A pilot study of defenses in adults with personality disorders entering psychotherapy

Maladaptive defense mechanisms moderate treatment outcome in 6 months versus 12 months dialectical-behavior therapy for borderline personality disorder

OBJECTIVE

We investigated whether defense mechanisms in patients with borderline personality disorder (BPD) predict treatment response of dialectical behavior therapy (DBT) and whether they moderate outcome in different treatment lengths.

METHOD

We analyzed a subsample of 60 outpatients with BPD, randomized into either 6 (n = 30) or 12 (n = 30) months of DBT. The average level of defensive adaptiveness, assessed with observer-rated overall defensive functioning (ODF) and "immature" (i.e., maladaptive) defenses were used as predictors and moderators of self-reported frequency of self-harm. We conducted a Generalized Linear Mixed Model (GLMM).

RESULTS

A lower ODF at treatment onset predicted smaller reductions in self-harm, irrespective of treatment length (IRR = 0.92, 95% CI = [0.86, 0.99], p = .020). Lower order "immature" ("major image distorting") defenses showed significantly smaller (IRR = 1.13, 95% CI = [1.06, 1.21], p < .001) and higher order "immature" ("minor image distorting") defenses showed significantly larger (IRR = .91, 95% CI = [.85, .97], p = .006) reductions in self harm in the 6-month but not in the 12-month treatment.

CONCLUSION

Even though the results have to be regarded as preliminary due to the small sample size, findings might indicate that patients with BPD and lower average defensive adaptiveness may benefit from individualized treatment plans including specific interventions targeting defense function.

Changes in Defense Mechanisms in Mothers From Pregnancy to 2 Years Postpregnancy

ABSTRACT

The objective of this study was to assess changes in maternal defensive functioning from the third trimester of pregnancy to 2 years postpregnancy. A community sample of at-risk mothers ( N = 84; non-White [61%], unmarried [67%], high school or less education [72%], and income less than $20,000 [50%]) were recruited for this longitudinal study. Mothers responded to a semistructured interview during pregnancy and at 2 years postpregnancy about the parent-infant relationship; interview transcripts were coded using the Defense Mechanism Rating Scale (DMRS). Results indicated a significant increase in both total defense mechanisms used and the relative percentage of immature defense mechanisms used over time. A significant decrease in the relative percentage of healthy/adaptive defenses was noted. When all seven levels of defenses of the DMRS were assessed, it was an increase in minor image-distorting defenses, mechanisms that supported vulnerable self-esteem, that accounted for most of the change in immature defenses. Stability coefficients of defense mechanisms were reported, with large effect sizes, for overall defensive functioning, and mature and immature defenses over a 2-year period. These findings lend support to the importance of assessing defense mechanisms to better understand stressful life transitions in mothers.

Defense Mechanisms and Treatment Response in Depressed Inpatients

The study investigated the extent to which defensive functioning and defense mechanisms predict clinically meaningful symptomatic improvement within brief psychodynamic psychotherapy for recurrent and chronic depression in an inpatient setting. Treatment response was defined as a reduction in symptom severity of 46% or higher from the baseline score on the Montgomery-Asberg Depression Rating Scale (MADRS). A subsample of 41 patients (19 responders and 22 non-responders) from an RCT was included. For each case, two sessions (the second and the penultimate) of brief inpatient psychodynamic psychotherapy (a manualized 12-session therapy program developed in Lausanne) were transcribed and then coded using the Defense Mechanism Rating Scales (DMRS) and the Psychotic Defense Mechanism Rating Scales (P-DMRS), an additional scale developed to study psychotic defenses. Results showed that defensive functioning and mature and immature defense changed during psychotherapy and predicted treatment response. Patient's defenses observed throughout therapy also predicted treatment response at 12-month follow-up. The addition of psychotic defenses allows a better prediction of the treatment response. Overall, these results are in line with previous research and provide further validation of defensive functioning as a predictor of outcomes and a mechanism of change in psychotherapy.

