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Supportive-Expressive Dynamic Psychotherapy

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From Sahin, Z., Barber, J.P., Luborsky, L. Supportive-Expressive Dynamic Psychotherapy.

In Reference Module in Neuroscience and Biobehavioral Psychology, Elsevier, 2017. ISBN
9780128093245
ISBN: 9780128093245
© 2017 Elsevier Inc. All rights reserved.
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Supportive-Expressive Dynamic Psychotherapyq

Z Sahin and JP Barber, Adelphi University, Garden City, NY, United States
L Luborskyy, University of Pennsylvania, Philadelphia, PA, United States
Ó 2017 Elsevier Inc. All rights reserved.

Description of Treatment 1
Initial Stages of Treatment 1
Treatment Arrangements 1
Setting Goals 2
Establishing the Therapeutic Alliance 2
Interpretations Around the Core Conflictual Relationship Theme 2
Supportive Procedures and Principles 2
Expressive Procedures and Principles 3
Ending Treatment 3
Theoretical Bases and Mechanisms of Change 3
Applications and Exclusions 4
Empirical Studies 4
Research on Core Conflictual Relationship Theme 5
Research on Insight as a Mechanism of Change in Supportive-Expressive Dynamic Therapy 5
Case Illustrations 6
Summary 7
References 7

Description of Treatment

Supportive-expressive (SE) dynamic psychotherapy is one among many manualized psychodynamic psychotherapy models. It was
the product of an attempt to conceptualize clearly, and manualize in a detailed manner what Lester Luborsky considered as the form
of dynamic therapy representative of common practice, as it was originally developed at the Menninger Foundation. In 1984, Lubor-
sky published Principles of Psychoanalytic Psychotherapy: A Manual for Supportive-Expressive Treatment, where he clarified the principles,
procedures, and existing empirical support for practicing this form of dynamic psychotherapy.
According to Luborsky, the main attractions of SE therapy for dynamic therapists are its adaptability in terms of treatment length,
and its flexibility for a wide range of severity and wide spectrum of diagnoses. The modality is thought to have the tools that enable
the mixture of supportiveness and expressiveness in a way that allows the treatment of patients with widely differing levels of severity.
Luborsky describes two main formats of SE therapy: time open-ended and time-limited psychotherapy. Howard Book (1998)
elaborated SE therapy further, with a focus on its implementation in a time-limited setting, and provided a verbatim complete
case as treated by short-term SE psychotherapy. In many cases, the decision of whether to use a short-term or an open-ended treat-
ment can be made either before the treatment starts, or in the early sessions. Luborsky believed that the time open-ended treatment
should be the preferred choice as it allows the clinician determine the length of treatment as a function of the patient’s needs and
wishes. Time-limited psychotherapy is chosen usually based on limitations in available time for treatment (including insurance
consideration), or of the needs of a research protocol or of the preferred practice in a particular treatment setting (e.g., university
counseling centers).

Initial Stages of Treatment

Treatment Arrangements
In the opening phase of psychotherapy, usually in the first session, treatment arrangements must be made explicit. These include the
frequency of sessions (usually one or two per week), the cost of each session, the method of payment, the handling of missed
sessions, and a guide for the patient’s style of speakingdthe patient should speak about whatever is on the patient’s mind, as
well as the patient can.

y
Deceased October 29, 2009.
q
Change History: October 2016. Z Sahin and JP Barber updated the article with a focus on the “Empirical Evidence” section of Lester Luborsky’s original article,
and added new sources.

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2 Supportive-Expressive Dynamic Psychotherapy

Setting Goals
In the early phase of treatment, it is essential to set the goals of the treatment. In the early sessions, and throughout the treatment,
the patient should specify what it is that he or she wishes to change. This is a crucial first step because it can lead to achievement of
the goals and to changes in the patient’s goals. Both the patient and the therapist should be working toward the achievement of the
same goals, and progress is gauged in terms of the achievement of these goals. Indeed, one of the most commonly accepted defi-
nitions of the working alliance, which may slightly differ from Luborsky’s conceptualization of the alliance, includes patient and
therapist agreement on goals, along with agreement on the tasks in order to achieve the goals and the development of a bond
between them (Bordin, 1979). Given the robust relation between the working alliance (based on Bordin’s conceptualization)
and outcome in various treatments, agreeing on goals might be important for the outcome of SE therapy (Barber et al., 2000;
Horvath et al., 2011).

