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Brief Supportive Psychotherapy

ii
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Brief Supportive
Psychotherapy
A Treatment Manual and Clinical Approach
JOHN C. MARKOWITZ
iv
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Names: Markowitz, John C., 1954– author.
Title: Brief supportive psychotherapy : a treatment manual and
clinical approach / John C. Markowitz, M.D.
Description: New York, NY : Oxford University Press, [2022] |
Includes bibliographical references and index. |
Identifiers: LCCN 2022012631 (print) | LCCN 2022012632 (ebook) |
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Subjects: LCSH: Supportive psychotherapy—Handbooks, manuals, etc.
Classification: LCC RC489. S86 M37 2022 (print) | LCC RC489. S86 (ebook) |
DDC 616.89/14—dc23/eng/20220610
LC record available at https://lccn.loc.gov/2022012631
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DOI: 10.1093/med-psych/9780197635803.001.0001
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Printed by Lakeside Book Company, United States of America

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Emotions can be powerful but they’re not dangerous.
Markowitz, 2016
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CONTENTS
1. Introduction 1
2. What Is Supportive Psychotherapy? 6
3. The Common Factors of Psychotherapy 11
4. Affect Focus 22
5. Formulation: Developing an Emotional Conceptualization of the Patient 40
6. The Structure of Brief Supportive Psychotherapy 48
7. Supportive Evidence: Research on a Treatment That Works 72
8. Adjusting Brief Supportive Psychotherapy to Different Disorders 85
9. Case Examples 88
10. Brief Supportive Psychotherapy Training and Supervision 130
Acknowledgments 135
References 137
Index 145
vi
1
Introduction
What is supportive psychotherapy? Is it important? Is it any good? The term has

been widely used and misused, variously and often poorly defined. “Supportive”
has frequently served as a pejorative or disparaging rubric for weak therapy. Yet
properly defined and employed, supportive psychotherapy is a potent interven-
tion whose elements emphasize the core of all good psychotherapy (Markowitz,
2014; Markowitz & Milrod, 2021; Markowitz, 2022a, 2022b).
I conduct psychotherapy outcome research. One of the problems that the field
faces is what to compare psychotherapies to, as there is no psychotherapy equiv-
alent to an inert pill placebo in a medication trial. Some psychotherapy research
studies have used a waiting list as a comparison. That is, patients enter the study
seeking treatment, hear that they might receive a treatment, and then are told,
“There’s no treatment; just come back after 12 weeks and we’ll rate your symptoms
again.” A waiting list is not only disappointing and unfair to suffering patients and
likely unethical for patients who have treatable disorders. It’s also very weak com-
petition, inasmuch as the measure of the robustness of an active treatment always
depends on the comparator: A treatment can only be better than what you com-
pare it to. So “compared to what?” is a key question in research trials. A treatment
that’s better than an inert or even harmful condition (a “nocebo,” which a waiting
list may be) hasn’t made much of a case for itself. A treatment that beats an active
control condition—in other words, exceeds a treatment that does something—
now, that’s an accomplishment.
More than thirty years ago, when I was a junior faculty member at Cornell
University Medical College interested in psychotherapy research, we needed a com-
parison condition for a psychotherapy study to treat an extremely vulnerable pa-
tient population. I worked with a senior Cornell psychoanalyst, Dr. Michael Sacks,
and got help from Drs. Allen Frances and Larry Jacobsberg as well. We wanted to
develop a treatment that was not an empty condition, that might help the patients
who received it. We wanted it to have generalizability: that is, to have some con-
nection to psychotherapy as it might be practiced in the community. We grounded
it in the basics of psychotherapy: building a treatment alliance, encouraging toler-
ance and expression of one’s feelings, and utilizing the other so-called “common
factors” inherent in all good psychotherapies (Rogers, 1951; Frank, 1971; Frank &
Frank, 1993). We hoped it would be an elemental, effective intervention.
2
2 B rief S upporti v e P sychotherapy
We wrote a treatment manual, somewhat crudely outlining a 16-session weekly

treatment we called Brief Supportive Psychotherapy (BSP). We then compared it in
a randomized controlled trial to proven alternatives: Interpersonal Psychotherapy
(IPT; Klerman et al., 1984; Weissman et al., 2018), Cognitive Behavioral Therapy
(CBT; Beck et al., 1987), and the tricyclic antidepressant medication imipramine.
We studied these as treatments for a sample of patients who had both depression
and human immunodeficiency virus (HIV) infection or acquired human immu-
nodeficiency syndrome (AIDS) at the height of a then untreatable, stigmatizing
epidemic. Dr. Sacks supervised the BSP treatment, which did quite well in the
trial. Patients generally improved, and BSP had benefits indistinguishable from
CBT, if less dramatic than those for IPT or medication (Markowitz et al., 1998).
Since then, we’ve used BSP as an active control condition in additional studies
funded by the National Institute of Mental Health (Markowitz et al., 2005, 2008a).
Other investigators have used it as well (Lipsitz et al., 2008; Kocsis et al., 2009;
Koszycki et al., 2012; Swartz et al., 2016; Schramm et al., 2017). The manual has
been tweaked slightly for the diagnoses of the patients receiving treatment, but
it has always retained its fundamental principles. BSP has performed quite well,
even though the therapists doing it frequently have had less experience conducting
the therapy than have their competitors doing other therapies. It has performed
well despite its perennial role as underdog in the randomized trial. So BSP works.
The cumulative study findings provide justification for the inclusion of supportive
therapy in depression treatment guidelines (see Chapter 7). Because BSP has been
used mostly to treat mood disorders, this book assumes major depression as the
modal treatment target; but the same principles apply to patients with anxiety
disorders (and possibly other psychiatric disorders) as well.
For years I’ve been asked to lend out the BSP treatment manual and to consult
on other researchers’ clinical trials of psychotherapy in order to teach and su-
pervise therapists in BSP. I have only agreed to do so when the study design has
looked rigorous. One consortium of clinical researchers used it in a multisite study
of chronic depression across the United States (Kocsis et al., 2009); another group
did so in a multisite study of chronic depression across Germany (Schramm et al.,
2017). I’m currently supervising (by Zoom) a trial at the Laureate Institute for
Brain Research in Tulsa, Oklahoma, where Dr. Robin Aupperle and her colleagues
are comparing BSP to Exposure-Based Therapy and to Behavioral Activation for
patients with depressive and anxiety symptoms (cf., Santiago et al., 2020).
“Supportive psychotherapy” is a vague catch-all term for what many therapists
in the community apparently have done and do. Supportive therapy has been cited
as the “most widely practiced” variety of psychotherapy (Tanielian et al., 2001), but
the term can mean almost anything. It’s hard to know how many clinicians really
do it or do it well. What this book calls BSP is carefully defined: It’s the treatment
described in our previously unpublished manual from three decades ago. From a
research standpoint, it’s what we call an active condition, perhaps not a “control”
condition at all; and if it is, then it’s a very rigorous control indeed. It’s not inert
treatment, it helps patients improve, and it’s a high bar for other psychotherapies
to outperform. They generally do not succeed in doing so (see Chapter 7).
3
Introduction3
BSP has roots in the pioneering work of psychotherapy giants like Carl Rogers
(1951) and Jerome Frank (Frank, 1971; Frank & Frank, 1993). It distills psycho-
therapy down to its emotional core. BSP is in the psychotherapy research liter-
ature. A review article titled “What is supportive psychotherapy?” I published
about BSP in Focus, an American Psychiatric Association Continuing Medical
Education journal, has turned out to be surprisingly frequently read and highly
cited (Markowitz, 2014). So there’s some demand for this psychotherapy among
researchers and clinicians.
I wrote this book hoping that it would serve a second purpose, as a clinical
guide to psychotherapists in general practice. This justified fleshing out the some-
what skeletal research manual. Again, “supportive psychotherapy” is reportedly
widespread in practice, but the term has suffered from both too many meanings
and too little definition. It has been disparaged, relegated to second-class status,
seen as unfocused, benign hand-holding, a last resort for chronically treatment-
refractory patients who haven’t responded to or cannot tolerate fancier treatments.
Indeed, the term arose in a pejorative context. During the mid-20th-century era
of psychoanalytic preeminence in psychotherapy, good “analyzable” patients were
treated on the couch with psychoanalysis, whereas less emotionally stable patients
unable to tolerate or too ill to benefit from that treatment instead received sup-
portive therapy. That meant the psychodynamic therapist met with the patient less
frequently and sought to foster stability more than exploration, trying to shore up
existing psychic defenses rather than interpreting and potentially altering them.
That is not what BSP is about. We define it here as a focal, affectively focused,
bare-bones common factors therapy. We review these “common factors” at
length in succeeding chapters, particularly Chapter 3, and the affective focus in
Chapter 4. On the one hand, the “bare bones” are simply those common factors,
the shared elements and basis of all good therapies: emotional arousal, helping a
patient to feel understood, providing a treatment ritual, etc. (Box 1.1).
On the other hand, well-conducted BSP looks and feels different from other
therapies; raters can discriminate it from other defined psychotherapies on
Box 1.1.
Common Factors of Psychotherapy
Affective arousal (response)

Feeling understood by therapist (relationship)
Framework for understanding (rationale)
Expertise (rigor)
Therapeutic procedure (ritual)
Optimism for improvement (realism)
Success experiences (remoralization)
Based on Frank & Frank, 1993

4
adherence rating scales (Markowitz et al., 2000; Amole et al., 2017); and it works.
BSP is not only an active control treatment for research studies but an active treat-
ment, period. There are several published books on supportive psychotherapy but
their scope is general, more principles than techniques, and not the basis for a
treatment study or the conduct of a really focused supportive treatment. None of
them has been used in a treatment study (although one study used elements from
two such books; see Chapter 7). I hope that readers will agree that BSP is both fa-
miliar in its elements and yet distinct from what they have practiced before. Some
of the many supportive therapists in practice may benefit from a defined approach
to what they’re already doing.
A third reason for publishing this book is a concern that there has been a loss
in psychotherapy training and practice of the balanced use of the psychotherapy
“common factors” (Frank, 1971; Frank & Frank, 1993) and principally of the cru-
cial factor of affect or emotion in treatment (Markowitz & Milrod, 2011, 2021; see
Chapters 2 and 3). Too many therapists today learn highly structured methods of
teaching cognitive skills or otherwise “instructing” patients, with minimal focus
on understanding how their patients are feeling and using that understanding
to manage the therapy and to help patients understand their own feelings. That
emotional understanding is valuable, both for therapist and patient, and its loss
is worrisome and meaningful (Schwartz et al., 2021). This book attempts to start
to remediate this problem. If passages of this text convey a hint of the feeling of
a psychotherapy supervision session, it reflects an attempt to communicate that
experiential focus on underlying feelings.
BSP employs an affect focus and the so-called “common factors” of psycho-
therapy, aspects of treatment that are essential to any clinician’s skill set yet too
often neglected. My experience in training sometimes quite experienced cogni-
tive behavioral therapists in affect-focused therapies like BSP (Markowitz et al.,
2008b) and IPT (Lowell & Markowitz, 2017) is that they initially balk, questioning
how and why this matters, or how it differs from CBT. They can feel deskilled, like
they’re “sitting on their hands” rather than more comfortably employing focused
interventional techniques such as eliciting and helping patients to challenge au-
tomatic thoughts. Good CBT, as practiced by its developer Aaron Beck himself,
indeed incorporates affective issues, but in other hands it too often has become a
dry, mechanical, intellectualized exercise, with suboptimal results (Markowitz &
Milrod, 2011, 2021; Schwartz et al., 2021). This is a reason for the rise of “third
wave” cognitive therapies like Acceptance and Commitment Therapy (Hayes
et al., 2012) that seek to reincorporate affect.
The term “common factors” encompasses those qualities supposedly shared
and therapeutic across interventions, but unfortunately not all therapists use these
common factors with equal or even sufficient frequency. Learning to conduct an
affect-focused therapy like BSP potentially adds a new dimension to therapists’
understanding and to their patients’ as well. Recognizing that even powerfully
painful feelings are valuable and meaningful, rather than “bad,” can be a reve-
lation. Having learned this, therapists often incorporate the approach into their
practices (Markowitz et al., 2008b; Lowell & Markowitz, 2017).
5
Introduction5
I find that by magnifying the basic elements of all good psychotherapies, BSP
expands my thinking in approaching various therapies I practice. I hope it may
provide a model and a way of thinking to help therapists enhance other thera-
pies they may already be doing by honing their affective focus. This makes for a
more intense therapeutic experience, indeed more of a “corrective emotional ex-
perience” (Alexander & French, 1946): that is, an encounter in which the patient
discovers that not all people react to him or her as feared.
In summary, BSP may be used either as an active control condition in a research
study, an active treatment in clinical practice, or an affective enhancement of and
vantage for understanding other psychotherapies. So this book is not only a treat-
ment manual but an outlook on psychotherapy for both researchers and general
therapists. Whatever your practice, a basis in common factors can enhance it.
6
What Is Supportive
Psychotherapy?
What is supportive psychotherapy? It is popular and unpopular. It is deeply mis-

understood (Hellerstein et al., 1994; Markowitz, 2014). It is in widespread use,
and training to “competence” in supportive therapy is a formal Accreditation
Council for Graduate Medical Education (ACGME) requirement of psychiatric
residency training (Mellman & Berensin, 2003; https://www.acgme.org/Portals/
0/PDFs/Milestones/PsychiatryMilestones.pdf)—although it is not clear what that
practically entails. As noted, the generic term “supportive therapy” can mean
almost anything and nothing. It can include “strengthening the therapeutic al-
liance, environmental interventions, education, advice and suggestion, encour-
agement and praise, limit setting and prohibitions, undermining maladaptive
defenses while strengthening adaptive defenses, and emphasis on strengths and
talents” (Rockland, 1993, p. 1053). Pinsker, who devoted decades to supportive
therapy, while conceding the vagueness of the term, wrote: “Supportive therapy
uses direct measures to ameliorate symptoms and to maintain, restore, or im-
prove self-esteem, ego function, and adaptive skills” (Pinsker, 2002, p. 1). An on-
line source elicited by Googling “supportive psychotherapy guidelines” on July 3,
2021, suggested: “Abundant praise is a good supportive technique” (https://med.
unr.edu/psychiatry/education/resources/supportive-psychotherapy).
Supportive therapy started out as a second-rate treatment for second-rate
patients (Markowitz, 2014), as an attempt to be “supportive” to those patients
unfortunate enough to be incapable of psychoanalysis (cf., Wallerstein, 1988).
The idea of such therapy was less to achieve gains than to stabilize patients who
were in deficit states, to maintain their functioning under the stress of character
pathology or struggles with reality testing. Some patients, for example, initially
appeared analyzable but then decompensated on the couch; hence they received
the diagnosis of “pseudo-neurotic schizophrenia” (meaning patients who looked
merely neurotic but revealed psychotic symptoms in the relatively structureless
process of psychoanalysis) (Hoch & Polatin, 1949), or “hysteroid dysphoria”
(Spitzer & Williams, 1982), subsequently retitled borderline personality disorder.
Based on disturbing outcomes, these patients were deemed inappropriate for
7
What Is Supportive Psychotherapy?7
psychoanalysis and instead were offered supportive therapy to buttress their psy-
chic defenses in a kinder, gentler, less intensive approach. Rather than offering
insight to patients with “primitive defenses,” the therapist functions as a “good
object” and preserves the safety of the therapeutic relationship (Buckley, 1994).
Its clinical definition in opposition to psychoanalysis made “supportive
therapy” a catch-all term for any non-psychoanalytic psychotherapy: Treatments
like Cognitive Behavioral Therapy (CBT) or Interpersonal Psychotherapy (IPT)
could be considered under the rubric, viewed from the psychoanalytic vantage
as Band-Aids that might offer symptomatic relief but did not reach the deeper
levels of character dysfunction and structural interpretations of psychoanalysis.
Supportive therapy became synonymous with hand-holding, as an empathic in-
tervention for difficult cases with limited prognoses.
Meanwhile, a strain of thinking at the forefront of what became psycho-
therapy research began to explore the active, effective elements they believed
common across psychotherapies. Therapists like Carl Rogers focused on em-
pathic understanding as a way of connecting with patients and helping them
to feel understood (e.g., Rogers, 1951). John Bowlby (1969) recognized the im-
portance of interpersonal attachment and bonding in human existence, and
its disruption as a factor in psychopathology. Jerome Frank (Frank & Frank,
1993) perhaps best defined the so-called common factors shared by all effective
psychotherapies. These are:
• Affective arousal: the emotional intensity of a psychotherapy that makes

