding confrontation or challenging their beliefs, behaviours, or patterns. The downsides of simply 'supportive' therapy can include:

  1. Stagnation: Without challenging the patient's conscious and unconscious assumptions or perspectives, therapy may remain stagnant, with little progress or change occurring over time.

  2. Reinforcement of Maladaptive Patterns: Collusion can reinforce maladaptive patterns by validating them rather than encouraging alternatives.

  3. Lack of Authenticity: Therapists who collude with patients may compromise their authenticity and professional integrity by avoiding necessary confrontations or discussions. Many patients pick up on this and become frustrated that they don't see changes in their lives despite investing a great deal of themselves in therapy and continuing to feel 'stuck.' Avoiding addressing important factors can undermine their well-being rather than improve mental health and erode trust in the therapeutic process.

Challenging the patient in an empathic way involves being curious about the patient's beliefs, behaviours, or patterns in a supportive and empathic manner. When therapy can adopt both a supportive and empathic challenge, patients generally feel that they are being genuinely engaged with and are learning things in their lives that other people either won't or don't know how to bring to their attention. 

The benefits of being challenged in therapy include:

  1. Growth: By challenging patients' perspectives or behaviours, therapists can help them explore new options for shifting their feelings, thoughts and behaviours.

  2. Increased Self-awareness: Empathic challenges can promote greater self-awareness by encouraging patients to reflect on their beliefs, emotions, and behaviours in a supportive and non-judgmental environment.

  3. Establishing Trust: When done empathically, challenging the patient can strengthen the therapeutic relationship and build trust, demonstrating the therapist's genuine concern for the patient's well-being and growth.

  4. Addressing Underlying Issues: Empathic challenges can help uncover and address underlying issues or conflicts contributing to the patient's distress or difficulties.

  5. Encouraging Autonomy and Interdependence: By challenging the patient's beliefs or behaviours, patients can begin to take ownership of their thoughts, emotions, and actions, promoting greater autonomy and the kind of interdependence and resilience that represent better mental wellness.

In summary, while collusion with a patient may provide temporary comfort or validation, it often leads to stagnation and reinforces maladaptive patterns. In contrast, empathically challenging the patient can facilitate growth, increase self-awareness, and strengthen the therapeutic relationship, ultimately promoting lasting change and well-being. Being challenged in therapy is not the path of least resistance. It is a challenging and demanding role for the therapist. It can evoke feelings of vulnerability in the person in treatment who is being challenged. The emotions evoked by this type of therapy may be uncomfortable at times. Ultimately, discussing and working through the reactions that arise is one of the most critical mechanisms of the treatment itself. 



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