Establishing the Therapeutic Alliance

The idea of this helping relationship between the therapist and the patient dates back to Freud’s (1912) views on the transference.
The hope of both patient and therapist is that in the early sessions, and certainly as the treatment goes on, a relationship of greater
trust, rapport, and alliance will be formed between patient and therapist. As examined by Safran et al. (1994), at times, there is an
oscillation between movement toward a rupture in the alliance that is usually followed by a movement toward reestablishing a posi-
tive relationship. According to Luborsky, the alliance is one of the main mechanism of change in SE therapy. Throughout the first
sessions, the therapist’s efforts to understand the patient’s treatment goals, and clarify to the patient how the treatment will proceed
will begin the formation of this positive relationship. Throughout the first few sessions, the therapist will already have begun the
work of exploring the “hidden meanings” of the patient’s problems. In these early stages, it will be important for the therapist to be
patient and wait until the appropriate time, where the patient is “nearly aware of the problem” before engaging in the expressive
techniques that will be mentioned further below (Luborsky, 1984, p. 70).

Interpretations Around the Core Conflictual Relationship Theme

Starting early in the treatment, the therapist, and then the patient, will be able to understand and subsequently respond more effec-
tively to the patient’s problems. By following the Core Conflictual Relationship Theme (CCRT) method described in Luborsky and
Crits-Christoph (1998), the therapist is able to formulate the central relationship problem of the patient. The CCRT is centered
around the most common wish of the patient with regards to their relationship with a significant other (W), the most common
response of the other to the patient (RO) and the most common subsequent reaction of the patient to this other’s response
(RS). It is this pattern of the patient in relationships that will guide the therapist to focus his/her interpretive responses. Luborsky
names the focus on the patient’s CCRT, the “focal” aspect of treatment, according to which the treatment is based on gradually
increasing patient’s understanding and awareness of the main relationship pattern, throughout the treatment and thereafter.
Over the course of the treatment, major changes in patient’s self-understanding and behavior are likely to occur as patient and ther-
apist together broaden, deepen, work through, and master the central theme.

Supportive Procedures and Principles

According to Luborsky’s version of dynamic theory of psychotherapy, a supportive relationship is vital, and the most important
supportive component is that the therapist is there to help the patient achieve their goals, and that the patient recognizes this.
Studies suggest that most forms of psychotherapy actually have similar amounts of supportiveness (Barber et al., 2001; Luborsky
et al., 1982). The following are the supportive principles of SE therapy enunciated by Luborsky:
l In most psychotherapies a rapport with the patient is developed, which, in turn, develops into the therapeutic alliance. The
alliance tends to improve when progress has been made and is recognized; in turn, the alternative sequence can also be that
when progress has been made the alliance tends to improve, as shown by Barber et al. (2000) for example.
l For some patients and during certain situations, it might be necessary to reemphasize the supportive quality inherent to the
therapeutic relationship. Luborsky (1984) clarifies that this might be the case with patients with personality disorders, low
anxiety tolerance, patients who have trouble being reflective, patients with whom regression should be avoided and defenses
strengthened by avoiding defense analysis.
l In order to strengthen the alliance, the therapist may: convey through words and manner, support for the patient’s wish to
achieve goals; convey a sense of understanding and acceptance of the patient; develop a liking for the patient; help the patient
maintain vital defenses and activities which bolster the level of functioning; communicate a realistically hopeful attitude that the
treatment goals are likely to be achieved; recognize that the patient has made some progress towards the goals; encourage a “we”
bond; convey respect for the patient; convey recognition of the patient’s growing ability to do what the therapist does in using the
basic tools of the treatment; refer to experiences that the patient and therapist have been through together; engage in a joint
search for understanding (Luborsky, 1984).

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l Interestingly, the joint search for understanding can be classified under supportiveness as well as under expressiveness, for it can
be bothdthe giving of interpretations can be experienced by the patient as supportive as the therapist makes an effort to
understand the patient, and it is expressive as it provides the patient with understanding.