it meaningful to patients, and that implicitly demonstrates to patients
that their feelings are not dangerous;
• Helping the patient to feel understood by the therapist, a form of
interpersonal support and a necessity for developing a treatment
alliance;
• Providing a framework for understanding: an explanation of what the
patient is suffering from and a rationale for why the therapy might bring
relief;
• Expertise: conveying that the therapist, while focused on the patient’s
experience, has experience and training that may help the patient and
provide effective treatment;
• A therapeutic procedure, a ritual or structure in sessions that becomes
familiar to the patient, providing a safe, expectable environment and a
method for change;
• Optimism for improvement: a realistic therapeutic outlook—
as opposed to chirpy reassurance, or acceptance of the patient’s
symptomatic pessimism (e.g., depression is painful but treatable; you’re
suffering now but have a good chance of getting better; hopelessness is a
symptom, not a prognosis); and
• Success experiences: the therapy helps the patient find ways to cope that
will help him or her make positive changes and feel better.
8
All of these elements are key to supportive psychotherapy as well to psychotherapy

in general. Therapies lacking aspects of this list generally do not fare well. Not all
therapies use the common factors to equal degree.
Subsequent chapters will address how you as a therapist can use these elements
in Brief Supportive Psychotherapy (BSP) in the course of:
(a) Focusing on the patient’s emotional life (how is he or she feeling, and
what do those feelings indicate about the patient’s inner and outward
life?);
(b) Enhancing the treatment alliance and providing social support by
helping the patient to feel emotionally understood by the therapist,
hence no longer alone with painful symptoms;
(c) Facilitating the other common factors known to benefit patients in
psychotherapy; and
(d) Developing and using an emotional conceptualization of the patient,
an understanding of how the patient characteristically feels, reacts to,
and copes with his or her life.
WHAT BSP ISN’T
BSP has no charts, exercises, homework, or agenda-setting. It incorporates min-

imal psychoeducation. Is it psychodynamic psychotherapy? Its common factors
underlie psychodynamic psychotherapy, much as they offer a basis for every
other effective therapy. Several versions of what has been called supportive psy-
chotherapy are psychodynamically based (e.g., Pinsker, 2002, Novalis et al., 2019).
Luborsky’s Supportive-Expressive Psychotherapy (Luborsky, 1984), a ground-
breaking attempt to manualize psychodynamic psychotherapy that allowed its
testing in randomized trials, could be considered a dynamically flavored sup-
portive psychotherapy. Supportive-Expressive Psychotherapy, however, builds the
treatment around a Core Conflictual Relationship Theme in a way BSP does not.
All of these therapies lack transference interpretations and unstructured temporal
immersion, forming a dividing line from psychoanalysis. Like BSP, these psycho-
dynamic therapies are affect-focused, emotionally centered rather than exposure-
based treatments.
BSP, as defined here, certainly seeks an emotional understanding of the patient
common to these other approaches. It does not address psychodynamic defenses
or the transference or make interpretations. It does not utilize unconscious fan-
tasy structures. So, on balance, I would call BSP as described here psychodynam-
ically friendly but not truly a psychodynamic therapy. (Douglas [2008] nicely
describes the range of opinions in the psychoanalytic and psychodynamic world
about what “supportive psychotherapy” means.)
How does BSP compare to other affect-focused therapies, such as Emotion
Focused Therapy (EFT; Greenberg et al., 1993) or IPT (Weissman et al., 2018)? An
experiential therapy, EFT acknowledges its source in Rogerian Client-Centered
9
What Is Supportive Psychotherapy?9
Therapy, which is the wellspring of BSP, and it has shown benefit in at least one
randomized trial for depression (Goldman et al., 2006). It differs from BSP in
having been applied in various formats, including couples and family therapy, and
it takes much more of a family systems approach, with the jargon (e.g., “emotion
schematic system”) and theoretical conceptualization that might imply. Similarly,
IPT overlaps with BSP in its grounding in eliciting and validating affects but adds
a more active interpersonal response focus atop it. You could consider IPT “BSP-
plus,” wherein BSP constitutes the inner, emotional aspect that IPT links to a more
external, environmental focus. BSP is IPT stripped to its affective core, focusing
on patient’s feelings, often but not necessarily in interpersonal situations; but
stripped of the action items that could be derived from the feelings. BSP therapists
do not ask IPT questions like, “What options do you have?” or routinely engage
in role play to encourage patients to take interpersonal action. Blinded raters lis-
tening to session tapes can distinguish BSP from IPT (Markowitz et al., 2000;
Amole et al., 2017). In effect, most affect-focused therapies inevitably start with
the foundation of BSP and then add bells and whistles, which may or may not
make a difference in augmenting outcome.
BSP is closest, perhaps, to Carl Rogers’s Client-Centered Therapy (also called
Person-Centered Therapy). This is where its roots lie, and we constructed BSP
based on a client-centered approach. BSP shares Rogers’s non-directive, emotion-
ally focused and emotionally aware approach, its emphasis on genuineness and
empathic understanding (Rogers, 1951). But BSP differs from Client-Centered
Therapy (1) in its application to patients with a particular diagnosis, which in
research studies has generally meant a depressive disorder; (2) in its time limit,
typically 10 to 12 weekly 50-minute sessions, suited for psychotherapy trials; and
(3) in its awareness of the particular diagnosis-specific difficulties patients tend to
have with particular negative affects.
At its heart—and heart is part of it—BSP is an emotionally validating treat-
ment. The therapist inquires about, elicits, and helps the patient to explore
and name feelings and to consider whether the feelings are reasonable to have,
or make sense to the patient, in the context they are arising. Implicit in this
process—rather than explicit, as in a therapy like IPT—is the likely conse-
quence that the patient will then not only tolerate but express and possibly
act on those feelings and use them to change his or her environment. Even if
that does not happen, it may suffice for the patient to define, understand, tol-
erate, and come to terms with his or her inner emotional world, terrain that has
previously seemed overwhelming and negative. Both environmental and inner
calming relieve symptoms.
Affectively focused treatments, as exemplified by BSP, aim to address and may
work through repairing dysregulated affect and insecure attachment (Milrod
et al., 2020). The goal of BSP, then, is to help patients who present with emo-
tional constriction or constraint, or who are overwhelmed by emotions, in the
context of a psychiatric disorder (the most studied instance being depression)
to gain understanding, tolerance, and thereby comfort in and some mastery of
their affects. This takes places in an emotionally focused, emotionally intense
10
brief treatment. Gaining some understanding and tolerance of emotions tends

not only to reduce patients’ symptoms (see Chapter 7) but to broaden their
lives, to convert an internal dimension from toxic to helpful. Rather than
having to fight or suppress bewildering emotions, patients can recognize, ac-
cept, and use them to more richly understand the world. They can learn to trust
their own feelings.
1
The Common Factors

of Psychotherapy
What are the building blocks of good psychotherapy? Some past masters of psy-
chotherapy have taken up this question and arrived at broad answers that are hard
to dismiss. Not all have been carefully tested, but they make good clinical and
emotional sense. Collectively, these are goals to which every good psychotherapist
should aspire, regardless of therapeutic orientation (Markowitz, 2014).
Let’s review the factors, first posited by Rosenzweig (1936), which Frank (Frank,
1971; Frank & Frank, 1993) later astutely described.
AFFECTIVE AROUSAL
Emotions matter. Many people find their feelings frightening, particularly “nega-
tive” affects such as anxiety, sadness, and anger. People often experience them as
crushing and painful. They judge them “bad,” dangerous, or unwelcome, often as
indications of their own inadequacy, and they strain to contain or suppress them.
Individuals with psychiatric disorders typically feel overwhelmed by their feelings
and try to avoid them. Such emotional distancing may involve defensive strategies
such as affective detachment, intellectualization, or dissociation.
This emotional retreat has several negative consequences. First, feelings are not
random, although they may appear so to the patients who are trying to shut them
out. Feelings tell you something about your mood state and what’s going on in
your life. They are responses to your sensory perceptions. Understanding how
you feel informs you about the situation you are facing. Second, feelings are not
“bad,” even if they can feel that way. The so-called “bad” feelings—negative affects
such as anger, anxiety, disappointment, sadness, etc.—tend to reflect bad events in
one’s life, and the intensity of the emotions reflects just how upsetting the event is.
Some individuals grow up in settings where strong feelings are not tolerated,
are considered inappropriate or even sinful. Moreover, anyone who has ever
suffered through an episode of depression tends to evaluate negative affects such
as sadness, disappointment, or anger as akin to that painful depressive state,
12
hence something to shut out or avoid. Similarly, anyone who has ever had a
panic attack—high anxiety, palpitations, lightheadedness and dizziness, difficulty
catching one’s breath, hot or cold flashes, the thought that one is going crazy or
having a heart attack—adjudges strong anxiety as dangerous, a loss of emotional
and bodily control. Panic patients shut out anxious and other negative affects, try
to suppress them. But the feelings don’t go away: They later boil up and surprise
them as further panic episodes. Traumatized individuals, too, suppress the pow-
erful feelings evoked by trauma and often feel numb as a result (Markowitz, 2016).
Given these contexts, patients often come to therapy hoping or actively trying
to avoid their emotions. They speak in abstractions and generalities rather than
detailing life circumstances, a distancing technique that keeps emotions at bay. In
describing other people, they frequently using distancing pronouns like “he” or
“she” rather than individuals’ names. They could be talking about the weather, or
about someone else’s life rather than their own.
Many therapists are uncomfortable with strong affects, too. Some prefer to
conduct highly structured therapies—which through their very structure tend to
limit much direct affect. Behavioral therapies are highly structured, can have lots
of agenda items, techniques to deploy, homework to assign and review. While
aspects of such structure and exercises can benefit patients, the risk is that affect
gets avoided during the busyness of sessions. Cognitive therapy risks becoming
too cerebral and emotionally remote unless the cognitions under study are linked
to associated underlying emotions: so-called “hot cognitions” (Ellis, 1991). It’s
possible, although not advisable, to conduct psychotherapy, cognitive behavioral
or otherwise, as an almost rote teaching exercise: crisp, dry, and abstract.
Good classroom teachers teach with verve, connect with their students emo-
tionally, inspire them. In contrast, students can get bored in a class with a dry
and abstract teacher. Sitting through an intellectualized, emotionally distanced
therapy session can equally be dull and uninspiring. It’s the affective arousal of the
encounter that makes it engaging and memorable. Thus in therapy sessions, affec-
tive arousal is important to help connect with the therapist—establishing a good
alliance—and to make the memory of the encounter stick (Christianson, 1992;
Holland & Kensinger, 2010; Catani et al., 2013). These are reasons why affective
arousal is a key common factor of psychotherapy.
Every therapeutic encounter thus offers therapist and patient a choice. They can
collude to avoid emotion and conduct an intellectualized, distanced discourse.
They can, in effect, talk about the weather. Or they can take the plunge into the
less comfortable but more invigorating pool of emotions, with their eddies and
currents. Because patients are often too anxious to initiate this, the responsibility
for doing so lies with the therapist. It becomes the job of the therapist to elicit
particulars—specific incidents rather than generalities, personal names rather
than pronouns—to bring the affect into the room. This is clearly key in an affect-
focused therapy, but it is essential to any psychotherapy in which the therapist
seeks to maximize impact.
In Brief Supportive Psychotherapy (BSP), the focus is always on emotion, with
the expectation that emotions are powerful, can be uncomfortable, but are not
13
Common Factors of Psychotherapy13
dangerous and indeed can impart meaning. A goal of BSP is to elicit feelings and
give patients a chance to sit with and tolerate them, experiencing that even painful
feelings are not so perilous, and that addressing them allows them to dissipate
rather than to build up and need constant suppression. Moreover, feelings orient
patients to what is happening in their lives. So a goal of BSP is to enable the
patient to identify and come to trust his or her own feelings, to learn to see
them as allies rather than enemies. Thus emotional arousal should be inherent
in every BSP session. Indeed, affect is so important in this treatment that we will
devote the next chapter to it.
Affect-Focused Versus Exposure-Based Therapies
The many different extant types of psychotherapies are broadly divisible into two
basic approaches. Affect-focused therapies, some of them listed in the previous
chapter, depend on helping patients to understand their feelings, although the
therapies can differ in how they encourage patients to respond to those feelings.
Psychodynamic, interpersonal, and supportive psychotherapies fall into this
category. In contrast, exposure-based therapies attend more to cognitions and
behaviors, with affect hopefully included (it being a “common factor”) but unfor-
tunately too often neglected in practice. Cognitive and behavioral therapies lie in
this realm. Such therapies are more structured and more likely to assign patients
homework than are affect-focused therapies.
It is possible, though inadvisable, for a therapist to avoid affect while practicing
any psychotherapy, but therapists with cognitive behavioral backgrounds seem
particularly prone to this (Markowitz & Milrod, 2011, 2021). It may be that affect-
averse therapists gravitate to more structured therapies, or that with the ubiq-
uity of cognitive behavioral therapy (CBT) training in psychology and psychiatric
residency programs, many therapists who learn CBT have just never learned to
address affect. It is not that all CBT therapists avoid affect. A quick peek at a vide-
otape of Tim Beck himself conducting CBT dispels that notion (cf., https://www.
youtube.com/watch?v=_dAPW9j3UW4). But an unfortunate risk of a highly
structured therapy, in which the therapist has to perform multiple tasks such as
agenda-setting, homework review, homework assignment, and charting thoughts
(despite the column for listing affect on the CBT Dysfunctional Thought Record
[Beck et al., 1987]), may lend itself to neglecting the emotions. It is at least in part
for this reason that subsequent “waves” of CBT have been developed—not neces-
sarily otherwise more potent, but with more pronounced focus on the affect that
can otherwise get lost.
Coming from a pure CBT, highly structured background does not mean that
therapists cannot expand into a more affect-focused approach (Markowitz et al.,
2008b; Lowell & Markowitz, 2017).
Does this distinction between affect-focused and exposure-based therapies
make a difference? We think it does in practice, and a scrap of neuroimaging data
supports this. Affect-focused and exposure-based therapies, when well conducted,
14
have roughly equal outcomes; that is, roughly the same percentage of patients will
improve on average (Wampold, 2001). As Chapter 7 will demonstrate, it is dif-
ficult to find consistent differences between two well-conducted treatments, re-
gardless of their theories and specific techniques (Wampold, 2001). On the other
hand, treatments may work through different mechanisms and benefit different
subsets of patients who share a given diagnosis. This therapeutic variation among
psychotherapies is analogous to the way differently formulated antidepressant
medications may work via different mechanisms (serotonin reuptake inhibition,
norepinephrine reuptake inhibition, N-methyl-d-aspartate receptor inhibition,
etc.) in helping different subgroups of patients with major depression.
We conducted a pilot neuroimaging study comparing Interpersonal
Psychotherapy (IPT), an affect- focused, non- exposure psychotherapy, to
Prolonged Exposure, an exposure-based therapy, and to Relaxation Therapy, for
110 unmedicated patients with chronic posttraumatic stress disorder. Overall, we
found these two treatments to have essentially equal outcomes (Markowitz et al.,
2015). In a subsample (N =35) of patients from this study who agreed to undergo
neuroimaging, we found that lower anterior hippocampus gray matter volume at
the start of treatment predicted response to IPT 14 weeks later, but not response
to Prolonged Exposure. The anterior hippocampus is part of the limbic system, in
effect the “emotional” circuit of the brain (Fanselow & Dong, 2010).
This was a small group of patients, the results could have been a chance
finding, and we had trouble publishing it. But Dr. Barbara Milrod happened to be
conducting a parallel pilot study (N =24) of patients with panic disorder, using
the same magnetic resonance imaging (MRI) scanner, comparing Panic-Focused
Psychodynamic Psychotherapy (PFPP; Busch et al., 2011), another affect-focused
treatment, to CBT and to Applied Relaxation Therapy, which fall in the exposure
therapy category. Her team had identical findings: Lesser anterior hippocampal
gray matter volume predicted better affect-focused therapy outcome, but not
exposure therapy outcome! These convergent findings of differing therapies for
different disorders convinced skeptics, ourselves included (Suarez-Jimenez et al.,
2020). So focusing on affect can make a difference, and hints of this may be locat-
able in the brain.
FEELING UNDERSTOOD BY THE THERAPIST
People who present for treatment frequently feel misunderstood. Internally, they
are too overwhelmed to really understand what is going on in their own lives.
Moreover, partly because they often are doing their best to “act normal” and con-
ceal their uncomfortable feelings and symptoms from others, they are often mis-
read by and feel misunderstood by others as well. Hence patients may come to
therapy expecting their therapists will misjudge them, too. You can expect this.
It’s accordingly crucial not to assume things about patients but to be curious and
ask, requesting specific examples rather than generalizations (“For example?” is
a helpful probe), and sometimes offering clarifications as feedback to check that
15
you have understood the patient’s answer (“So you felt ashamed and angry after
your manager publicly criticized you?”).
If the therapist can help the patient to feel understood, to see sessions as a
safe place to actively explore emotions and work toward a treatment goal, the
two can establish a therapeutic alliance. The alliance, endlessly studied in psy-
chotherapy research, is a positive predictive factor of eventual treatment success
(e.g., Horvath et al., 2011). Some qualities that influence the treatment alliance
include therapist empathy, genuineness (Nienhuis et al., 2018), and a nonjudg-
mental stance. No wonder an alliance is important: If the therapist and patient
don’t connect and form an alliance, things are not going to go well between
them. If they can establish some mutual trust, that bodes well for the patient’s
capacity to build other relationships and social support, which is itself a good
prognostic factor (Ozer et al., 2003; Gariépy et al., 2016; Southwick et al., 2016).
The therapeutic alliance does not guarantee good treatment outcome, but it’s
a sine qua non: Without one, treatment will likely go awry. For that reason,
a therapeutic alliance is just as important in pharmacotherapy as in psycho-
therapy: Without one, a patient is unlikely to trust the therapist enough to take
the medication (Krupnick et al., 1996).
BSP helps patients feel understood by allowing them to lead the sessions (rather
than the therapist providing an agenda), by eliciting patients’ feelings in response
to whatever material they bring up, and by showing curiosity, concern, and em-
pathy. A mutual understanding of the patient’s emotional life is likely to help the
patient feel understood. The patient is treated as an autonomous individual, not
dictated to.
Helping a patient to feel understood also provides a measure of social support,
the sense that one is not alone, that someone else understands and cares. Social
support is itself protective against a host of psychiatric and other symptoms (Ozer
et al., 2003; Gariépy et al., 2016; Southwick et al., 2016). Social support is thus
associated with resilience and clinical improvement (Ozer et al., 2003; Southwick
et al., 2016).
Optimizing the Alliance
How do you maximize the treatment alliance? The most important element in
achieving this is to provide warm, empathic, and understanding responses. These
are key interventions. They can be verbal (“That sounds dreadful!”) or non-
verbal, such as leaning forward in one’s chair and looking sympathetic when a
patient touches on difficult material. These responses are a major component of
the supportive atmosphere already described as essential to BSP. Another useful
supportive technique is the use of the word “we”—for example, “We will work
together to help your depression [or situation] to improve” or “It’s difficult to dis-
cuss this problem you’re having with your anger, but we can make more sense
of it if we understand how it happens that you lose your temper.” Note that “we”
is reserved for the shared enterprise of therapy. You do not want to use “we” to
16
indicate that you know what the patient is feeling (e.g., “We know you’re angry
at your mother”), which patients may find presumptuous and controlling. That
would not build an alliance.
The therapist will need to adjust to the patient’s particular needs. Aloof and
distant patients require a complementary adjustment on the part of the ther-
apist. Not that the therapist should be aloof and distant, but some titration of
affect will be important: Too much warmth and intimacy from the therapist may
frighten such patients. A therapist’s normal spontaneous supportive behaviors,
such as offering a tissue or opening the door for a patient, may need to be in-
hibited in order to avoid possibly humiliating certain patients. (Nor should of-
fering tissues be rushed so as to cut off the patient’s emotional outflow.) Other
patients may require a more intense supportive behavior with expressions of
concern and more self-disclosure (of emotion, not personal details) on the
therapist’s part. Clues to the management of the therapeutic relationship can
often be gleaned from a history of the patient’s previous therapists and what the
patient liked or disliked about them, or from a general review of the patient’s
relationships at work or play.
Managing the therapeutic alliance in these ways is an important aspect of
maintaining a supportive atmosphere tailored to the patient. In general, depressed
and anxious patients are looking for understanding of their suffering and will
experience interactions with others as additional opportunities for failure. If a pa-
tient is describing an encounter with another person that went painfully wrong,
how should the therapist react? A sympathetic statement such as “Brave that you
tried. You did the best you could” will be more successful in initiating exploration
of what went wrong than something (non-BSP) like “Okay, now let’s see how you
can improve on this behavior.” (Such an intervention would cut off emotional ex-
ploration.) Appreciation of the effort and pain that the patient endured in having
an unsuccessful date will produce better results than saying that you have to cast
ten lines to catch one fish; moreover, it maintains the therapist’s focus on affect
rather than on problem-solving.
An important aspect of maintaining the positive therapeutic alliance is fos-
tering a basic patient confidence in the therapist’s therapeutic abilities and
allowing these to spontaneously emerge. This is indeed one of the benefits many
BSP trainees have described: the capability of “just sitting” with and helping a
patient without employing fancy techniques. One cannot pretend to be warm,
caring, or interested, and it is an error to try to do so because it will usually
appear stilted and artificial. The same goes for false optimism. (On the other
hand, therapists need to maintain realistic therapeutic optimism in the face of
the patient’s depressed pessimism.) Our assumption is that everyone—not just
a therapist—possesses the capacity to feel relaxed, warmly related, and caring in
a situation. Over time most therapists acquire this ability, and if it fails them in
a particular session they can ask themselves why and engage in a personal ex-
amination of themselves, utilizing outside supervisors if necessary. Beginning
therapists may lack this confidence and may benefit from the temporary sup-
port of a supervisor.
17
Maintaining a positive alliance also does not mean that patients may not get
angry at you. Therapists make missteps, and even without intending to they may
alienate or distress a patient. Hence it’s important to allow and indeed encourage
patients to raise any emotions they feel about the therapist or therapy, including
the negative ones: Most patients do not feel comfortable criticizing an expert au-
thority. Yet you are interested in their feelings, want to encourage their comfort
in raising them, and also need to know about potential therapeutic “ruptures”
(Safran & Muran, 1996) in the alliance.
FRAMEWORK FOR UNDERSTANDING
Patients generally enter treatment feeling bewildered and overwhelmed by both

