Supportive vs. Expressive Therapy Approaches

Therapy approaches and techniques tend to be on a supportive/expressive continuum.

What this means is that sometimes a therapist focuses on helping a client gain deeper insight into memories, feelings, thoughts, wishes, and expectations that are dynamically unconscious (out of one’s awareness because they were or are too painful to acknowledge); these are known as “expressive” interventions.

Other times a therapist focuses more on interventions that help a person feel better or experience less distress, or cope more effectively with their difficulties; these are known as “supportive” interventions.

Clients and therapists who prefer an exploratory or expressive approach tend to feel that opening up painful areas and exploring them more deeply will lead to more of a “cure” or lasting change than supportive interventions, even if the process takes longer or involves more pain. Techniques such as affirmation and validation; encouraging medication; working on coping skills such as distraction; etc., which are considered “supportive”, are seen by some as “putting a bandaid” on one’s problems or as being more superficial in nature, and therefore inferior to expressive types of therapy.

For me as a therapist, it’s not so black and white when it comes to knowing when it’s more beneficial to probe more deeply into a client’s unconscious or painful experiences, vs. when it makes more sense on a practical level to focus on improving symptoms or decreasing pain, even if it involves leaving some issues unexamined or unresolved on a deeper level.

One of the paradoxes in this work is the need to allow for a dialectical focus on change and acceptance simultaneously or sequentially (this is in fact an important dialectic often referred to in DBT work). In truth, there is often something very therapeutic and important about accepting that which is damaged inside of us; grieving losses that have occurred and can’t ever really be fully reversed or recovered; and acknowledging the limits of realities we often wish were not so. Being practical about improving functioning and decreasing distress is often constructive and is sometimes less risky than “rocking the boat” with exploratory interventions.

On the other hand, running away from attempts at a “cure” or deeper resolution, is at times a giving up of sorts that may be unnecessary for some clients even when the therapist thinks it may be what is needed, or, even if necessary or prudent in terms of the risks of destabilization to a given patient, may be unwelcome to those clients who believe and hope their symptoms can be resolved if they’re willing to do deeper work, and who may experience a therapist’s attempts to help them “settle” for acceptance of a less than perfect cure (or the need for a crutch such as medicine) as a concrete expression of a deeply feared despair about their worthiness or intactness.

Clients who lack a strong sense of self may be particularly sensitive to the idea that an aspect of self in need of help can’t be “cured”. This can feel tantamount to the therapist saying that one’s entire fragile self is at risk of collapsing, and the hope they place in a cure (or in the idea that any symptom can be resolved with a focus on past trauma or a psychological cause) seems their only chance at redemption. Those with a stronger sense of self may be able to accept their “lack” as just a tiny piece of a more intact whole, and can usefully do the work of grieving, settling, or accepting, without a complete psychic collapse.

Making a judgment call about when it’s best to support coping or stabilization (or to close up painful areas that have been opened), vs. when it makes sense to dive into painful areas more deeply (even if dysregulating; supportive of a fantasy; or disruptive to one’s functioning), is not always an easy call. Some clients find medication or behavioral tips helpful, and even ask for practical suggestions such as these when their distress is pressing and the therapy process of exploring what lies underneath their symptoms seems to be taking too long or making them feel worse (or when they feel there’s a biological or other cause). Other clients find practical suggestions to be dismissive of their deeper emotional experiences or feel the therapist is trying to shut them down and can’t handle their pain.

We all have transferences to different types of therapies…projections and expectations from past experiences in reaction to different techniques or approaches. It can be helpful to find a therapist who works in a style that isn’t too out of one’s comfort zone but who also pushes a person to explore any resistances or reactions to specific ways of their attempts to help.