Expressive Procedures and Principles

The other broad category of technique alongside supportiveness is expressiveness. Luborsky viewed expressiveness as referring to the
state of the patient that permits the patient to express his or her thoughts and feelings as fully as possible. The therapist then uses
what is expressed by the patient to frame interpretations of the main relationship themes that are drawn from aspects of the CCRT,
a theme that is reevaluated by the therapist in each session. The patient then uses the therapist’s responses, as well as their own
knowledge of themself to advance in mastery of their relationship conflicts. This sequence is essentially what is done in dynamic
psychotherapies and in psychoanalysis.
The therapist tries to help the patient to be free enough to share thoughts about themself and their main problems in several ways:
l Within each session, the therapist often responds to the patient by offering facets of the CCRT. The therapist should not try to
encompass the entire CCRT in each of the few interpretations given, but instead, presents the separate components from time to
time, so that the patient has a chance to build up a concept of the broader pattern of the relationship themes.
l The basic principles underlying expressive techniques are: attending to redundancy and coming up with themes across situa-
tions; attending to temporal contiguity in the associations of the patient; and attending to shifts in state (Luborsky, 1984).
l In the course of each treatment, there will be times in the sessions in which the patient’s alliance moves toward a near-rupture.
These alliance shifts tend to occur when the patient experiences the relationship with the therapist in terms of a major negative
pattern in the patient’s CCRT. When deemed appropriate, this should be commented on.
l Some expressions of the components of the CCRT can be thought of as a test of the relationship with the therapist. It has been
shown by Weiss et al. (1986) that it is helpful for the treatment that the therapist passes the test.
l The movements toward mastery are an important aim in psychotherapy. In the course of the sessions, most patients will succeed
in achieving improved mastery of the relationship conflicts, and they will have significantly more positive relationship repre-
sentations (Grenyer and Luborsky, 1996; Zilcha-Mano et al., 2016).

Ending Treatment

Treatment endings tend to correspond with the achievement of the patient’s goals as patients tend to end treatment when they have
achieved at least some of their goals. Both in open-ended and in time-limited treatment, as the treatment ending approaches, the
patient and therapist remind each other of when the termination will take place, so that they can be prepared. If the patient does not
spontaneously address the issue of termination, the therapist might bring it up, and this will indeed be very important for the termi-
nation of treatment to have a positive impact on the patient.
According to Luborsky, a common occurrence toward the end of treatment is the resurgence or reemergence of the initial symp-
toms. This typically implies that the patient experiences the anticipation of not seeing the therapist at a time when the patient does
not recognize that he or she has enough of a reliable internalized image of the therapist and the treatment. Usually, even a brief
review by the therapist of the meaning of such recurrence of initial symptoms tends to bring back the patient’s level of control.
Another aspect that should be paid close attention to is with regards to the meaning of termination for the individual patient.
Often times, termination will reactivate experiences of previous endings and separations for patients. It will be important for the
therapist to bring up the parallels between the CCRT and aspects of the termination, and enable the expression of emotions asso-
ciated with termination in order to offer a new understanding of the CCRT as well as a sense of control and mastery over it.

Theoretical Bases and Mechanisms of Change

In his book, Luborsky (1984) described the principles of psychoanalytic psychotherapy and exemplified the principles underlying
supportive-expressive psychotherapy. These principles were mostly based on Sigmund Freud’s (1912) and (1913) writings on
dynamic psychotherapy and on SE adaptations of Freud by Robert Knight (1945) and other collaborators, including Karl
Menninger.
Luborsky proposes three main curative factors in SE treatment: self-understanding/insight, the helping alliance, and the incor-
poration of gains. According to Luborsky, the most significant of these three factors, insight, refers to the patient’s understanding of
their symptoms and the relationship problems associated to these symptoms, and is achieved by expressive techniques around the
CCRT. The helping relationship according to Luborsky, refers to the collaborative relationship between the patient and the therapist,
that would lead to the goals of treatment, and is mainly achieved by the usage of supportive techniques. Incorporating the gains is
the mechanism via which it is ensured that the gains of treatment will remain with the patient and is facilitated by termination work
and patient’s internalization of the therapist as a helpful person.