internal symptoms and external events. People need some degree of structure to
orient themselves (Ehlers et al., 1988), and patients entering treatment generally
lack that. Thus two important aspects of beginning treatment are (1) to explore
the patient’s expectations of the therapy and (2) to provide some structure for the
therapy itself: that is, to explain what the patient can expect in and from the treat-
ment. This helps acclimate the patient to the treatment process and provides an
opportunity to agree on goals that can contribute to a therapeutic alliance.
For BSP, the message is simple. The organizing theme is that treatment will
focus on how the patient is feeling in day-to-day life. A therapist could note that
the patient seems wary about the strength of his or her feelings, that feelings can
be powerful but are not dangerous, and that they’re important to explore, accept,
and understand. It is best not just to announce this but to present the explanation
in the experiential context of the patient having already voiced some emotional
reaction to a particular life situation.
Another aspect of a framework for understanding is giving the patient a di-
agnosis. This helps contextualize symptoms as an illness from which the patient
is suffering, not—as it often feels—as some inherent flaw in the patient’s char-
acter or person. In a research protocol, the diagnosis is a study entry criterion, so
the patient should have received some explanation of the diagnosis as part of the
evaluation and consent process. Nonetheless, this insight is frequently lost in the
maelstrom of symptoms patients experience, and in the peculiar amnesia for the
fact that they may well not always have felt as they now do or could recover. Thus
at points—not too often—the therapist may want to remind the patient that some
of the feelings he or she is experiencing are symptomatic. If a depressed patient
is feeling very hopeless and despairing, the therapist lets the patient sit with the
feeling, but having it explored it with the patient can underscore: “Hopelessness
is a symptom of your depression. As you get better, it is likely to recede. Your sit-
uation may be difficult, but despite the feeling, things are almost never hopeless.”
The BSP therapist aims to minimize intellectualized psychoeducation and to
present points about the patient’s feelings or diagnosis as a clarification at a mo-
ment when the patient is feeling something important. BSP is primarily experien-
tial rather than didactic in its work.
18
EXPER TISE
A distressed patient wants to know that he or she is in good hands. It is reassuring

to convey to the patient that you know how to proceed, that you have the know-
ledge and experience to have a good chance of helping the patient. The patient
has a treatable condition, and the treatment you are providing is likely to help
(see Chapter 7). The implicit message is that you understand what is going on,
even if the patient does not as yet. It is best to communicate this implicitly rather
than explicitly: not by, for example, announcing your credentials, but nonverbally,
through your poise and your responses to clinical situations (Greenacre, 1957;
Markowitz & Milrod, 2011).
Again, patients find feelings dangerous and threatening and are likely to avoid
them, by not raising them in the first place and by changing the topic when
they do arise. When a patient does talk about a painful situation or painful
feelings, you as BSP therapist can mutely indicate, through a concerned but
unpanicked expression, by a relaxed rather than tense posture, by maintaining
empathic eye contact and nodding seriously, that you’ve heard such things be-
fore and are not alarmed, and that feelings are meaningful and you’ll hear them
through with the patient. If need be you can say so explicitly, but it’s preferable
to have the patient recognize this through your manner. If the patient changes
the subject, you can note this and, after a pause, steer the patient back to the
threatening topic:
I notice you changed the subject. Why? What were you feeling? . . . Can we
go back to what you were just saying, which you seemed to have some strong
feelings about?
The goal is always to pursue patient emotion.

If a patient does release a blast of affect, bursting into tears or turning red with
rage, this may rattle not only the patient but potentially the therapist. Yet should
the therapist flinch, it disconfirms the key message: that feelings are powerful but
not dangerous. Thus it’s crucial as a therapist generally (Markowitz & Milrod,
2011), and certainly as a BSP therapist, to treat patients’ emotions seriously
without pulling back or cutting them off. Catharsis matters. Reaching too soon
for the Kleenex box, or trying to prematurely calm an angry patient, gives pre-
cisely the wrong message. Rather, it’s important to show that you can tolerate
such emotions and that the patient can too. It can feel frightening to have a very
angry patient in your office, but unless you seriously expect the patient to become
violent, the danger lies only in the perception. Having discharged strong emo-
tion, the patient spontaneously calms—and realizes nothing lethal has occurred.
A session in which this transpires, with the therapist concerned but always en-
gaged rather than withdrawing or deflecting the affect, and perhaps saying little
or nothing in the process, is a nice demonstration of subtle therapeutic expertise.
That’s a great and memorable session, and the patient is likely to decompress and
relax thereafter.
19
You as a mental health professional also have the expertise to know that the
patient’s symptoms are treatable, however hopeless the patient may feel about
them. Hopelessness is a depressive symptom, not an accurate prognosis. You
should look concerned and sympathetic if the patient expresses distress but not
look resigned or defeated. In the battle between your realistic morale and a de-
pressed patient’s despair or an anxiety patient’s panic, your calm poise is likely to
carry the day. And the less you say in the interval, the better. Just be there with the
patient. Wait out the storm.
THERAPEUTIC PROCEDURE
Every psychotherapy has its own ritual. This procedure is part of what provides
structure to sessions, creating a safe and expectable environment for the patient.
In CBT, for example, it involves setting an agenda at the start of each session,
reviewing and assigning homework, eliciting and behaviorally testing out whether
“automatic” negative thinking in depression is distorted, etc. (Beck et al., 1987).
In BSP, the tacit rules are these:
• The topic of sessions is up to the patient, and the therapist follows the
patient’s lead. This imbues a sense of patient autonomy even at a time
when the patient may not be feeling very competent.
• Treatment has a fixed duration and timing: for example, 12 weekly
50-minute sessions. BSP studies have ranged in dosing between 10 and
16 weekly sessions; it is unclear what an optimal duration may be. The
design of a research trial typically sets this length so that patients in
different treatment conditions receive equal doses of psychotherapy. In
general practice, the therapist can pick a length but should stick to it. The
10-to 12-session time limit presses the patient to work hard during the
limited interval of treatment, moving therapy forward. It also implicitly
suggests that the patient is likely to be better after a relatively brief
period, countering patient symptoms of hopelessness.
• In the context of whatever specific life circumstances the patient brings
up (financial worries, an encounter with another person), the therapist
will help the patient explore the patient’s emotional responses to the
situation.
Most patients will grasp these parameters in the first session or two without
formal instruction. If this is a research study, the time limit and assessment
schedules will already have been explained as part of the informed consent pro-
cess, although some patients may need reminding. In non-research clinical prac-
tice, the therapist will have to explain some structural elements of the course
of therapy: that is, the time limit and timing of sessions, any planned therapist
vacations that might interrupt treatment, and the schedule of symptom ratings
that will inform you both about the patient’s progress.
20
Beyond that, however, BSP is a relatively unstructured therapy, and optimally

