A recent article published in the journal World Psychiatry argues for a “back to the basics” psychotherapy that prioritizes emotional expression. Against the potential for “exposure” based therapies such as CBT to become too intellectual, technique-heavy, and drained of emotion, psychiatrist John Markowitz explores the clinical effectiveness and importance of Brief Supportive Psychotherapy.
“People get carried away by bells and whistles, but sometimes it is the basics that matter. Psychotherapists, like their patients, face discomfort with and may shy away in the face of strong emotions. Yet focusing on strong emotions lies at the heart of psychotherapy. That is what good therapy, and particularly good supportive psychotherapy, should do,” Markowitz explains.
Despite the expanding influence of cognitive-behavioral therapies (CBT), some practitioners still believe in the therapeutic effectiveness of person-centered or humanistic approaches, even criticizing CBT’s status as the “gold standard.”
Person-centered or humanistic forms of therapy tend to privilege client autonomy and dignity, the therapeutic relationship, emotional expression, and validation—essentially acting as a caring guide for the client’s self-exploration.
The current article, by psychiatrist John Markowitz, argues for a return to these core therapeutic values and practices. Markowitz examines the evidence for the effectiveness of Brief Supportive Psychotherapy (BSP) and states that more “technique-heavy” approaches such as CBT can drain the emotion from therapy.
According to Markowitz, out of nine randomized controlled therapy trials that have been done over the years, seven found that “BSP worked as well as the favored treatments,” despite being an “underdog comparison condition” primarily used to assess other approaches. These trials examined therapeutic effectiveness for mood and anxiety disorders, including depression.
The two studies where BSP did not perform as well as the favored treatments were still a “credible, near-miss second.” Accordingly, Markowitz argues that BSP should be included in depression treatment guidelines.
Explaining the tenets of BSP, Markowitz states that it is grounded in common factors research and shares similarities to other forms of “supportive” psychotherapy, such as person-centered and humanistic therapies, which were at one time the most common form of therapy. Carl Rogers and Jerome Frank are discussed as important figures in this lineage.
Common factors research suggests that five different “core” elements tend to account for successful therapy:
- Affective/emotional arousal
- Feeling understood by the therapist and developing a therapeutic alliance
- Providing a framework for understanding, as well as a therapeutic ritual
- Showing optimism around improvement
- Encouraging “success” experiences
In particular, Markowitz believes that psychotherapy should return to the significance of emotion. He argues for the importance of therapies that emphasize emotional regulation and expression.
In terms of therapeutic technique, this approach is simple but profound and harder 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 powerful emotions.
The underlying belief is that this can improve quality of life and reverse tendencies which may exacerbate things like depression—for example, people experiencing anxiety and depression “frequently avoid interpersonal confrontations, having trouble asserting their wishes and struggling to say no.”
Through normalization 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 believes can sometimes be problematic:
“A danger with fancier, technique-heavy psychotherapies is that they can become mechanical, intellectualized, affect-drained exercises. One reason for the rise in so-called “third wave” cognitive-behavioral therapies has been recognition of the sapping of affect from exposure-based treatments.”
“There are other affect-focused treatments, including interpersonal psychotherapy, well-conducted psychodynamic psychotherapies, and mentalization-based therapies. BSP is the pared-down core of these approaches. It lacks and needs no bells and whistles. It just sticks with feelings.
By letting the patient lead and focusing on their emotions, it maximizes patient autonomy. The therapist assigns no homework and applies no structure beyond the affect focus. A transportable, disseminable, inexpensive intervention, affect-focused BSP deserves a second look.”
Markowitz, J. C. (2022). In support of supportive psychotherapy. World Psychiatry, 21(1), 59-60. (Link)
If psychiatrists, who have all of the power in a relationship/treatment ‘team’ meeting, show even a modicum of care about the patient’s dignity and autonomy, it could do so much good! It could do even more good than a highly trained psychotherapist with many years of experience who has very little power in most psychiatric settings. By power, I mean influence over the circumstances that really matter in the life of a labeled person.
Psychiatrists in an in-patient setting have all of the power. They can reduce or increase drug prescriptions, authorize special privileges (such as ethnic or dietary preferences being honored by staff, enabling a patient to a different level of the hospital where there are more fun things available, or authorize discharge. They can influence a judge in a hearing, they can squash hope or they can create hope.
With such huge things at stake, imagine the good if a psychiatrist who is considered the number on ‘authority’ were to display more than a modicum of concern for the dignity and autonomy of the patient!
I doubt it was Markowitz’s intention, but by calling for a “back-to-basics”, emotions-involved approach to psychiatry, he is arguing that psychiatry currently lacks firm grounding in dealing in a healthy way with human emotion. It does indeed lack that foundation. Psychiatry is a pseudoscience, a drug racket, and a means of social control. It needs to be ABOLISHED…..
And he’s being disingenuous because MOST psychiatrists have NO regular on-going therapy relationship with their victims, er, “clients”. They are merely glorified DRUG DEALERS….
Psychiatry belongs on the scrap-heap of history, ASAP!….
Bradford, if you had a loved one in a psychiatric ward at this moment, you would choose a emotionally intelligent psychiatrist who was grounded in compassion over a revolution in the mental health system that may take another 50 years to unfold!
Thanks, madmom. I’d go so far as to say that there is NO SUCH THING as an “emotionally intelligent psychiatrist”. Much less one who is “grounded in compassion”. Psychiatry is a pseudoscience, a drug racket, and a mechanism of social control. Psychiatry has done, and continues to do, FAR MORE HARM than good. Psychiatry is the absence of compassion. I’m not looking for a “revolution” in the so-called “mental health system”. I want to abolish it altogether. NOBODY should EVER have a loved one in a psych ward, because there shouldn’t be any psych wards. Period. We could easily do that in 5 years, not 50. Thanks for the reply. // Do I assume correctly that YOU DO have a loved one in a psych ward right now?
As long as we are not addressing “power” between two people where one person provides service and the other payment and yet the payee is “powerless” = western type therapy are bound to be harmful or inhibitions or label making business and as we become more diverse, more useless.
The process of therapy is set in a way to provide imbalance of power between two people and never addressing the “pink elephant” and getting lost all the emotions, feelings, thoughts arising from that source but ignoring = gas lighting. I think enough people on this website wrote much better way of expressing what I am getting.
Anyone who ever had trauma knows: the loss of inner power was the traumatic thing not because one forgot how to emote.
Maybe this method is not good cause it may create a real consciousness in the room.
Thank-you, “dogworld”. May I assume that American English is NOT your native language? Yet, you write very well, and make a very good point. One that needs repeating, and emphasizing. When a “therapist” depends on a paycheck, there can be NO PERSONAL affection or relations between those persons. There is ONLY a business relationship. But even a good business relationship COULD, and SHOULD be between 2 adult, informed, consenting persons. That is NOT the case in the current “Western Allopathic Medicalized Mental Health Industry” of the PSEUDOSCIENCE DRUG RACKET of Psychiatry, which is nothing more than 21st Century Phrenology with potent neuro-toxic snake oil pills.
We now have a system-centered system, & a process-centered process. We CAN, and MUST CHANGE that into a person-centered process, & a services-centered system. Simple. But very difficult. But that is our work. Do you agree, “dogworld”? Thanks for writing, and please, I hope you keep sharing here! Welcome!