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Applications and Exclusions

One of the attractions of SE psychotherapy is its broad applications to patients with varying degrees of severity and varieties of diag-
noses. According to Luborsky, even patients with the most severe psychiatric status can be treated through modifications of the
method in terms of increased supportiveness and decreased expressiveness of SE psychotherapy, whereas the reverse is feasible
for less severely ill patients. However, there is also some research supporting the hypothesis to the opposite direction, suggesting
better outcome as a result of expressive techniques in the context of high severity (e.g. Høglend et al., 2006). Research addressing
how to utilize different techniques on the supportiveness-expressiveness spectrum as a function of patient severity is yet to unfold.

Empirical Studies

The efficacy and effectiveness of SE therapy have been evaluated in multiple randomized controlled clinical trials (RCT) for a variety
of disorders including opiate dependence, cocaine dependence, generalized anxiety disorder, personality disorders, bulimia nerv-
osa, social anxiety disorder and major depressive disorder. The overarching conclusion is one of non-inferiority, with SE therapy
leading to similar outcomes as alternative treatments. The findings of these various studies are summarized below.
There were no significant differences between cognitive behavioral therapy (CBT) and SE therapy for the treatment of opiate
dependence, with both psychotherapies leading to better results than drug counseling alone, with moderation analyses showing
patients with higher levels of symptom severity making significantly more progress when SE therapy or CBT was added to drug coun-
seling (Woody et al., 1984, 1990). A subsequent study by Woody et al. (1995) provided additional support for the superiority of SE
therapy in addition to drug counseling compared with drug counseling alone. However, among cocaine dependent patients, indi-
vidual drug counseling was superior to both SE therapy and CBT combined with group drug counseling and group drug counseling
alone for cocaine dependence, with no significant differences between the latter three conditions (Crits-Christoph et al., 1999).
In a study comparing SE therapy and CBT for bulimia nervosa, both treatments were equally effective in treating target symptoms
such as binge-eating and self-inducing vomiting. However, in terms of some of the assessed non-target symptoms such as disturbed
attitudes toward eating and weight, depression, self-esteem, general psychological distress and some personality aspects, there were
significant differences in favor of CBT (Garner et al., 1993).
Concerning the treatment of personality disorders, with a sample including any axis II disorder, manualized time limited SE
therapy was found to be as effective as community delivered psychodynamic psychotherapy. Both conditions were successful in
achieving significant and similar changes in patients’ personality disorder severity, psychiatric symptoms and their fulfilling of person-
ality disorder criteria. Additionally, the follow-up findings of the same study showed that SE patients were significantly less likely to
visit community mental health centers during the first year following the completion of SE treatment (Vinnars et al., 2005).
When SE therapy was compared with CBT in the treatment of generalized anxiety disorder, Leichsenring et al. (2009) found no
significant differences in changes in anxiety and interpersonal problems; however, there were significant differences, in favor of CBT
with regards to changes in trait anxiety, worry, and depression. Similar findings were reported when SE therapy was assessed in the
treatment of social anxiety disorder. Leichsenring et al. (2007) have adapted Luborsky’s SE manual for the treatment of social
anxiety disorder. When compared with CBT, this specialized form of SE therapy was found to be similarly efficacious in treating
social anxiety disorder with small differences favoring CBT (Leichsenring et al., 2013).
In the treatment of major depressive disorder, Barber et al. (2011) did not find any significant differences in the outcome of SE
therapy compared to pharmacotherapy with clinical management and pill-placebo with clinical management. However, there was
a significant effect of gender and minority status on outcome, with minority men having better outcome in SE psychotherapy than
in the two other conditions; and white women having better outcome in the pharmacotherapy and SE therapy conditions than in
the placebo condition. Most recently, no significant differences were found when cognitive therapy was compared to SE therapy for
depression in a community mental health setting (Connolly Gibbons et al., 2016).
In 2016, Leichsenring et al., used Process Q-set (PQS) to develop a prototype of SE therapy. The PQS is a psychotherapy process
measure composed of 100 items that tap onto the attitude, behavior or the experience of patients, therapists and the interaction
between these two parties in therapy. The authors have asked seven experts in SE therapy to rate the items according to their repre-
sentativeness of SE therapy and developed the SE prototype. When compared with previous findings on the psychoanalytic, CBT,
IPT and CMT prototype, the SE prototype correlated highly but not perfectly with the psychoanalytic prototype (r ¼ 0.53), with 28%
of variance in SE prototype explained by the psychoanalytic prototype. The SE prototype correlated highly with the CBT and the IPT
prototypes (r ¼ 0.69 and 0.43 respectively). The 10 most characteristic items of SE therapy from the PQS are as follows: therapist
asks for more information or elaboration; therapist identifies a recurrent theme in the patient’s experience or conduct; patient’s
recurrent or recent life situation is emphasized in discussion; termination of therapy is discussed; therapist communicates with
patient in a clear, coherent style; patient’s interpersonal relationships are a major theme; therapist conveys a sense of non-
judgmental acceptance; therapist is sensitive to the patient’s feelings, attuned to the patient, empathic; therapist adopts supportive
stance; the patient’s treatment goals are discussed.
To conclude, research on SE dynamic psychotherapy support the hypothesis of non-inferiority of SE therapy compared to alter-
native treatments such as cognitive behavioral therapies, psychoactive medication and community delivered dynamic treatments.
Small differences in some of the secondary outcomes that favor CBT might suggest the need to improve the treatment manuals for
generalized anxiety disorder and bulimia nervosa.