the patient learns the treatment method by osmosis rather than your spelling it
out. If a patient asks, you can briefly answer, but if you begin sessions by saying
hello and silently looking expectant, or simply asking, “How are you?”, most
patients will start talking about what’s on their minds. (Although: see the case of
Mr. F in Chapter 9.) Over time patients glean the rhythm of the therapeutic ap-
proach. This is far preferable to the therapist rigidly spelling everything out at the
start. If you must say something—which is preferable to a lengthy, confused initial
silence—you can say that you are interested in the patient’s emotional life: “I’m
interested in your feelings about your life.”
OPTIMISM FOR IMPROVEMENT
Patients arrive for treatment feeling demoralized and pessimistic. They often see
their problems as hopeless, themselves as incurable due to what feels like their
defective character. Yet patients with depressed and anxious diagnoses gener-
ally have good prognoses; it’s just that their symptoms are misleading them. And
when such symptoms remit, it often turns out that they are not “character”—even
though they have registered that way to the suffering patient. What appears to be
personality pathology often fades with treatment of the Axis I disorder (Markowitz
et al., 2015a; Keefe et al., 2018).
A treatment in which a therapist evinced no belief in the therapy he or she
was providing would likely have a poor outcome, confirming the patient’s pessi-
mism. (This is a problem with having the same therapist conduct competing ther-
apies in a research trial, only one of which he or she feels skilled in and believes
in [Falkenström et al., 2013].) Nor should the BSP therapist be blithely, cheerily
positive, as this risks trivializing patients’ suffering and may cause them to feel
misunderstood (Markowitz & Milrod, 2011). (This is a potential problem with
positive psychology.)
Instead, the therapist should recognize and acknowledge the patient’s suffering
while recognizing that it is treatable. Such balanced therapeutic realism is a lot
more optimistic than the patient’s initial perspective: In fact, most patients are
likely to improve with effective treatment. And should the current treatment not
help, as no treatment is a panacea, there remain numerous effective alternatives
for mood, anxiety, and all psychiatric disorders.
SUCCESS EXPERIENCES
Depressed and anxious and other patients tend to have pessimistic expectations,
to anticipate that life will go wrong. It is therefore helpful for them to have posi-
tive experiences that contradict such expectations. These successes might include
a pleasant encounter with another person, an achievement at work, or a sense
of mastery over one’s thoughts and feelings. When things go well, people tend
21
to feel better; and if they are the active agents in making things go well, they feel
empowered and still better. It’s the difference between winning the lottery and en-
gineering a life change: Both are good, but being able to credit oneself for active
agency inspires a sense of self-confidence and competence. If in the course of a
therapy a patient can generate a positive experience, it tends to contradict symp-
tomatic pessimism and generally contributes to feeling better and more in control
of one’s life.
In BSP, that success experience is generally an emotional one: tolerating a
strong feeling and possibly expressing it to the therapist or to someone else. The
BSP therapist does not tell the patient what to do, simply validates the patient’s
feelings. Once they’re validated, the patient may decide to express the feelings
not only in session but in interpersonal relationships. Or the “success experience”
may be simply the discovery that one’s internal emotional churnings are distin-
guishable, meaningful, and tolerable, not “bad.” The BSP therapist helps elicit
these emotions, encourages the patient to explore and distinguish among them,
and validates the patient’s understanding and toleration of such feelings. An im-
portant dimension of life is recognizing the meaning of your internal life: that
how you feel, positive or negative, has value. Many patients enter therapy unaware
of this dimension, and many leave with a new appreciation of their emotional life
and its uses.
To summarize, these “common factors” are essential elements of any psycho-

therapy and account for much of all psychotherapies’ benefits (Wampold, 2001,
2015). The common factors also make up pretty much the entirety of BSP. Thus in
training BSP therapists, I have offered them a paradoxical therapeutic challenge
(Markowitz, 2014):
First: If you can’t do this, the rest of psychotherapy doesn’t matter. Delivering the
common factors well is the sine qua non of all treatment. You won’t be able to de-
liver the specific techniques of CBT or the pills of pharmacotherapy if you can’t
make a strong alliance.
Second: If you can do this, the rest of psychotherapy doesn’t matter. The bulk of
what you can provide, you’re already providing.
That is, naturally, an oversimplification. But these are key skills, and for many
patients these skills will suffice to get them better while helping them to under-
stand something important about their emotional lives.
2
Affect Focus
Think about what’s happened in your day so far today. Perhaps you woke up with
something to look forward to and felt excited. Or, conversely, awoke with a sense of
dread or annoyance about something you didn’t want to face. In the course of the
day, something may have occurred or you may have done something that affected
your mood for the better or worse: Perhaps you had a pleasant encounter with
someone that left you with a positive emotional residue, or an unpleasant one that
left you disappointed or angry. You probably take such feelings for granted, seeing
them as expectable responses or cues for what has happened or what lies ahead.
Many of your patients, however, may not approach their lives and feelings in
this manner. Living with depression and anxiety, they are likely to awaken in a
haze of misery to which they attach no particular meaning, or for which they
simply blame themselves as evidence of weakness, a defect in character, or a
doomed, cursed fate. They are thus beset from both within and without: by ex-
ternal pressures and internal surges of distressing negative affect. They try to
suppress or ignore such feelings, and in general regard their emotional life as
a problem, not a benefit. Yet it takes considerable effort to constantly suppress
strong emotions, which will generally well up either as emotional outbursts or as
psychiatric symptoms.
Thus we tend to take for granted that others share our emotional range and
comfort with reactions, but clearly that is often a mistaken assumption. Some
people, particularly those with psychiatric disorders, lack a basic attunement to
and vocabulary for their feelings and have great discomfort in tolerating them.
The goal of Brief Supportive Psychotherapy (BSP) is to rectify this state. It may be
helpful to briefly review the key negative emotions with which patients struggle.
ANGER
In some ways, this is the hardest emotion for many patients to own. It feels, and
is, aggressive: It’s the “fight” alternative to “flight” at the prospect of a confronta-
tion. Anger has a long history as a taboo emotion. The sainted sixth-century Pope
Gregory the Great established it—wrath—as one of the Catholic Church’s seven
deadly sins. (Patience is its virtuous antidote.)
23
Affect Focus23
Depressed individuals avoid anger for multiple reasons. They tend to find anger
a frightening, “bad” emotion, evidence of their own defectiveness. They see anger
as proof that they are nasty or “mean,” even when the anger is provoked and even
if it remains unexpressed. Feeling unlovable, and that people only put up with
them out of pity anyway, they perceive that, were they to angrily complain or
object to anything, others would abandon them. Depressed individuals feel un-
worthy of getting angry at others or having desires or dislikes of their own. They
always uncannily see and place the other person’s needs and perspective ahead
of their own. If they have a history of having been bullied, abused, or otherwise
viciously mistreated, they may fear behaving so cruelly themselves and hence say
nothing even when appropriately provoked (Markowitz, 1998). That’s patience to
a fault.
As a result, depressed individuals avoid confrontation, don’t object to the irri-
tating behavior of others, and keep the feeling in. The only options they perceive
are to put up with slights and indignities in relationships or to leave them. Years
ago, psychoanalysts ranging from Abraham (1911) to Freud (1917) and Rado
(1927) connected anger to melancholia, or depression, so-called “anger turned
inward.” Although that is surely an oversimplification, it is clinically astute to
see that such contained anger contributes to depression: It’s uncomfortable and
hard to keep a strong emotion like anger contained. It’s often emotionally ex-
hausting to keep such feelings down while feigning a “normal,” peaceable facade.
Many depressed patients end up hating themselves for their own weakness and
impotence—while simultaneously feeling they’re bad people for harboring anger
toward others.
Anger in excess can be problematic. Having been on the receiving end of abu-
sive anger may sensitize an individual to forswearing it. Yet taking a dichotomous,
“all or nothing” approach to the emotion has obvious problems. If you don’t re-
spond to an angry feeling by objecting to other people’s obnoxious behavior, you
end up with pent-up discomfort. Meanwhile, the other people’s uncorrected be-
havior is likely to continue. The depressed individual becomes increasingly irri-
table. When individuals who are holding in such emotions lose control and have
an angry outburst, it is often misdirected, a response to some trivial event with
a relatively innocent bystander rather than targeting the behavior of the person
they’re really mad at. This misguided paroxysm frequently reinforces the convic-
tion that the individual is an overly angry person, getting angry at a third party for
“no reason.” The individual then works that much harder to suppress the emotion.
To the extent that depressed individuals do respond to others’ behavior with
more than acquiescence, their feelings tend to come out in indirect, “passive-
aggressive” ways or as sarcasm. The term “passive-aggressive” is often unhelpfully
applied to many depressed individuals (even by themselves), in effect blaming the
victim for not knowing how to more comfortably and directly express an uncom-
fortable feeling. The goal of therapy should be to allow the patient to acknowledge
anger as appropriate, not “bad,” and to find a modulated range of expression for
that anger, as opposed to either explosion or suppression.
24
Ms. A, a chronically depressed and anxious 52-year-old married business-

woman, had hired a personal assistant to help her manage both work and
personal affairs but found that she was unhappy with their relationship.
She had difficulty in asking the aide to do things and ended up feeling
bullied, in fact doing more for the assistant than the assistant was doing
for her. The patient feared that if she said anything critical she would
“poison” their relationship, leaving the assistant with a sullen attitude.
The therapist, who had said little in the session to this point, focused on
Ms. A’s emotions.
Therapist: “So how do you feel about employing Marta and having her
boss you rather than doing what you’ve asked?”
Ms. A: “I don’t like it. I’ve been upset.”
Therapist: “What kind of upset?”
Ms. A: “It doesn’t feel right. I guess . . . I feel angry. [Pause.] I don’t like it.”
Therapist: [After a pause, waiting to see if she would elaborate] “What do
you think: Does it make sense to you that you’re angry?”
Ms. A: “I guess so, yes, sometimes. But let me tell you about my doctor’s
appointment . . .” [Goes on for a minute or two]
Therapist: [Interrupting] “I’m sorry. So you feel angry at Marta, and
then what?”
Ms. A: “I don’t want to upset her. I just have to hope she’ll do what I asked.”
Therapist: “Did she put in the order you asked her to?”
Ms. A: “I don’t think she has yet. I don’t know.” [Looks uncomfortable]
Therapist: “So how do you feel?”
Ms. A: “I told you, I don’t like it, but I’m not sure what I can do about it.
I mean, I don’t want an employee mad at me.”
Therapist: “And the emotions?”
Ms. A: “Angry, but also nervous that she won’t like me, our relationship will
go bad.”
Therapist: “So you feel angry. Is it reasonable to be angry if you ask her to
do it and she apparently hasn’t?”
Ms. A: “Yes, I guess so.” [Silence]
Therapist: [After another lengthy pause, awaiting whatever Ms. A might
bring up] “So when you feel anger, reasonable anger, what do you do
with it?”
Ms. A: “I get busy with other things: I go for a walk, work out at the gym.”
Therapist: “That all sounds healthy, but how does that help you with
Marta?”
Ms. A: “It doesn’t . . . So what I do with the anger? Get a punching bag? Go
to HR? . . . I’m afraid if I say anything to her she’ll have a bad attitude, she
won’t like me, and I’ll never get anything out of her.”
Here is an instance where a fairly high-powered executive finds herself at the

mercy of an employee because she is so uncomfortable with her own emotions
25
Affect Focus25
that she cannot use them to confront her. Note the lengths to which she goes
to avoid her feeling state, trying to reduce tension through exercise. While this
physical activity may have some benefits, it in no way addresses the ongoing inter-
personal problem or the patient’s feelings about it. It simply blows off steam and
releases muscle tension.
This sort of situation frequently arises for patients with depression and other
psychiatric disorders. The key to treatment, then, will require the patient’s iden-
tification of her feelings (which Ms. A can already name) and a willingness to
stay with them (she tries to evade them in this vignette). The therapist can then
validate Ms. A’s anger (“Of course you’re angry if you hired her to do things and
she’s giving you a hard time instead”) and explore: What happens to that feeling
of anger? It may emerge that containing the anger is effortful and tiring, leaving
Ms. A feeling pent-up, and allowing the pathological relationship to continue.
Eventually, Ms. A might confront Marta and tell her she’s dissatisfied with her
work and needs to get things done more promptly. This would (1) give Ms. A a
sense of the utility of her emotions and a sense of having some control over them,
(2) provide a directed emotional release (catharsis) by discharging them in the
confrontation, and (3) hopefully lead to a greater sense of emotional and environ-
mental mastery and symptom relief.
Like patients with mood disorders, patients with anxiety disorders gravitate
toward the anxious, avoidant pole of the fight-versus-flight dichotomy. They, too,
feel dependent on and do not want to risk alienating others. They find the strength
of the anxious feelings dangerous, hence try to suppress them. Pushed out of con-
sciousness, these submerged feelings can bubble up as seemingly “out of the blue”
panic attacks with seemingly dangerous physical symptoms.
Yet anger is normal: We all feel it, and we feel it for good reasons. Anger iden-
tifies some noxious, irksome, unjust life situation that evokes it, offering us the
opportunity to respond in order to correct the problem. That correction could be
as simple as saying, “That bothers me. Please don’t do that.” This may seem very
basic—it is very basic. Nonetheless, it presents a huge problem for depressed and
anxious patients. First, the feeling may not register at all, being almost reflexively
suppressed or pushed aside. Even when they recognize the emotion, they feel un-
sure how to respond. They are not practiced in confronting people. They may
literally lack the words, not know how to say that they’re angry. Mistrusting their
anger as an internal problem rather than a signal, and therefore not acting on it
to confront others, means that the bothersome situation that provoked the anger
will continue.
The person who is bothering the individual might be abusive, which would
complicate a response. On the other hand, in the course of everyday life individuals
often bother one another unintentionally. In either case, the offending party does
not receive the usual feedback to stop and may not even realize that the individual
objects to the behavior. Over time, patients become sensitized to minor slights,
which build into greater irritations. The environment, and the people around you,
understandably feel oppressive when you lack a sense of control over it.
26
SADNESS
Sadness is another emotion that many depressed individuals find intolerable,

in part because it feels too uncomfortably akin to depression. Yet it too is
meaningful. People do not feel sad at random. The feeling arises with sep-
aration or loss: homesickness, losing a game, having someone whom you
care about die. This is painful but nevertheless helpful information about the
environment.
Grief is a normal if sometimes excruciating response to death, and depressed
patients tend to avoid and suppress it because it feels too close to depression. Yet
failing to process grief is a set-up for depression, what is termed complicated be-
reavement. It’s the people who become too avoidantly busy, too occupied with
other things to have a chance to mourn, who are at greatest risk for unresolved
grief and clinical depression. It’s important, therefore, to be able to recognize
painful negative affects of loss and mourning as healthy sadness—the pain of
breaking a bond with someone close to you. How much you miss the deceased
may be a marker of how painful the loss feels; but in any event it’s normal, and
important to experience.
In a manner analogous to the angry person trying to physically exercise his
or her emotion away, individuals with complicated bereavement get busy rather
than mourn. They may distract themselves by focusing on the needs of others—
facilitating their mourning—while neglecting their own, avoiding the pain of loss.
For such patients, it will again be helpful to come to terms with painful sadness
as a normal feeling, its intensity proportionate to the attachment bond that death
has ruptured. Such feelings, if processed, transmute and diminish in strength, al-
though recurrent waves of mourning on anniversaries and other occasions are
normal. Suppressed, however, such feelings fester as ongoing depressive and anx-
ious symptoms.
ANXIETY
The flip side of the coin from anger, anxiety denotes a threat or uncertainty in
the environment. When in danger, we should feel fearful: It’s important to know
when trouble is brewing in order to respond to it either through fight or flight.
That is how the species has survived. The prevalence of anxiety disorders, ranging
as high as 29% (Baxter et al., 2013), suggests that elements of anxiety must offer
evolutionary advantage; otherwise, they would have been selected out. Yet de-
pressed and anxious patients tend to see anxiety as a purely internal, disembodied
emotion, as a threat in itself rather than a signal of threat; or else as embodied
somatic symptoms (palpitations, shortness of breath, dizziness, hot and cold
flushes, etc.) disconnected from any environmental stimulus. The Diagnostic and
Statistical Manual of Mental Disorders (DSM) definition of panic attacks, which
includes such symptoms, elides the understanding that they stem from defensive
27
Affect Focus27
avoidance of affect (Milrod et al., 1997): “The panic just came out of the blue!” “I
thought I was having a heart attack!”
Psychic and somatic anxiety can be intensely uncomfortable, making it un-
derstandable that individuals want to avoid it. Avoidance of anxiety often leads
to increasing constriction and withdrawal from life, ultimately resulting in
agoraphobia.
And although frightening and uncomfortable, intense anxiety is not
dangerous—it just feels that way. Nor does it last forever: The individual who can
recognize that he or she is anxious, and identify the threat that is provoking this
reaction, can often calm down.
Many anxious patients present with conversion symptoms. Their anxiety
registers not as an emotion, but as a physical symptom such as a stomachache,
headache, or episode of dizziness. This somatic event appears to occur “out of the
blue.” The patient focuses on the physical, but the BSP therapist needs to recognize
this as an anxiety equivalent to a panic attack, and to try to help the patient rec-
ognize it as a response to some anxiety-provoking event. The implicit message is
that anxiety, unrecognized, emerges in the body. The therapist does not point this
out to the patient but asks about what might have happened to distress the patient,
helping to connect the symptom to a stressor.
EXPLORING THE PATIENT’S EMOTIONAL LIFE
Anger, sadness, and anxiety constitute the “big three” of uncomfortable negative
affects. It is important to help patients recognize that these differing affects signal
different things. There are other negative affects, of course: disappointment,
shame, jealousy, loneliness, disgust. All of these may arise singly or in combina-
tion. As a BSP therapist, you have neither the time nor the need to systematically
review and address all of these with the patient. Your goal is to help the patient
identify and understand whatever feelings he or she is experiencing, normalizing
them when appropriate.
From a BSP perspective, the fundamental problem patients have is that
they find their feelings unduly frightening. This should not surprise the clini-
cian: The affects of depression and anxiety can feel excruciating. On the other
hand, one cost of depression, panic attacks, and posttraumatic stress disorder
(PTSD), or perhaps a latent vulnerability to them, is that patients then gen-
eralize their discomfort to any sort of strong feeling: The whole domain feels
best avoided. Yet competent social functioning requires the ability to react to
and to express feelings: If someone makes you angry and you don’t tell him or
her, he or she will probably continue to do so. Getting used to feelings and let-
ting them out—catharsis—is unburdening and helps patients come to tolerate
strong affect. They can then restore it (if they had previously been better able
to deal with feelings before the current episode of illness), or perhaps add it for
the first time, to their repertoire.
28
Meanwhile, the cost of not addressing feelings is high. Strong negative affects
may be painful, but suppressing them helps to maintain symptoms. It’s effortful,
exhausting work to do so. Affectlessness leaves you blind to upsetting events and
to difficult relationships in your environment. Dissociation is one way of warding
off strong affect, but it’s an uncomfortable state for most people. Without explic-
itly saying so, the therapist’s job is to rectify this situation.
So an initial challenge of BSP is to explore the patient’s emotional life, a topic
that the affect-phobic patient may not welcome. You need to gauge the following.
How Aware Is the Patient of His or Her Emotional Life?
Some patients present as practically alexithymic, not acknowledging feelings at

