Psychodynamic and supportive psychotherapy

Meet the patient — the woman who texts you at midnight

A 28-year-old woman with borderline personality organisation has been in once-weekly psychodynamic psychotherapy with you for three months. After a session in which you raised the cancellation policy, she texts at midnight: "You're the only person who has ever cared about me. Can we meet twice a week? I'll pay anything." The next morning she sends a second text cancelling all future sessions. The viva question is live: what is happening, and what do you do?^[12][18]

The honest formulation is countertransference data, not crisis. The midnight text is idealising transference; the morning cancellation is the devaluing flip. The move is not to lengthen the frame, lower the fee, or argue — it is to bring both texts into the next session, name the pattern without humiliation, hold the frame, and take the whole thing to supervision. Acting on the countertransference is how boundary violations begin.^[12][13][18]

References21ShowHide

1. [1]Shedler J The efficacy of psychodynamic psychotherapy Am Psychol, 2010.PMID 20141265
2. [2]Leichsenring F, Rabung S Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis JAMA, 2008.PMID 18827212
3. [3]Leichsenring F, Rabung S Long-term psychodynamic psychotherapy in complex mental disorders: update of a meta-analysis Br J Psychiatry, 2011.PMID 21719877
4. [4]Wienicke FJ, Beutel ME, Zwerenz R, et al. Efficacy and moderators of short-term psychodynamic psychotherapy for depression: A systematic review and meta-analysis of individual participant data Clin Psychol Rev, 2023.PMID 36958077
5. [5]Town JM, Abbass A, Driessen E, et al. Updating the Evidence and Recommendations for Short-Term Psychodynamic Psychotherapy in the Treatment of Major Depressive Disorder in Adults Can J Psychiatry, 2017.PMID 28055257
6. [6]Clarkin JF, Levy KN, Lenzenweger MF, et al. Evaluating three treatments for borderline personality disorder: a multiwave study Am J Psychiatry, 2007.PMID 17541052
7. [7]Doering S, Hörz S, Rentrop M, et al. Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial Br J Psychiatry, 2010.PMID 20435966
8. [8]Levy KN, Meehan KB, Kelly KM, et al. Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder J Consult Clin Psychol, 2006.PMID 17154733
9. [9]Bateman A, Fonagy P Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial Am J Psychiatry, 1999.PMID 10518167
10. [10]Bateman A, Fonagy P 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual Am J Psychiatry, 2008.PMID 18347003
11. [11]Milrod B, Leon AC, Busch F, et al. A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder Am J Psychiatry, 2007.PMID 17267789
12. [12]Gabbard GO A contemporary psychoanalytic model of countertransference J Clin Psychol, 2001.PMID 11449380
13. [13]Gabbard GO The role of countertransference in contemporary psychiatric treatment World Psychiatry, 2020.PMID 32394567
14. [14]Winston A, Pinsker H, McCullough L A review of supportive psychotherapy Hosp Community Psychiatry, 1986.PMID 3781499
15. [15]Hellerstein DJ, Pinsker H, Rosenthal RN, et al. Supportive therapy as the treatment model of choice J Psychother Pract Res, 1994.PMID 22700197
16. [16]Hellerstein DJ, Rosenthal RN, Pinsker H, et al. A randomized prospective study comparing supportive and dynamic therapies. Outcome and alliance J Psychother Pract Res, 1998.PMID 9752637
17. [17]Markowitz JC Supportive Evidence: Brief Supportive Psychotherapy as Active Control and Clinical Intervention Am J Psychother, 2022.PMID 35232221
18. [18]Gutheil TG, Gabbard GO The concept of boundaries in clinical practice: theoretical and risk-management dimensions Am J Psychiatry, 1993.PMID 8422069
19. [19]Rosenthal RN, Muran JC, Pinsker H, et al. Interpersonal change in brief supportive psychotherapy J Psychother Pract Res, 1999.PMID 9888107
20. [20]Dotson S, Markowitz JC Planting the Tree Right-Side Up: Supportive Psychotherapy as a Priority in Residency Training Acad Psychiatry, 2025.PMID 40921918
21. [21]Salzer S, Stefini A, Kronmüller KT, et al. Cognitive-Behavioral and Psychodynamic Therapy in Adolescents with Social Anxiety Disorder: A Multicenter Randomized Controlled Trial Psychother Psychosom, 2018.PMID 29895001