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Supportive-Expressive Dynamic Psychotherapy 5

Research on Core Conflictual Relationship Theme

A different line of research related to SE therapy has been with regards to CCRT and how it relates to transference and psychotherapy
outcome. Luborsky started his empirical work on CCRT in order to understand and classify transference, relationship problems in
patients’ life, and the interaction between these. In addition to the original tailor-made coding technique, the gold standard in
clinical work due to its idiographic nature, Luborsky and colleagues developed standardized categories according to which the
components of the CCRT –W, RO, RS- can be classified in order to facilitate research. To avoid the overlap between these categories
and have a clear delineation between them, these categories have subsequently been categorized into fewer clusters by Barber et al.
(1990). Usage of these clusters have resulted in high agreement between judges in terms of CCRT codings, with weighted kappas
between .61 and .71. The distribution of standard category components into these clusters are as follows: W: to assert self and be
independent; to oppose, hurt, and control others; to be controlled, hurt, and not responsible; to be distant and avoid conflicts; to be
close and accepting; to be loved and understood; to feel good and comfortable; to achieve and help others; RO: strong; controlling;
upset; bad; rejecting and opposing; helpful; likes me; understanding; RS: helpful; unreceptive; respected and accepted; oppose and
hurt others; self-controlled and self-confident; helpless; disappointed and depressed; anxious and ashamed. Subsequently, two
coding systems were developed in order to quantify CCRT in research, namely the quantitative assessment of interpersonal themes
(QUAINT; Baranackie and Crits-Christoph, 1992) and the CCRT-Leipzig/Ulm (CCRT-LU; Albani et al., 2002). Investigating the rela-
tion between patients’ CCRT toward therapists and their CCRT toward significant others using the QUAINT system, Connolly et al.
(1996) and Crits-Christoph et al. (1990) have found strong correlations between the two, with an increasing parallel from the first
half to the latter half of treatment.
Another question that has been explored is whether changes in therapy outcome and symptom severity is associated with
changes in patients’ CCRT. Crits-Christoph and Luborsky (1998) have addressed this question by looking at changes in CCRT perva-
siveness –the proportion of patients’ relational episodes with the main CCRT to the total number of relational episodes in session-
throughout psychotherapy. Based on the idea that new opportunities for different relationships would unfold in treatment, the
authors predicted that CCRT pervasiveness would decrease over time. Indeed, their findings suggest that, except for main wish
(W), there is a significant decrease in CCRT pervasiveness from early to late sessions in psychotherapy. Changes in W and negative
RS were also correlated with changes in symptom levels, while controlling for baseline CCRT pervasiveness and symptom levels.
While there were significant changes in CCRT pervasiveness, patients’ CCRTs remained recognizable, suggesting that despite
a stability in the CCRT, patients managed problems surrounding the CCRT in a better way. Zilcha-Mano et al. (2016) have further
shown in a sample of patients with major depressive disorder (Barber et al., 2011) that negative interpersonal representations
decreased and positive interpersonal increased significantly, as assessed by a self-report assessment of CCRT (CRQ-R; McCarthy
et al., 2008) over time in SE psychotherapy. Additionally, they reported that while decrease in negative relational representations
predicted symptom improvement similarly across treatments, greater increase in positive relational representations predicted signif-
icantly greater symptom improvement in the SE therapy condition compared to the placebo condition.