all. Others may acknowledge emotional “upset” but lack an emotional vocabulary
with which to parse their feelings and the feelings’ respective meanings. They may
report events but not associated emotions: One thing happened, then another,
but it all sounds distanced, detached, and flat. Others describe feelings at an intel-
lectualized remove: “There was anger,” as opposed to “I was angry.” Still others
may acknowledge feelings but feel guilty about them: “It was terrible of me to feel
like I hated my husband then”—even if the husband had provoked anger through
enraging behavior.
How Does the Patient Handle Feelings, and Especially

Negative Affect?
Depressed and anxious patients may mistrust even positive emotions as

treacherous: Getting your hopes up risks having them dashed. But negative
affects—anger, disappointment, sadness, etc.—register as painful, counterpro-
ductive: “What’s the use of feeling like that? It just hurts.” It may be that the pa-
tient grew up in a home where feelings were in fact dangerous, associated with
abusive, perhaps intoxicated parents. A rageful parent wielding a belt buckle
is in fact an embodiment of dangerous anger: “I never want to get angry be-
cause I’ve seen how destructive it is.” This is a powerful rationale for trying to
avoid getting angry, but absence of anger is unfeasible in the course of daily life.
Moreover, it of course doesn’t follow that the patient’s anger is dangerous just
because the sadistic abuser’s was.
Or perhaps the patient was raised in a household where no strong feelings of
any kind were tolerated, where children were entrained to be seen but not heard.
In eliciting a history, it’s helpful to gather specific instances of how the patient
interacts with other people and handles feelings in the process. How aware is the
patient of different feeling states? How tolerant is the patient of a range of feelings?
Does the patient have the sophistication to recognize that feelings can be mixed
and modulated?
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Affect Focus29
To What Degree Does the Patient Express Those

Feelings?
The patient may report: “I felt a little annoyed at her, but of course I didn’t say an-
ything.” “What’s the point of telling Jim how I feel? It would only cause trouble.”
Some people may avoid direct confrontation because it is culturally unaccept-
able, but even in such cultures there is generally some indirect mechanism for
expressing dissatisfaction, disappointment, irritation. For example, in rural
Uganda a wife may not directly express anger toward her husband but can un-
ambiguously communicate her displeasure by cooking him a bad meal (Verdeli
et al., 2003).
Depressed and anxious (and other) patients often have emotional reasons for
avoiding confronting others, beginning with the discomfort they themselves feel
about the feelings to be expressed. Or they may expect retribution should they
(timidly) state their annoyance. Or they may systematically avoid anger, keeping
feelings internalized until grievance piles upon grievance in a relationship to the
point that the patient explodes—a pressure cooker effect—but then finds the out-
burst over the top, disproportionate to whatever minor event provoked the re-
action. The patient then concludes, “I’m a really angry person” and repeats the
pattern of suppressing anger until it once again wells over. This maladaptive pat-
tern is worth addressing.
Depressed and anxious patients often feel ashamed of their feelings, that they
would present an embarrassing weakness if revealed. This may be true even for
positive affects (“Real men don’t show their feelings”) but is particularly the case
for the negative affects that characterize mood, anxiety, trauma-related, and other
disorders. In particular, sadness, anger, and anxiety, as signs of their weakness and
defectiveness, are emotions to conceal. Because patients feel this way, they assume
others would, too: “If I told her how I feel, she’d think I was weak, a loser.” “The
fact that I sometimes hate my family shows what a terrible human being I am. I’d
never admit that to anyone.”
BSP distills psychotherapy down to its emotional essence. Much of what you
will do as a BSP therapist is to elicit these feelings, let the patient sit with and tol-
erate them, then try to normalize them for the patient. It is hard to get through life
if you can’t trust your own feelings.
How Much of What the Patient Internally Experiences Is

Appropriate (But Discounted) Versus Symptomatic?
Some emotional responses, such as guilt, or anxiety about others, may be

symptoms of the depressive syndrome, with little substance in the patient’s ac-
tual life. Or is there indeed a reason for feeling guilty about some aspect of the
patient’s life? This is a difference that matters, and the patient may be unskilled at,
or confused by the current syndrome in, differentiating between the two. Again,
30
it is typical of mood, anxiety, and trauma-related disorders that, having lived with
symptoms for a period of time, patients see them as part of who they are, rather
than symptoms they have.
How Is the Patient Feeling About You and the Therapy?
This is a slightly different issue but relates to those above. It concerns the thera-
peutic alliance, which you want to facilitate so that therapy will proceed well. The
alliance deserves monitoring in any treatment setting. How the patient feels about
you as the therapist may involve transferential feelings, but you will not interpret
them in BSP. It could reflect aspects of structural racism (Stoute, 2020). It might
relate to negative experiences the patient has had with previous therapists or in
other health care encounters, a history every psychotherapist needs to know about.
If a prior therapist or doctor has been ineffective, confusing, critical, rude, or
abusive, you can apologize on behalf of the profession, thank the patient for having
told you, and promise to try to avoid such behavior. It’s always worth saying, and
particularly to patients with checkered therapy histories:
“If anything happens in our therapy that bothers you, please tell me. I will not
be trying to upset or offend you, and it’s important that you be as comfortable as
possible. It’s okay to tell someone when he or she is bothering you.”
As the therapy progresses, you are likely to see and feel changes in the patient’s
moment-to-moment expression and attitude. A traumatized, anxious patient may
relax his or her guard and open up, showing some trust in the therapist; and then at
some tiny misstep—which the therapist may not even perceive having made—snap
back into a wary attitude. This happens frequently in the treatment of patients with
PTSD who, having been repeatedly wounded by unpredictable circumstances, scan
the environment and struggle to trust others. If such a therapeutic “rupture” occurs
(Safran & Muran, 1996), the therapist cannot ignore it: “You had been sounding
more open and trusting with me, and you suddenly pulled back and looked un-
comfortable. Can you tell me what just happened, please?”
In particular, it’s important to ask: “What did you feel then?” If the patient then
blames the therapist for some peccadillo, it is worth exploring what happened,
and good form to then apologize: “I’m sorry, I didn’t mean to upset you. Good that
you tell me when I do something that bothers you.” Such an intervention can only
build trust and give the patient some sense of control within the relationship—
which so many patients lack.
A therapist, seeing the patient become silent and frozen, and look off into
space, asked what had just happened. Ms. B replied that she felt humiliated
and hurt by what the therapist had said. She then again lapsed into silence.
After several minutes the therapist said, “You look angry at me for what
I said, and it would helpful if we could talk about it.” Ms. B this time vir-
tually screamed at the therapist that she was not angry, but that the thera-
pist should just be silent. (The therapist stayed silent.) After a while Ms. B
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Affect Focus31
volunteered that she often got these “silence attacks,” and that her parents
and husband recognized and understood them and avoided her when they
arose. The therapist thanked Ms. B for the explanation and apologized for
what had offended her.
Appreciating that these “silence attacks” were attempts to control hurt and
anger was a turning point in the treatment. It deepened the therapeutic alli-
ance. The therapist avoided repeating her mistake. Ms. B, meanwhile, became
more frank in expressing her negative affects, both in therapy and—without
therapist prompting—at home and work.
As a BSP therapist, you need to work from the premise that emotions are
normal (and unavoidable) in daily life, including negative affects. This is a
viewpoint many of your patients will need help in understanding and accepting.
It is useful as you listen to put yourself in the patient’s shoes, to envision how
you might feel and respond in the patient’s situation. This can provide clues to
how the patient might be feeling, whether or not those feelings are verbalized or
even within the patient’s current awareness. Think about what might be missing
from the patient’s acknowledged responses to a situation. (How would you feel?)
If someone treats the patient discourteously, does the patient ignore parts of his
or her emotional reaction? For instance, does the patient seem aware of feeling
anger? Exploring these discrepancies can be valuable in helping the patient to de-
velop an emotional vocabulary to parse his or her feelings.
Many patients are so uncomfortable with their emotions that negative affects
simply register as a nebulous “I’m upset.” That’s a start, but it’s not really helpful
for decoding life: Different emotions have different meanings. Sadness generally
indicates a separation or loss; anxiety, a threat in the environment; anger, unfair
or hurtful treatment; disappointment, that someone has let you down. Lumping
them all together provides little understanding of why the patient might feel upset.
Identifying and naming sadness, anxiety, anger, disappointment, embarrassment,
and so forth therefore matter. Helping a patient to articulate just what kind of
upset he or she feels can provide a new outlook on life and on emotional life. It
explains the feelings, and the feelings explain the situation.
So if you feel angry and there’s a reason for it—someone is mistreating you,
something feels unfair—the feeling helps to explains the event, and you can use
that emotional signal to decide how to respond. This is an inevitability of life: Many
things are annoying and we may want to pick our battles, but some are worth
fighting. Just how to fight them is a challenge for most people. We tend to over-
react or underreact; perhaps no one is perfectly comfortable with intense anger.
Exploring this can be an important part of psychotherapy—the more so for indi-
viduals with anxiety or mood disorders, who tend to misperceive these feelings and
to avoid confrontations. As Aristotle (1992) noted more than two millennia ago:
Anyone can become angry—that is easy; but to be angry with the right person
and to the right degree and at the right time and for the right purpose, and in
the right way—that is not within everyone’s power and is not easy.
32
Aristotle got it right, at least in theory, long ago. How many of us have gotten it
right in practice since? But it’s a worthy focus. The same goes for sadness, a normal
response to which depressed patients are allergic. And for anxiety, an often useful
cue that patients with anxiety disorders shun due to a similar blurring of signal
and symptom (Roose & Glick, 2013).
PROCEDURE
Eliciting Feelings
The first challenge in BSP lies in eliciting feelings from patients who lack comfort
in expressing or even acknowledging them. For patients who present distanced
reports of their activities or speak in broad abstractions (“My marriage is fine”),
ask for particulars. “For example?” is a helpful interjection. This recalls Myrna
Weissman’s injunction that the Interpersonal Psychotherapy (IPT) therapist dig
for “the nitty gritty” details of the patient’s life (Weissman et al., 2018). Specific
incidents, encounters with other people, tend to evoke specific emotions, and thus
provide a wonderful focus for affect-focused treatments.
Beginning with the first sessions, in taking a history, reserve most of your
interventions for asking about specific circumstances and emotions. If “For ex-
ample?” elicits a particular event, listen for how the patient describes, or doesn’t
describe, associated feelings. If the patient omits them, “How did you feel then?”
is a good follow-up. If this pattern continues over time in sessions, the patient
will get the message that you are interested in these emotional responses and will
likely provide them more spontaneously. In the meantime, each time the patient
processes and survives an emotion tends to decrease discomfort about such emo-
tion. A collection of such emotional responses will give you an ever more complex
and fuller understanding of the patient’s emotional world.
In addition to jumbling negative affects under the rubric of “upset,” patients are
often unaware (or embarrassed) that it’s possible to have multiple reactions to a
given person or situation. Depressed and anxious individuals are often horrified
if they find themselves hating someone close to them: “What kind of horrible
person does that make me?!” Yet of course it’s the people you care most about,
whom you may love the most, who can provoke the strongest negative affect when
they hurt or disappoint you. The concept of complex, multiple emotions is an eye-
opener for many individuals. Thus if the patient volunteers some feelings, the first
step is to explore them. It doesn’t then hurt to ask whether the patient also had
additional reactions: “Did you have any other feelings?”
Having elicited these feelings, the therapist lets the patient sit with them and
learn to tolerate them. Then—and not too quickly—when the patient has been
bathing in this affect, or in these affects, the therapist can normalize it for them
(this assumes, of course, that the feelings are appropriate to the circumstance, not
symptoms like depressive guilt): “Of course you feel this way.” “You can have pos-
itive and negative feelings at the same time.” It’s important not to intervene too
3
Affect Focus33
soon, which is likely to render the patient’s understanding of the emotions merely
intellectual rather than fully emotionally experienced. It’s also important to find
language for validation that the patient won’t hear as paternalistic approval.
There are various ways of drawing attention to an affect-loaded situation. One
is to echo a patient’s statement.
A patient discovered she was pregnant from a relationship with a boyfriend

who had just broken up with her. Planning to keep the baby, she had called
him and asked, “How involved do you want to be?” with the future child. The
boyfriend had not commented, so after a fruitless discussion of other matters
she got off the phone, feeling miserable.
One way of addressing feelings here would be simply to wait for what emerged—
but in this case the patient simply changed the subject. A second approach would
be to ask, “So how did you feel about his response to your question?” A third
would be to ask, “How involved would you like him to be?” A fourth might be
simply to echo her question, “How involved would you like him to be?”, which
invites the patient to reflect on what she wants and her manner of expressing it.
Clearly (at least to the therapist), she had some feelings about how involved she
wanted the ex to be, perhaps what she felt his responsibility was in the pregnancy,
a host of other feelings. As is typical for non-confrontational patients, she asked
a tentative question (what does the other person want?) rather than making a de-
clarative statement (what does she want?). Echoing the phrase brings all of this
back to the patient’s focus. While not spelling out these issues, the BSP therapist
lets the patient confront and reflect on them.
Therapist Stance
Your role in eliciting these feelings and conducting the therapy is to fulfill the
general requirements of a good therapist. First, you need to “be yourself ” in that
you don’t want to be a blank, distanced, formal “psychotherapist,” but rather a
fellow human being who has and understands feelings. You want to relate on a
human level, as another person sharing an emotional experience. You don’t want
to intrude: The focus is on the patient, not on who you are. Parse your words,
and remember the dictum attributed to Cicero, Twain, and many others: “If I had
had more time, I would have written a shorter letter.” Less is more: The patient is
more likely to remember a pithy statement than a paragraph. Limit what you say
to what you really need to say to keep the session moving. Don’t offer treatment
proposals; let the patient lead.
You want to form a comfortable supportive relationship, a patient–therapist
interaction wherein the patient feels safe and secure and perceives the therapist
as caring, interested, warm, understanding, and hopeful. The therapist strives to
foster this relationship, most often by attempting to demonstrate just these qual-
ities. This does not mean that you become a friend; you must maintain a clear
34
awareness of engaging in a helping relationship. Your goal as a therapist is to

