Overview of Supportive-Expressive Dynamic Psychotherapy

Supportive-expressive psychotherapy was developed at the Menninger Foundation and Clinic, Menninger School of Psychiatry, Topeka, Kansas in the late 1940s and 1950s and originated in the papers on technique by Freud (Freud, 1910a; Freud, 1910b; Freud, 1912a; Freud, 1912b; Freud, 1912c; Freud, 1913a; Freud, 1913b; Freud, 1914; Freud, 1915; Freud, 1916-17; Freud, 1919; Freud, 1926; Freud, 1937). The treatment is systematically documented in a manual (Luborsky, 1984) that includes methods for evaluating adherence to the technique.

This present manual should be read in conjunction with the Freud papers on technique cited above and the general Luborsky (1984) SE manual. A number of special versions of the main SE manual exist which are tailored for specific disorders : opiate dependence (Luborsky, Woody, Hole & Velleco, 1995), depression (Luborsky et al.,1993), cocaine dependence and now this version for cannabis dependence. Although supportive-expressive dynamic psychotherapy has been established as an effective form of treatment for opioid dependence and depression, its effectiveness is as yet unevaluated for cannabis dependence. This manual was developed for the purpose of conducting a controlled study of SE psychotherapy of cannabis dependence. A controlled evaluation is presently being conducted at the National Drug and Alcohol Research Centre (1995-1996) and preliminary results suggests it is of significant benefit to this drug using population. However, final results and follow-up data are not yet in at the time of the publication of this manual.

The treatment can be either time-limited (with a set termination date) or unlimited. The term 'supportive-expressive' (SE) refers to the two main treatment techniques of this approach. Supportive techniques are ones developed by the therapist to create a positive, helpful and empathic relationship with the patient. Expressive techniques are those used by the therapist that are aimed at helping the patient to express and to understand and change problems. The focus is on identifying and interpreting each patient's recurring problematic interpersonal relationship themes as they occur (a) with the therapist (transference), (b) in relationships with other people, such as partners, family, friends and parents, and (c) around specific behaviours (e.g. drug taking) as attempts at finding solutions to the life problems.

The treatment has been repeatedly and successfully evaluated over the past thirty years. For example, the Penn Psychotherapy Project (Luborsky, Crits-Christoph, Mintz & Auerbach, 1988) evaluated the treatment on 73 mixed diagnosis patients and found a high mean Effect Size of 1.05. It has been used in the treatment of Chronic and Major Depression with even higher mean Effect Sizes of 1.80 and 2.75 respectively on the Global Assessment Scale (Luborsky, et al, 1993; Luborsky et al., in press). It was a key treatment in the VA-Penn psychotherapy study of treatment for opioid dependence (Woody et al., 1983), the largest and and most successfully conducted study of its type. In this study, SE psychotherapy plus drug counselling was compared to cognitive-behavioural (CB) therapy plus drug counselling and drug counselling (DC) alone. At one month follow up, pre vs post differences tended to be significant for the SE and CB groups and slightly less often for the DC group. The SE and CB groups reduced drug use more than the DC group. The SE patients made significantly greater improvements than the CB group on measures of psychiatric functioning and employment, whilst the CB group had greater improvements in legal status. These gains were maintained at 12-month (Woody, et al. 1987) follow up for the SE group, with further improvement in psychiatric functioning, legal status and employment. The CB group also maintained gains with further improvements in drug use and psychiatric condition. Supportive-expressive psychotherapy is currently being compared to cognitive-behavioural therapy in a large scale NIDA-funded collaborative study of treatment of cocaine abuse.