Research on Insight as a Mechanism of Change in Supportive-Expressive Dynamic Therapy

Developments in psychotherapy research and statistics have enabled investigations into the mechanisms of change in therapy, which
in turn allowed researchers to test whether or not change in dynamic therapy occurs via the mechanisms theoretically proposed. One
such theoretical mechanism associated with SE therapy has been insight. Insight has long been considered as the main mechanism of
change in SE therapy (Barber et al., 2013; Messer and McWilliams, 2007). It may lead to change by increasing the sense of control
through the formation of a narrative about the symptoms, or it might liberate the individual to behave in new ways through an
emotional release (Barber et al., 2013). Two main questions surrounding insight as a mediator of change have been: (1) Whether
it is specific to dynamic treatments, and (2) Whether it precedes change in outcome or is simply a by-product of change.
In one of the first studies assessing insight as a potential mechanism of change in treatment, Connolly et al. (1999) have found
that despite lack of differences in symptomatic improvement between SE therapy and medication, there was greater change in self-
understanding with regards to problematic relationship patterns in the SE condition. However, contradictory to original hypotheses
and general psychodynamic thinking, the authors have failed to show that within SE condition, change in self-understanding was
related to changes in symptoms. Investigating similar questions in a later study, with a larger sample including data from five
different psychotherapy studies, Connolly et al. (2009) have found that significant change in self-understanding was specific to
dynamic psychotherapies (including SE). While the change in self-understanding in other modalities remained insignificant, it
was still associated with change in symptoms across modalities (Connolly et al., 2009). Taking this line of research one step further,
Johansson et al. (2010) showed that change in insight was associated with the use of the specific technique of transference inter-
pretations. However, there is some evidence indicating that change in insight might not be specific to dynamic treatment. Hoffart
et al. (2002) have shown that self-understanding is related to outcome in Schema Focused Therapy as well. The question of whether
increase in insight indeed precedes outcome has only partially been addressed by Johansson et al. (2010) who provide some prelim-
inary findings supporting that it might. However, further studies with more sophisticated analyses, such as structural equation
modeling, are required to further clarify the temporal sequence of insight and outcome. Finally, it is important to note that lack
of precision in the definition of insight and the differences in measures underlain by these various definitions might explain the
differences in these findings.

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Case Illustrations

Howard Book (1998) offered a vivid, complete, and highly instructive book including a case illustration of a supportive-expressive
psychotherapy in a generally well-functioning patient who developed a very positive alliance with her therapist.
Another example offered below explains in greater detail the operation of the CCRT. Mr. EH, age 18, was a college student with
problems of guilt, anxiety, sporadic pain in his penis, difficulty in dealing with a new girlfriend, and resentment of his parents. As
a youngster he had never felt close to his father but had felt very close to his mother. He often felt he could not experience closeness
from others. The seriousness of his conflicts were difficult to evaluate. They seemed either a worsening of normal adolescent devel-
opment with intense guilt over sex or there was a thought disorder involved with his wishing to be an exalted spiritual leader. The
start of his treatment also showed that he had difficulties in being assertive and separating from his family.
The relationship episodes in his third session contained six condensed examples. These six relationship episodes are followed
here by a CCRT formulation in which the most frequent components are summarized: He wishes to be close, the other person rejects
him, and he feels rejected, ashamed, and upset. What follows below are brief summaries of the six relationship episodes that he told
during session 3 of his psychotherapy and the CCRT scoring of each one.
This CCRT, as is usual, formed the basis for the interpretations given by the therapist:

CCRT Scoring Precis of First Six Relationship Episodes

Mother#1
W: To get information about sex This might have been a dream. Mother says it didn’t happen. Up until we moved, when I had questions about
sex, mother would explain to me. One day I asked and she said, “Sorry E. we can’t talk about that anymore.
You’re getting to that age.” Bothered me ’cause my young sister went into fits of laughter.
(W1): To get closeness
RO1: Rejection
RS1: Feel rejected
RS2: Shame
RS3: Upset
Mother#2
W: Get in bed with Parents Mother said this never happened: we, brother and Idbefore sister was bornd when it was really cold, would
sleep with parents. Parents took my brother in bed with them and they wouldn’t take me.
(W1): To get closeness
RO1: Rejection
RS1: (Rejected)
Therapist#3
W: To get rapport T: What’s happening now?
(W1): To get closeness P: I feel generally unresponsive. I’m getting a headache, tense, been thinking all week about relating all this
stuff to what I was 10 years ago (sigh) and not getting anydI mean, nothing comes out. like groups of
guys who have embarrassing silences. It proves no perfect rapport exists. I Feel blank.
RO1: Rejection
RS1: Feel blank (empty)
Mother#4
W: To kiss mother Before I went to school I always used to kiss mother. I’m not sure it was a big thing, but it was a big thing
when it stopped. She made a big thing about how I didn’t want to kiss her anymore. I Was suddenly out in
the cold again.
RO1: M. criticizes him
RO1: Rejection, kissing stopped
RS1: Rejected, out in the cold
E (girlfriend)#5
(W1): Closeness to girlfriend I’m beginning to feel a lot of resentment to E (girlfriend). I Went with her for a couple of years. It’s just been
severed. I’m fearful of seeing her and feeling something for her. She just doesn’t give a dame Bothers me I
used to be so screwed up about her.
RO: Doesn’t like me
RO1: Rejection, broke off
RS2: Self-blame
RS1: Rejected (“severed”)
RS3: Upset
Mother#6
(W1): To get a response One thing that started my resentment against my parents. I Told her about E (girlfriend) that everything was
cut off. I Said E’s not writing and it upsets me. She said, “well, I’m sure about you and you aren’t sure about
her.” that really cut me up because she . she . a . assumes between us is like between E and me.
RO1: Rejection
RS: Resentment
RS1: Rejected
(Continued)

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CCRT Scoring Precis of First Six Relationship Episodes

N Total CCRT formulation

6 Wish 1 W1: To be close
6 response from other 1 RO1: Rejection
6 response from self 1 RS1: Feel rejected
2 response from self 2 RS2: Shame
2 response from self 3 RS3: Upset, anxious.

Summary

Manualized by Lester Luborsky in the 1980s, supportive-expressive psychotherapy is a commonly practiced form of dynamic
psychotherapy. Its main principles are basically derived from Sigmund Freud’s as these were shaped by clinicians at the Menninger
Foundation, starting around 1940. In each session, the therapist allows the patient to express themself in their own way and to
choose their own goals. A main technique for helping the patient is provided by the therapist who formulates the patient’s
main conflictual pattern of relationships in terms of the Core Conflictual Relationship Theme (CCRT). CCRT is the patient’s
main pattern of relationships, especially those that are conflictual; it is derived from narratives about relationships that the patient
shares with the therapist during each session. The treatment is called supportive-expressive because supportiveness and expressive-
ness are the two main approaches that the therapist adopts. When the treatment conditions are more supportive, the therapist
provides support when needed; when the approach is more expressive, the therapist provides help by increasing understanding,
clarifying the patient’s struggles in interpretations. The length of the treatment is either time open-ended or time-limited. The treat-
ment comes to a close when the main goals have been achieved and there has been sufficient occasion to work through the mean-
ings of termination in order to optimize the retention of the gains. Supportive-expressive treatment has been evaluated in many
randomized controlled clinical trials covering a wide range of diagnoses and was found to be at least as effective as alternative
treatments.

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