create a warm, caring, emotionally intense alliance in which it’s safe to express
and tolerate feelings, and in which healing can occur.
You want to come across as nonjudgmental, empathic, curious about the
patient’s emotional life and about the patient’s life in general. Maintain eye contact
and feel free to express sympathy in your facial expression and posture, perhaps
mirroring the patient in nonverbal synchrony (Prinz et al., 2021; see Chapter 6).
Don’t offer gratuitous advice, feedback, or solutions to problems. Don’t volun-
teer your own life story. Your goal is to maximize patient autonomy. Just as you’re
allowing the patient to lead the session, you want to let the patient figure out
problems for himself or herself. The patient probably has a better sense of most
aspects of the patient’s life and options than you do. Ask rather than telling: If
there’s a point you want to get across, is there a way to phrase it as a question to
the patient rather than making a formal declaration? For example, if a patient
describes a frightening situation but omits mention of an affect, you have a choice
between an initial impulse to say, “That sounds really scary” (which presumes an
affect of which the patient may or may not be aware) versus asking, “So what were
you feeling then?”
Don’t talk too much; be an active listener. Be patient. Silently, expectantly en-
courage the patient to speak, intervening only as needed to pursue affect if the
patient is avoiding it. Within a session or two you will develop a sense of whether
the patient, even if roundabout in approach, will return from a digression to ad-
vance a topic. (The patient is simultaneously learning the rhythms of the therapy
during this interval.) Pay attention to your sense of how the patient is feeling and
relating to you. If you feel you’ve made a misstep, you can say so and apologize.
That rarely hurts a therapeutic alliance.
What does it mean to be an active listener? Listen for themes in the patient’s
story, particularly emotional themes. Try to imagine how the patient experienced
whatever happened, and listen for emotional dissonances: What does the patient
emphasize in the story, and what might the patient be omitting? If the patient
brings up an emotionally charged circumstance and then retreats or changes the
subject, remark on that to yourself. After an interval, if the patient seems to be
retreating into something abstract or intellectualized, note it to the patient: “I no-
tice you changed the subject. What were you feeling when you started to mention
X?” or simply, “What were you feeling when you were talking about X?” Again,
your stance should be a supportive, empathic, inquisitive mode rather than cross-
examining or dictating anything to the patient.
Your role is to be curious. If there’s something you don’t understand, give the pa-
tient space to clarify the issue: It’s better not to interrupt if the patient is describing
something important. If by the end of that description you remain confused, be
careful to phrase your attempt to clarify matters as reflecting your confusion, not
the patient’s problem: “You’re not being clear” is accusatory, whereas “I’m having
trouble understanding . . .” indicates your own curious uncertainty (Schafer, 1974).
Many therapists who hail from “fancier” therapies with more therapist
interventions may feel at first that they’re “sitting on their hands” as they try to
35
Affect Focus35
adjust to BSP (Markowitz et al., 2008b). Yet patients can often figure out things on
their own; they simply lack confidence in their ability to do so. You need to sup-
port their ability and confidence, so telling them what to do can be counterpro-
ductive. Trust in the patient’s underlying competence (rather than their depressed
or anxious judgment of that confidence). Support their autonomy. Trust in the
time limit to push the therapy forward. If in the end the patient can make life
changes that he or she has come up with, rather than ones that you as the therapist
have suggested, the patient will feel that much more competent and successful.
This often happens in this brief treatment.
Any intervention you make is a choice: It can deepen the emotional direction
of or truncate the dialogue. If the patient is talking about feelings, don’t interrupt;
wait to see where this leads. It is easy—particularly on Zoom, where your view of
the patient’s cues is constrained (Markowitz et al., 2021)—to misjudge a pause and
intervene too quickly, disrupting the patient’s train of thoughts and feelings. It is
often better to wait, count to five or ten, and listen. This also gives you the luxury
of time to edit your words so that, when you do intervene, your interjection is
pithy and to the point, rather than a paragraph that might distract the patient.
If a patient gets uncomfortable with your expectant silence and asks why you
are silent, you can explain: “I’m listening. . . I’m interested in whatever’s on your
mind, especially about your feelings.” Sometimes an “Mm-hm” moves the pa-
tient forward. You can convey by your actions, without specifically announcing it,
that it’s up to the patient where things go, and that you’ll comment when you have
something to say. When you do comment, it should be to heighten or bring the
patient back to an affect. Patients quickly learn the rhythm of sessions, the thera-
peutic ritual that is a “common factor” of psychotherapy.
Naturally, you don’t want to have a ten minute silence, which would only make
you and particularly the patient uncomfortable. If a patient appears to be dis-
tracted rather than in the midst of a feeling state, you can ask general questions
about themes that the patient has previously raised, areas of his or her life that
have evoked strong feelings (“What’s going on in your marriage?”). Or ask the
patient how he or she has been feeling lately. Silence should not, however, lure
you as therapist into scattershot questions or comments simply to keep an inter-
change going.
Always pursue affect. If a patient looks upset but then changes the tenor of the
conversation to a bland topic, note that: “What were you just feeling when you
changed topics?” On the other hand, if you wait, the patient may spontaneously
return to the original theme. Such active listening helps provide an underlying
structure to a relatively unstructured therapy.
Tolerating Strong Affects
Part of the challenge of encouraging affective arousal is that it affects both people
in the room (or on the Zoom call). It is not solely patients who find strong emotion
challenging; therapists feel it too. You need to model for the patient the dictum
36
that emotions can be powerful but they are not dangerous (Markowitz, 2016).
If a patient, starting to discuss the death of a significant other, or a trauma earlier
in life, or some other distressing event, suddenly bursts into tears or otherwise
communicates deep sadness, anger, or other pain, it surely affects the therapist
as well.
My concern, based on decades of supervising both young and experienced
therapists in affect-focused treatments, lies in how therapists handle such strong
emotions. If you are a psychotherapist at a relatively early developmental stage
of your career, relatively inexperienced and still finding yourself, and not having
been in a personal therapy yourself, you may gravitate toward some idealized,
scrubbed, airbrushed goal of presenting yourself as a calm, composed, unflap-
pable healer, modeling yourself as generically “nice” as opposed to a messier,
more realistic and balanced portrait. In my experience, good therapists are not
afraid to show some of their own feelings in response to patient affects, to “be
yourself.”
Novice therapists too often try to reassure patients when they get emotional,
in effect muting the emotion and contradicting the message of BSP. They might
say something like: “That’s okay, that was long ago, you’re okay now.” Or change
the subject altogether: “Tell me more about your mother. What was she doing
at the time?” Far better to remain silent, attentive, looking concerned, perhaps
even tearing up yourself, at the same time silently demonstrating through your
calm that this is no emergency, you have survived such tempests before: The
feelings will pass, dissipate. Don’t say it, just show it. This helps to demonstrate
your therapeutic expertise (see Chapter 3). Jointly surviving such emotional
explosions strengthens the therapeutic bond while allowing the patient needed
catharsis.
Such a session is emotionally draining. Both parties may feel exhausted by
the end. But you and the patient will survive, and the patient often feels relieved
at having, perhaps for the first time, related buried feelings to another person.
Describing such events and feelings, verbally articulating them, often turns them
from dark, shameful, suppressed secrets to still disturbing but far more manage-
able, better understood aspects of the patient’s life. In the end, we all should have
big, strong feelings about big events, including very painful feelings about very
painful events. Seen in the light of day, they are intelligible and proportionate
responses to extraordinary circumstances.
Even when patients related obviously skewed psychopathological emotions,
overwhelming depressive affect and hopelessness, it’s best to sit there with the
patient and absorb them, demonstrating that while such feelings are painful, they
are not dangerous. After having done so for a decent interval, you can ask the pa-
tient whether such feelings are wholly reasonable: “Do those feelings make sense
to you?” Many patients will recognize that they are at least exaggerated. You can
then point out that they are questions on the depression rating scale, or in the
DSM: symptoms, in distinction to emotional responses to whatever is occurring
in the patient’s life.
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Her Majesty, however, continuing to express herself of a different
opinion, I found it useless to offer objections.
When I returned home in the evening, I set myself, therefore, to
consider how I might best execute her orders, and before I went to
bed I drew up a sort of plan, which I thought might furnish some
ideas for the formation of the establishment in view, and sent it off to
the Empress, more, indeed, for the purpose of complying with her
wishes than from any serious thought of furnishing a design worthy
of her choice and adoption. My astonishment may therefore be
imagined, when I received back, from the hands of her Majesty, this
imperfect outline of a scheme hastily conceived and informally drawn
up, with all the ceremonial of an official instrument, confirmed by the
sanction of her Imperial signature, and accompanied with an ukase
which conferred on me the presidentship of the embryo academy. A
copy of this ukase, I at the same time learned, had been transmitted
to the Senate.
Though this had the air of the Empress’s being in earnest, and
resolute in her intentions with regard to me, I nevertheless went to
Tsárskoe Seló two days afterwards, still hoping to prevail on her
Majesty to make choice of some other president. Finding my efforts
unavailing, I told her Majesty that as Director of the Academy of Arts
and Sciences I had already at my disposal sufficient funds for the
maintenance of the new establishment, and that she need be at no
other expense, at present, than the purchase of a house for it. These
funds, I observed, in explanation, would arise out of the five
thousand roubles which she gave annually, from her private purse,
for translations of the classics. The Empress evinced her surprise
and satisfaction, but expressed her hopes that the translations
should be continued.
“Most assuredly, madam,” said I, “the translations shall be carried
on, and I trust more extensively than hitherto, by the students of the
Academy of Sciences, subject to the revision and correction of the
professors; and thus the five thousand roubles, of which the directors
have never rendered any account, and which, to judge from the very
few translations that have appeared, they seem to have put into their
own pockets, may now be turned to a very useful purpose. I will have
the honour, madam,” added I, “of presenting you soon with an
estimate of all the necessary expenses of the proposed
establishment; and considering the sum I have stated as the extent
of its means, we shall then see if anything remains for the less
absolute requisites, such as medals and casts,—a few of which may
be deemed, indeed, almost indispensable, in order to reward and
distinguish the most deserving of its students.”
In the estimate, which I accordingly made, I fixed the salary of two
secretaries at 900 roubles, and of two translators at 450 roubles
each. It was necessary, also, to have a treasurer, and four persons,
invalid soldiers, to heat the stove and take care of the house. These
appointments together I estimated at 3300 roubles, which left the
1700 for fuel, paper and the occasional purchase of books, but no
surplus whatever for casts and medals.
Her Majesty, who had been accustomed to a very different scale of
expenditure, was, I think, more surprised than pleased at this
estimate; but signified her desire to add whatever was wanted for the
purposes not provided for in it, and this I fixed at 1250 roubles. The
salary of the president, and contingent perquisites of office, were not
usually forgotten in estimates of this nature, but in the present I had
not assigned myself a single rouble; and thus was a most useful
establishment, answering every object of its institution, founded and
supported at no greater expense to her Majesty than the price of a
few honorary badges.
To sum up all that may be said on the subject of the Russian
Academy, I may be allowed to state the following particulars: viz., in
the first place, that with three years’ arrears of her Majesty’s bounty,
originally granted for the translation of the classics, which had not
been paid to Mr. Domáshnev,—that is to say, with 15,000 roubles, in
addition to what sums I could spare from the economic fund,—I built
two houses in the court of the house given by the Empress for the
Academy, which added a rent of 1950 roubles to its revenue; I
furnished the house of the Academy, and by degrees purchased a
very considerable library, having, in the meantime, lent my own for
its use; I left 4900 roubles as a fund, placed in the Foundling
Hospital; I began, finished and published a dictionary; and all this I
had accomplished at the end of eleven years. I say nothing of the
new building for the Academy, the elevation of which has been so
much admired, executed, indeed, under my directions, but at the
expense of the Crown, and therefore not to be enumerated among
those labours which were more especially my own. Besides, had it
been, strictly speaking, a work of mine, I could never have
considered it as one of my labours; for with so decided a taste, or
rather passion, as I had for architecture, such a work would have
formed one of my highest gratifications.
I ought to observe, before I dismiss the subject, that many things
occurred at Court relative to the concerns of my office both to vex
and disgust me. The enlightened part of the public, indeed, rendered
me more than justice in the tribute of praise they bestowed on my
zeal and public-spiritedness, to which they were pleased to refer all
the merit of the institution of a Russian Academy, as well as the
astonishing rapidity with which the first dictionary of our native
language was completed.
This latter work was the subject of a very clamorous criticism,
particularly as to the method of its verbal arrangement, which was
not according to an alphabetical, but an etymological order. This was
objected to, as rendering the dictionary confused, and ill adapted for
popular use; an objection very loudly echoed by the courtiers as
soon as it was known to have been made by the Empress, who
asked me more than once why we had adopted so inconvenient an
arrangement. It was, I informed her Majesty, no unusual one in the
first dictionary of any language, on account of the greater facility it
afforded in showing and even discovering the roots of words; but that
the Academy would publish, in about three years, a second edition,
arranged alphabetically, and much more perfect in every respect.
I know not how it was that the Empress, whose perception could
embrace every object, even those the most profound, appeared not
to comprehend me, but this I know, that I experienced in
consequence much annoyance, and notwithstanding my repugnance
to declare the opinion which her Majesty had pronounced against
our dictionary, at a sitting of the Academy, I determined to bring
forward the question again at our first meeting, without entering into
some other matters connected with it for which I had often been
made accountable.
All the members, as I expected, gave their judgment that it was
impossible to arrange otherwise the first dictionary of our language,
but that the second would be more complete, and disposed in
alphabetical order.
I repeated to the Empress, the next time I saw her, the unanimous
opinion of the academicians, and the reason for it. Her Majesty,
however, continued to retain her own, and was, in fact, at that time
much interested in a work dignified by the name of a dictionary, of
which Mr. Pallas was the compiler. It was a sort of vocabulary, in
nearly a hundred languages, some of which presented the reader
with about a score of words only, such as earth, air, water, father,
mother and so forth. Its learned author, celebrated for the publication
of his travels in Russia, and for his attainments in natural history, had
dared to run up the expense of printing this work, called a dictionary,
to flatter a little prejudice of her Majesty, to a sum exceeding 20,000
roubles, not to mention the very considerable cost it brought on the
Cabinet in dispatching couriers into Siberia, Kamchatka and so forth,
to pick up a few words in different languages, meagre and of little
utility.
Paltry and imperfect as was this singular performance, it was
extolled as an admirable dictionary, and was to me at that time an
occasion of much disgust and vexation.
Semén Andréevich Poroshín. (1741-1769.)
Poroshín studied in the military school, where he
distinguished himself for his knowledge of foreign languages
and mathematics. Even as a student, he became a
contributor to literary magazines. After leaving school, he was
attached as adjutant to Peter III. From 1762 he was teacher of
mathematics to Paul, whom he tried to impress with a sense
of duty and love of country. In 1764 and 1765 he kept a diary
of his relations to the young Grand Duke, hoping some day to
use it as material for a history of his reign. In 1769 he died
during an expedition against Turkey, being then commander
of a regiment of infantry.
FROM HIS “DIARY”
October 29, 1764.—Having dressed himself, his Highness sat

down to study. Then he went incognito to his drawing-room to get a
look at the Turkish ambassador, who was having an audience with
his Excellency Nikíta Ivánovich. He was received in the same
manner as the first time. But when I arrived, his Highness did not
receive me so kindly as to make me satisfied with him. I do not wish
now to enter into any especial discussion of the cause of it, but will
only remark that his Highness is frequently greatly influenced by the
remarks made in regard to absent persons which he happens to
overhear. I have repeatedly noticed that if anything favourable or
laudatory is said in his hearing of someone, his Highness later
shows himself kindly disposed to him; if, on the contrary, something
unfavourable and deprecatory is said of anyone, especially when the
remark is not made directly to his Highness, but as if by accident, he,
seeing him, appears to be cold to him.
We seated ourselves at the table. His Excellency Nikíta Ivánovich
did not dine with us. Of outsiders there was only Count Alexander
Sergyéich Stroganóv. I have suffered terrible anguish to-day at table.
How could one help suffering, considering what had taken place?
We were talking about Peter the Great. Someone, passing in silence
all the great qualities of that monarch, deemed it proper to dwell only
on the fact that the Tsar used often to get drunk, and that he beat his
ministers with his cane. Another person, incautiously emulating this
conversation, which ought in no way be tolerated in the presence of
his Highness, added that when the Tsar was at one time beating with
his cane one of his generals who was a German, the latter later
repeated from the Bible: “The hand of the Lord was upon me, etc.”
The first person continued, saying that history knew only of two royal
wallopers, Peter I. and the late King of Prussia, the father of the
present King. Later he began to praise Charles XII., the King of
Sweden; I told him that Voltaire had written that Charles XII.
deserved to be the first soldier in Peter the Great’s army. Upon this
his Highness asked whether it was really so. The speaker answered
his Highness that it was very likely written that way, but that it was
nothing but mere flattery.
When I later spoke of the Emperor’s letters, which he had written
from abroad to his ministers, and remarked that for the correct
understanding of his time it was necessary to have these letters, and
that I possessed many of them, and so forth, the first speaker did not
deign to make any other remarks thereupon except that these letters
were very funny because the Emperor often addressed them to “Min
Her Admiral,” and signed them “Piter.” I found it difficult to dissemble
my dissatisfaction, and to subdue my excitement.
I leave it to the whole intelligent and unbiassed world whether it is
proper to let his Imperial Highness, the heir apparent of the Russian
throne, and a great-grandchild of Emperor Peter the Great, to be a
witness to such malicious remarks. Xenophon has represented in his
Cyrus a perfect king, and his rule a beneficent rule, and an example
for the emulation of the monarchs of future generations. Senseless
historians in many points contradict Xenophon’s history, and try to
point out the weaknesses of his hero. But clever and far-sighted men
care very little whether Cyrus was really such as Xenophon has
painted him, or otherwise, and extol the historian for having given us
a perfect model for kings, and they adduce his wise rule as an
example for them to follow. Thus, too, many other monarchs, whose
great deeds history has preserved to our own days, are adduced as
an example. Is it not necessary to present to his Highness the
praiseworthy deeds of famous heroes, in order to rouse in him the
desire and noble impulse of emulating them? That seems to be
evident and incontrovertible. Now, whose deeds will awaken in him a
greater attention, will produce a stronger effect upon him, and are
more important for his knowledge, than the deeds of Emperor Peter
the Great of blessed memory? They are esteemed great and
glorious in the whole subsolar world, and are proclaimed with
ecstasy by the lips of the sons of Russia. The Grand Duke, his
Highness’s own grandchild, was born in the same nation, and by the
decree of God will in time be the ruler of the same nation.
If there had never been on the Russian throne such an
incomparable man as was his Highness’s great ancestor, it would be
useful to invent him, for his Highness’s emulation. But we have such
a famous hero,—and what happens? I do not mean to say that the
Emperor Peter the Great was free from imperfections. Who of
mortals is? As many great men as history knows have all been
subject to certain weaknesses. But when they are used as
examples, we must not sermonise about their vices, but about their
virtues. Vices may either entirely be passed over in silence, or they
may be mentioned, but only incidentally, with the remark that the
ruler who is taken as a model tried his best to free himself from them
and that he overcame them. And the very opposite has happened....
At table Prince Baryatínski remarked that during his stay in
Sweden he had heard that all the wearing apparel, sword, boots and
everything else that had belonged to King Charles XII. was
preserved in the arsenal. I retorted that in our Museum are
preserved the wearing apparel and other belongings of Peter the
Great, but that we naturally had more reason to keep these things
than the Swedes, because the one defended his country and
brought it to a nourishing condition, while the other had brought his
to such ruin that even to the present day it has not been
resuscitated, and that, of course, not one intelligent Swede could
mention the name of Charles XII. without disgust. Prince Sergyéich
assented to this. Then the conversation turned to Keissler’s travels,
and then to the academic translators Teplóv, Golubtsóv and
Lébedev. I said that they knew and translated Russian well. The first
speaker remarked to that: “And yet they all died the same death,
namely, from drinking.” Thereupon the Grand Duke turned to me and
said: “Now, you hear that yourself. I suppose that is not a lie?” I
answered that I did not know them intimately, that I was not
acquainted with the manner of their demise, and that equally I did
not know where that gentleman got his information.
February 28, 1765.—His Highness arose at eight o’clock. After
having dressed himself, he sat down to his customary studies. After
his lesson he looked with me carefully at the road map to Moscow,
and recollected where and how we passed the time on our last
journey thither. I read to his Highness Vertot’s History of the Order of
Maltese Knights. Then he amused himself with his toys, and,
attaching to his cavalry the flag of the admiralty, imagined himself a
Maltese Knight. At ten o’clock we sat down to breakfast. We spoke
of Moscow and dramatic performances. We were about to rise from
table, when someone, I do not remember who, asked for butter and
cheese. The Grand Duke became angry at the butler and said: “Why
did you not put it on the table before?” and then turning to us: “They
simply steal the things for themselves!” We all armed ourselves
against the Grand Duke and told him in French how bad it was to
insult in this way a man of whom he could not know whether he was
guilty or not.
When we left the table, this sermon was continued. Mr. Osterwald
and I told his Highness in strong terms how bad his action was, and
how easily he could cause those people to hate him. Then our
conversation turned to the labours that an Emperor must undertake.
His Highness remarked among other things: “But an Emperor cannot
work all the time! He needs also some rest, and his amusements.”
To this I retorted to the Grand Duke: “No one demands that an
Emperor should never have any rest, for that is above human
strength, and an Emperor is just such a man as anybody else; only
he has been exalted to his position by God for his nation, and not for
himself; that, consequently, he must use all his endeavour in the
welfare and advancement of his nation; that his amusements and
pleasures ought to consist in his knowledge and vivid representation
of the great mass of his subjects who through his labours and cares
enjoy well-being and numberless advantages, and of the flourishing
condition of his country as the result of his work, and how his name
will in just glory redound to the future generations.” These are the
exact words which I spoke to his Highness. He listened to them very
attentively.
September 20, 1765.—The birthday of his Imperial Highness; he is
eleven years old. His Highness arose a little after seven.... I was not
yet all dressed, when he appeared in my room, took me by my hand
and began to walk around with me. I congratulated the Tsarévich
upon his birthday, and explained to him my wishes in regard to him,
which were similar to those of all the faithful sons of the country.
Having dressed himself, he went into the yellow room. His
Reverence, Father Platón, addressed to the Tsarévich a short
congratulation, in which he presented very strongly and wittily our
wishes and hopes in the progress of his Highness’s studies. Then
his Highness went into the interior apartments to the Empress, and
from there with her Highness to church. At the end of the liturgy,
Father Platón spoke a sermon on the theme: “Settle it therefore in
your hearts, not to meditate before what ye shall answer” (Luke xxi.
14). The whole sermon was beautiful. But especially the final
address to her Highness and the Grand Duke visibly moved the
hearts of all. Many eyes were seen in tears.... The Empress went
from church to her inner apartments, and his Highness followed her.
As we were there admitted to kiss her hand, she said among other
things: “Father Platón does with us what he wants. If he wants us to
weep, we weep; if he wants us to laugh, we laugh.”
The Satirical Journals (1769-1774), and Nikoláy
Ivánovich Nóvikov. (1744-1818.)
The first attempt at a periodical was made as early as the
year 1728, when literary essays were regularly added to the
news of the day in the St. Petersburg Gazette, but the first
literary journal was established in 1759 by Sumarókov under
the name of The Industrious Bee. The example of Russia’s
first littérateur was at once imitated by a number of private
individuals, and magazines became common, though their life
was nearly always very short. In 1769 there was issued by
Grigóri Kozítski, under Catherine’s supervision, the first
satirical journal, under the name of All Kinds of Things. During
the time of reforms, satire appears as a natural weapon of
attack against the old order of things, and there was,
therefore, nothing unusual in the popularity which this and the
following satirical journals attained. There is, however, also
another reason for their appearance. The English Spectator,
Tatler and Rambler were at that time well known in Russia,
and the literary part of the St. Petersburg Gazette brought out
a large number of translations from these English journals. All
Kinds of Things shows plainly the influence of Addison in the
tone of playful censure which was to Catherine’s liking and
which it cultivated.
Of the several satirical periodicals that followed, the Hell’s
Post; or, Correspondence between the Lame and the Halt
Devils, by F. Émin, and the famous Drone, by N. I. Nóvikov,
may be mentioned. The name of the latter is evidently chosen
in contradistinction to Sumarókov’s Industrious Bee, and its
editor, of whose imposing personality we shall speak later,
belonged to that enlightened class of men who were in
sympathy with the most advanced reforms, but had no love
for the flimsy Voltairism which pervaded Russian society, and,
like the Slavophile Shcherbátov (see p. 287), thought he
discerned some stern virtues in the generations preceding the
reforms of Peter the Great. He therefore set out to scourge
vice wherever he found it. The satirical journals were divided
into two camps: some clung to the mild and harmless satire of
All Kinds of Things, the others took the Drone for their model.
When the collaboration of Catherine in the first became
known, Nóvikov found it necessary to desist from his attacks,
to avoid the displeasure of the Empress, and soon his journal
stopped entirely. He later edited for a short time the Painter
and the Purse, but in 1774 all satirical journals ceased to
exist. The most important of these journals has been the
Painter, from which a generation of writers drew subjects for
their satire or comedy.
Nóvikov’s early education was received at the Gymnasium
connected with the Moscow University; he was excluded from
it in 1760 for laziness and insufficient progress. He soon
drifted into literature, and directed his attention to the
dissemination of useful knowledge among the people. He
developed a prodigious activity from 1772 to 1778, publishing
a large number of chronicles and documents dealing with
Russian antiquity. In 1779 he rented the University press for
ten years, published in three years more books than had been
issued by that institution in the preceding twenty-four years of
its existence, opened bookstores all over Russia and
encouraged and protected a whole generation of young
writers. He was a zealous Mason, and in that capacity
practised a most generous philanthropy by using the very
great income from his venture for the establishment of
charities and schools. Catherine was never favourable to the
Masons and other mystics who had got a firm foothold in St.
Petersburg and Moscow, and when the French Revolution
had broken out, she suspected such men as Radíshchev (see
p. 361) and Nóvikov of belonging to a secret society whose
object was the overturning of the existing order of things. At
first she ordered the metropolitan Platón to examine into the
soundness of Nóvikov’s religious views, but the enlightened
prelate reported: “I implore the all-merciful God that not only
in the flock which has been entrusted by God and you to me,
but in the whole world there should be such good Christians
as Nóvikov.” Nevertheless, Catherine later found an excuse
for seizing Nóvikov and imprisoning him in the fortress of
Schlüsselburg, from which he was released by Emperor Paul,
who is said with tears in his eyes and upon his knees to have
begged Nóvikov’s forgiveness for his mother’s cruelty to him.
He passed the rest of his days in his estate of Tikhvín.
FROM “ALL KINDS OF THINGS”
I lately went to dine in a Moscow suburb with a friend of mine. To

my great displeasure I found the house in great sorrow because his
wife had had a bad dream which threatened some danger to him,
her and their children. We seated ourselves at the table. Their
youngest boy, who was sitting at the end of the table, began to cry:
“Mamma, I shall begin my problems on Monday.” “On Monday!”
exclaimed his mother: “The Lord preserve us! Nobody begins
anything new on Monday. Tell the deacon to begin on Tuesday.” The
lady of the house asked me to pass her the salt. I hastened to do her
the favour, but, being timid and overzealous, I dropped the salt-cellar
in passing it. She trembled when she saw the mishap, and
immediately remarked that the salt was spilled in her direction.
Collecting herself again, she sighed and said to her husband: “My
darling, misfortune never comes single. You will remember that the
dove-cot broke down the same day our servant girl spilled the salt on
the table.” “Yes, I remember,” said her husband, “and next day we
received the news of the battle of Zorndorf.” I managed to finish my
dinner, though with a heavy heart. The dinner being over, I
accidentally placed my knife and fork crosswise on my plate. The
hostess asked me to put them together. I soon learned from the
lady’s behaviour that she looked upon me as an odd fellow and
foreboder of misfortunes.
Gentlemen:—He who writes All Kinds of Things ought not to
disdain anything. In this hope I, though a common labourer, take up
the pen without hesitation, thinking that you might find something of
interest in what I write. I have no intricate style, but write simply, just
as I think.
I am a silversmith. Though I was not born here, I love Russia. I am
not the only German whom it supports. The Lord may grant all to feel
as gratefully to Russia, but people feel differently about that. I work
for many people, among them for a French teacher. You know there
are bushels of them in Moscow. The one I am telling you about came
to his profession in a strange manner. He was originally a
shoemaker. Suddenly he was seized by the spirit of heroism, or, to
tell the truth, indolence and starvation compelled him to enlist as a
soldier. After the battle of Rossbach, he fled in company with many
others. He worked in many capacities, wandering about from place
to place, and finally reached Russia, where he developed the proper
qualifications for a coachman. But he soon grew tired of sitting on
the coachman’s seat, and had a strong desire of getting inside the
carriage. He found no easier way of accomplishing his ambition than
by becoming a teacher, emulating in this the example of many of his
countrymen who, some from the box, like him, others from the
footman’s stand, have found their way into the carriage. And he
succeeded. Thus a lazy shoemaker, runaway soldier and bad
coachman was turned into a first-class teacher. At least he appears
to me to be good because he pays promptly for my work and does
not feed me, as other gentlemen do, with to-morrows.
SOUND REASONING ADORNS A MAN
My teacher made me once a present of a doll on my name-day,

accompanying it with the following noteworthy words: “Every
brainless man is a doll.” I asked him whom he meant by the word
“brainless,” and he answered: “Him who obeys more his will than
established rules.” I wanted to know why. He said: “Will without rule
is licence, and licence is injurious to oneself and his neighbour,
whereas rules have been established in life in order to curb harmful
lusts.” I sighed and said: “Oh, I see, then our neighbour committed
an act of licence, and did not obey the established rules, when he
took away our meadows so that our cattle are starving.” “Our
neighbour,” he answered with a smile, “has his own rules. He
belongs to the class of people who say every morning: ‘Lord, I am in
need of everything, but my neighbour is in need of nothing.’”
We paid such a high salary to this teacher that my step-mother
found it necessary to dismiss him, in order to add one hundred
roubles to the cook’s wages, and another cheaper teacher was hired
for me. He belonged to the class of people who write in their will that
they are to be buried without being washed. His affection for his
ungrateful country was so strong that he always had the name of
Paris in his mouth, in spite of the fact that he had been driven out of
his country with the coat of arms of a full-blown lily imprinted on his
back.[144] He knew by heart the names of all the streets of Paris, and
the external walls of all the prominent buildings of that city were
familiar to him, but he had never had the courage to enter them. He
was so adorned with wisdom that he knew everything without having
studied anything. He had an absolute contempt for everything that
did not transpire in France. For other things he had no mind, for
frequently, in a fit of abstraction, he put other people’s property into
his pockets, the result of which was a certain misunderstanding, as
he called it, between him and the police. The police proved that he
had stolen, but he affirmed the word “steal” was the invention of
crass ignorance, and that an honest man must defend his honour
from the police by means of the rapier. So he invited the commissary
of police to fight a duel with him. The latter not being as good a talker
as he was wont to stick to incontrovertible proofs, ordered my mentor
to be cast into prison. My mother was quite put out about him, for
she said she did not know where to get another cheap teacher like
him. However, there arrived at that time some guests at our house
who assured her that that very day there had arrived in Moscow the
coachman of the French ambassador, with his scullion, hair-dresser,
courier and lackey, who did not wish to return with him, and that for
the common good of the people of Moscow they had the intention of
imparting their arts to those who wanted to be instructed for a
reasonable consideration, though somewhat higher than the price
they had received in the stable, kitchen, kennel, or for blackening
shoes and making wigs.
I once went to see my friend and, as he was not at home, went to
his wife’s apartments. She had stepped down into the nursery. As I
am quite at home there, I went down into the nursery myself and
found her surrounded by her four children. The smallest boy started
crying; to pacify him, his mother made him beat the nurse with a
handkerchief. She pretended she was crying, while the mother kept
on repeating: “Beat her, my darling, beat well the stupid nurse! She
had no business annoying baby.” The child was trying to strike the
nurse hard; and the harder he struck her, she feigned weeping
harder, whereat the child smiled. A little while later, another child fell
down. The mother told it to spit on the floor and to kick the place
where it had stumbled. When I remarked that it was not good
education to allow the child to do that, she answered me: “My friend,
you are always philosophising. As if we had not been brought up in
the same way! Why should it be different with these babies?” Then I
heard the whining of a dog. I looked around and saw a third child
pinching a pup, while another child was frightening a canary bird by
striking with his hands against the cage: the poor little bird flitted
about distressed from one corner to another. I lost my patience, and
told their mother: “You are making tyrants of these children, if you do
not teach them to respect man and beast. I’ll tell your husband so!”
and I slammed the door as I went out.
FROM THE “DRONE”
RECIPE FOR HIS EXCELLENCY, MR. LACKSENSE
This nobleman suffers from a quotidian fever of boasting of his

family. He traces his family tree to the beginning of the universe, and
hates all those who cannot prove their aristocratic blood at least five
hundred years back, and loathes to speak with those whose nobility
is only a hundred years old or less. He shakes with fever the
moment somebody mentions burghers or peasants in his presence.
In opposition to the modern current appellation, he does not even
honour them with the name “low-born,” but in the fifty years of his
fruitless life he has not yet been able to find a proper term for them.
He does not travel to church nor in the streets, for fear of a dead
faint which would unavoidably fall upon him the moment he met an
ignoble man. Our patient complains hourly against fate for having
destined him to share the same air, sun and moon with the common
people. He wishes there were no other beings on the whole globe
but aristocrats, and that the common people should all be
annihilated. He had repeatedly handed in projects to that effect, and
they had been highly praised for the good and novel ideas contained
therein, though many rejected them, because the inventor
demanded three million roubles in advance in order to execute his
plans.
Our aristocrat hates and loathes all the sciences and arts, and
regards them as a disgrace for any noble gentleman. In his opinion a
blueblood can know everything without having learned it; but
philosophy, mathematics, physics and all the other sciences are
trifles that are below a nobleman’s attention. Books of heraldry and
letters patent that have just escaped the dust-pile and mould are the
only books which he continually reads by spelling out. Alexandrian
sheets, on which the names of his ancestors are written in circles,
are the only pictures with which his house is adorned. But to be
short; the trees by which he illustrates the descent of his family have
many a dry limb, but there is no more rotten twig upon them than he
himself is, and in all his family coats of arms there is not such a
beast as is his Excellency. However, Mr. Lacksense thinks differently
of himself, and worships himself as a great man in mind, and as a
small god in his nobility. To make the whole world believe the same
way, he tries to differ from all others, not by useful and glorious
deeds, but by magnificent houses, carriages and liveries, though he
spends on his foolishness all his income that ought to support him
ten years hence.
Recipe, to cure Mr. Lacksense of his fever.—It is necessary to
inoculate the sick man with a good dose of common sense and
philanthropy, in order to kill in him his empty superciliousness and
the lofty contempt for other people. Noble descent is, indeed, a great
privilege, but it will always be dishonoured if it is not fortified by
personal worth and noble services to your country. Meseems it is
more laudable to be a poor yeoman or burgher and a useful member
of society than a distinguished drone who is known only for his
stupidity, his house, carriages and liveries.
THE LAUGHING DEMOCRITOS
Bah! There is the miser in his rags and tags, who has all his life
been hoarding money and squandering his conscience; who is dying
from hunger and cold; who teaches his servants to eat to live, that is,
not more than is necessary to keep body and soul together; who is
known far and wide for his unlawful usury; who has imposed upon
himself and all his slave cattle a whole year’s fast; who in winter
heats his miserable hut only once a week; who is ready to sell
himself for a dime, and who has forty thousand roubles, in order to
leave them after his death to his stupid nephew, that seventeen-
year-old wretch who in miserliness and unscrupulous usury has
surpassed his uncle of sixty years; who steals money from himself
and takes a fine from himself for this theft; and who does not want to
get married all his life, only not to spend his income on his wife and
children. Oh, they deserve being laughed at. Ha, ha, ha!
Meseems I see his opposite. Of course, it is Spendthrift? Certainly.
Oh, that young man has not the vices of his father, but he is infested
by other vices, not less objectionable. His father hoarded money by
unlawful exactions, and he spends it recklessly. His miserly father
consumed in one month what he ought to have eaten in one day;
Spendthrift, on the contrary, devours in a day what he ought to eat
up in a year. The other walked in order not to spend money for the
feeding of the horses; this one keeps six carriages and six tandems,
not counting the saddle and sleigh horses, only that he may not get
tired of travelling all the time in one and the same carriage. The other
wore for twenty years the same miserable caftan; while to
Spendthrift twenty pairs a year seem too little. In short, his father
collected a great treasure through all illegal means, usury,
maltreatment of his kin, and ruin of the helpless; but Spendthrift ruins
himself and lavishes on others: they are both fools, and I laugh at
both. Ha, ha, ha, ha!
Who is galloping there so swiftly? Bah! it is Simple. He is hurrying
to some aristocratic house, to show there his stupidity. Simple glories
in visiting distinguished people. He goes to see them as often as
possible and, to please them, makes a fool of himself, then boasts to
others of the influence he has there. He takes part in their
conversations and, though he knows nothing, thinks he is posing as
a wise man; he reads books, but he does not understand them; goes
to the theatre, criticises the actors and, repeating what he has heard
elsewhere, speaks authoritatively: this actor is good, that one is bad.
He tells distinguished people all kinds of jokes, and wants to be
cutting in his remarks, though he never adapts them to the occasion;
in short, Simple tries to convince himself that his acts are intelligent,
but others think that they are silly. Ha, ha, ha!
Hypocrite steps humbly out of church and distributes to the poor
that surround him a farthing each, and counts them off on his rosary.
As he walks along, he mumbles his prayers. He turns his eyes away
from women, and shades them with his hands, for he avers he would
take them out if they tempted him. Hypocrite sins every minute, but
he appears as a righteous man that walks over a path strewn with
thorns. His simulated prayers, piety and fasts in no way keep him
from ruining and oppressing his like. Hypocrite has stolen thousands,
and he gives them away by farthings. By such appearances he
deceives many. He hourly preaches the nine virtues to young
people, but in the sixty years of his life he has never carried out one
himself. Hypocrite always walks humbly and never turns his looks to
heaven, for he cannot hope to deceive those that abide there; but he
looks upon the earth whose inhabitants he cheats. Ha, ha, ha!
FROM “HELL’S POST”
LETTER FROM HALT TO LAME
Last evening I took a walk in the park where nearly the whole town
disports itself twice a week. I seated myself with a friend on a bench:
four men, all acquaintances of my friend, passed by us; one of them
was an ex-officer who had left the service, in order that he may not
serve the Tsar, that he may cheat the world and become rich through
illegal means. All the pettifoggers and the minor officials at the court
of justice, and all the large litigators are known to him. He hardly
ever goes out of the Land Office, and even in other places there
appears almost every day a complaint of his. All the doubtful villages
are his, and he frequently makes application for them, proving that
they once belonged to his ancestors. He has no end of genealogies
in his pocket, and upon request can prove his descent from any
family he pleases. He buys promissory notes at a great discount,
and gets the money from the creditor with all the interest due
thereupon. If anybody borrows money from him, he never asks more
than five kopeks from the rouble a month, and he deducts the
interest in advance.
FROM LAME TO HALT
A certain secretary of a government office in this town got himself

into trouble by taking bribes, but he very soon freed himself through
his cunning. Although many orders explicitly demand that no bribes
should be received by officers, yet they insist that it is superhuman to
receive nothing from complainants. Many people of that class,
however, do not submit to the common weakness of the office, and
live on their incomes and salaries, but they have always empty
pockets. Scribe S. is much richer than Secretary V. because the one
sells every step of his, while the other attends to the affairs under his
charge for nothing. Now many of these gentlemen have discovered a
secret of stealing in a diplomatic way, that is, they no longer take
bribes themselves, but send the complainant to their wives, who
receive them very graciously. If he is a merchant, she asks for some
stuffs or velvet for a dress. When the goods have been brought to
her house, she says to the merchant: “My friend, come again in a
few days, and I will pay you!” The merchant knows what that means
and, being in need of her husband, goes home and for ever bids
good-bye to the goods he has furnished. If the complainant is a
nobleman, the officer’s wife tells him that she has no servant-girl, or
boy, and that she is compelled to do all the work herself; and the
complainant, having of necessity learned this conventional language,
answers her as she wants to be answered. Thus, in the taking of
bribes there has been produced this change: formerly the husband
was dishonest, now his wife helps him. But there are some officials
who are even more cunning and who steal in an honourable manner.
They invite the complainant who has any dealing with them to dinner,
after which they sit down and play cards with him. When they lose,
they assume a very angry look, but when they win, they look
exceedingly satisfied: this language the complainants have soon
learned to understand. To please the host, they throw off trumps and,
losing to the host, say two hundred roubles or as much as the host
expects for the case in hand, receive the next day a favourable
decision for it. Even the merchants have become refined and
frequent the houses of officials to play cards with them.
FROM THE “PAINTER”
To My Son Falaléy:—
Is that the way you respect your father, an honourably discharged
captain of dragoons? Did I educate you, accursed one, that I should
in my old age be made through you a laughing-stock of the whole
town? I wrote you, wretch, in order to instruct you, and you had my
letter published. You fiend, you have ruined me, and it is enough to
make me insane! Has such a thing ever been heard, that children
should ridicule their parents? Do you know that I will order you to be
whipped with the knout, in strength of ukases, for disrespect to your
parents! God and the Tsar have given me this right, and I have
power over your life, which you seem to have forgotten. I think I have
told you more than once that if a father or mother kills a son, they are
guilty only of an offence against the church.[145] My son, stop in time!
Don’t play a bad trick upon yourself: it is not far to the Great Lent,
and I don’t mind fasting then. St. Petersburg is not beyond the hills,
and I can reach you by going there myself.
Well, my son, I forgive you for the last time, at your mother’s
request. If it were not for her, you would have heard of me ere this,
nor would I have paid attention to her now, if she were not sick unto
death. Only I tell you, look out: if you will be guilty once more of

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Brief Supportive Psychotherapy: A

Treatment Manual and Clinical

Brief Supportive Psychotherapy

Oxford University Press is a department of the University of Oxford. It furthers

Published in the United States of America by Oxford University Press

© Oxford University Press 2022

All rights reserved. No part of this publication may be reproduced, stored in

You must not circulate this work in any other form

Library of Congress Cataloging-in-Publication Data

Printed by Lakeside Book Company, United States of America

Emotions can be powerful but they’re not dangerous.

What is supportive psychotherapy? Is it important? Is it any good? The term has

2 B rief S upporti v e P sychotherapy

We wrote a treatment manual, somewhat crudely outlining a 16-​session weekly

Affective arousal (response)

4 B rief S upporti v e P sychotherapy

What is supportive psychotherapy? It is popular and unpopular. It is deeply mis-

What Is Supportive Psychotherapy?7

• Affective arousal: the emotional intensity of a psychotherapy that makes

8 B rief S upporti v e P sychotherapy

All of these elements are key to supportive psychotherapy as well to psychotherapy

WHAT BSP ISN’T

BSP has no charts, exercises, homework, or agenda-​setting. It incorporates min-

What Is Supportive Psychotherapy?9

10 B rief S upporti v e P sychotherapy

brief treatment. Gaining some understanding and tolerance of emotions tends

The Common Factors

12 B rief S upporti v e P sychotherapy

Common Factors of Psychotherapy13

Affect-​Focused Versus Exposure-​Based Therapies

14 B rief S upporti v e P sychotherapy

FEELING UNDERSTOOD BY THE THERAPIST

Common Factors of Psychotherapy15

Optimizing the Alliance

16 B rief S upporti v e P sychotherapy

Common Factors of Psychotherapy17

FRAMEWORK FOR UNDERSTANDING

Patients generally enter treatment feeling bewildered and overwhelmed by both

18 B rief S upporti v e P sychotherapy

A distressed patient wants to know that he or she is in good hands. It is reassuring

The goal is always to pursue patient emotion.

Common Factors of Psychotherapy19

20 B rief S upporti v e P sychotherapy

Beyond that, however, BSP is a relatively unstructured therapy, and optimally

OPTIMISM FOR IMPROVEMENT

Common Factors of Psychotherapy21

To summarize, these “common factors” are essential elements of any psycho-

24 B rief S upporti v e P sychotherapy

Ms. A, a chronically depressed and anxious 52-​year-​old married business-

Here is an instance where a fairly high-​powered executive finds herself at the

26 B rief S upporti v e P sychotherapy

Sadness is another emotion that many depressed individuals find intolerable,

EXPLORING THE PATIENT’S EMOTIONAL LIFE

28 B rief S upporti v e P sychotherapy

How Aware Is the Patient of His or Her Emotional Life?

Some patients present as practically alexithymic, not acknowledging feelings at

How Does the Patient Handle Feelings, and Especially

Depressed and anxious patients may mistrust even positive emotions as

To What Degree Does the Patient Express Those

How Much of What the Patient Internally Experiences Is

Some emotional responses, such as guilt, or anxiety about others, may be

30 B rief S upporti v e P sychotherapy

How Is the Patient Feeling About You and the Therapy?

2 B rief S upporti v e P sychotherapy

We wrote a treatment manual, somewhat crudely outlining a 16-session weekly

4 B rief S upporti v e P sychotherapy

What Is Supportive Psychotherapy?7

8 B rief S upporti v e P sychotherapy

BSP has no charts, exercises, homework, or agenda-setting. It incorporates min-

What Is Supportive Psychotherapy?9

10 B rief S upporti v e P sychotherapy

12 B rief S upporti v e P sychotherapy

Common Factors of Psychotherapy13

Affect-Focused Versus Exposure-Based Therapies

14 B rief S upporti v e P sychotherapy

Common Factors of Psychotherapy15

16 B rief S upporti v e P sychotherapy

Common Factors of Psychotherapy17

18 B rief S upporti v e P sychotherapy

Common Factors of Psychotherapy19

20 B rief S upporti v e P sychotherapy

Common Factors of Psychotherapy21

24 B rief S upporti v e P sychotherapy

Ms. A, a chronically depressed and anxious 52-year-old married business-

Here is an instance where a fairly high-powered executive finds herself at the

26 B rief S upporti v e P sychotherapy

28 B rief S upporti v e P sychotherapy

30 B rief S upporti v e P sychotherapy

32 B rief S upporti v e P sychotherapy

34 B rief S upporti v e P sychotherapy

36 B rief S upporti v e P sychotherapy