Countertransference responses mediate the relationship between patients' overall defense functioning and therapists' interventions

Objective: The aim of this work was to investigate the relationship between therapists' techniques (supportive/expressive intervention level - ESIL), therapists' countertransference (CT) and patients' defense level of functioning (ODF). We hypothesized that CT could play a mediating role in the relationship between patients' ODF and therapists' ESIL. Method: 65 psychotherapy sessions were rated by two different raters each with the Psychodynamic Interventions Rating Scale and the Defense Mechanisms Rating Scale. Clinicians used the Therapist Response Questionnaire to provide information on their CT. The 65 sessions referred to 65 clinicians (25 = females, 40 = males; 38 = psychodynamic, 27 = cognitive). More than half of the patients (n = 40; 61.5%) had a diagnosis of personality disorder. Among clinical disorders the most frequent were mood (n = 12) and anxiety disorders (n = 11). Five patients had no diagnosis. Results: Four CT responses (parental; positive; criticized; overinvolved) completely mediated the relationship between patients' ODF and therapists' ESIL, while no effect resulted in relation to overwhelmed, helpless, sexualized and disengaged CTs. No effect of theoretical orientations on mediation pathways was found. Conclusion: Both positive and negative CT feelings seemed to play a crucial role in the relationship between therapists' interventions and patients' ODF.

Integration Between Cerebral Hemispheres Contributes to Defense Mechanisms

Defense mechanisms are mental functions which facilitate coping when real or imagined events challenge personal wishes, needs, and feelings. Whether defense mechanisms have a specific neural basis is unknown. The present research tested the hypothesis that interhemispheric integration plays a critical role in defense mechanism development, by studying a unique sample of patients born without the corpus callosum (agenesis of the corpus callosum; AgCC). Adults with AgCC (N = 27) and matched healthy volunteers (N = 30) were compared on defense mechanism use across increasing levels of developmental maturity (denial, least; projection, intermediate; identification, most). Narratives generated in response to Thematic Apperception Test images were scored according to the Defense Mechanism Manual. Greater use of denial and less identification was found in persons with AgCC, compared to healthy comparisons. This difference emerged after age 18 when full maturation of defenses among healthy individuals was expected. The findings provide clinically important characterization of social and emotional processing in persons with AgCC. More broadly, the results support the hypothesis that functional integration across the hemispheres is important for the development of defense mechanisms.

Disentangling within- and between-patient effects of defensive functioning on psychotherapy outcome using mixed models

Abstract There is a great need to identify predictors of treatment response, and the analysis of defense mechanisms is a promising approach. Defensive functioning may influence psychotherapy outcome in two ways: First, when it is generally higher or lower for some patients relative to others and second, as it shifts in individual patients over time. The present study examined both within- and between patient effects of defenses using hierarchical linear modeling. Forty-seven patients diagnosed with depression, anxiety, or adjustment disorders received 25 ± 3 sessions of integrative cognitive-behavioral therapy in a university outpatient clinic. The Defense Mechanism Rating Scale (DMRS) was used to assess defenses in the 1st, 8th, 16th, and 24th session and relate them to symptom severity of depression and anxiety. A higher number of adaptive defense mechanisms was associated with less severe depressive symptoms during treatment while a higher number of immature defenses was related to more severe depressive and anxiety symptoms. An increase in adaptive and a decrease in immature defenses over the course of treatment predicted symptom reduction of depression whereas a decrease in neurotic and immature defenses was associated with reductions in anxiety symptoms. Our results empirically support defensive functioning as a mechanism of change in psychotherapy.

Comparison and change of defense mechanisms over the course of psychotherapy in patients with depression or anxiety disorder: Evidence from a randomized controlled trial

BACKGROUND

Defense mechanisms play an important role in the development and maintenance of both health and psychopathology. Research is still in the early stages of investigating the specific relationships among diagnostic groups and defense mechanisms along with their response to different treatment types.

METHODS

For the present study a total of 47 outpatients diagnosed with depression or anxiety disorders were randomized to receive 25±3 sessions of cognitive-behavioral therapy with integrated elements of either emotion-focused therapy (CBT + EFT) or treatment components based on self-regulation theory (CBT + SR). An observer-rated method, the Defense Mechanism Rating Scale (DMRS) was used to code transcripts of the 1st, 8th, 16th and 24th session to assess change in defensive functioning.

RESULTS

Over the course of therapy, overall defensive functioning (ODF) as well as adaptive defenses increased significantly, whereas maladaptive and neurotic defenses did not change. At the beginning of treatment, the proportion of adaptive defenses and ODF was significantly higher in patients diagnosed with anxiety disorders than in patients with depressive disorders. However, depressed patients exhibited greater improvement in their defensive functioning over the course of therapy.

CONCLUSIONS

Results support the view of defense mechanisms as a useful transdiagnostic and transtheoretical concept and supports the notion that change of defense mechanisms may be a relevant mechanism of change in psychotherapy.

Assessing Level of Personality Organization With the Psychodiagnostic Chart: A Validity Study

Heterogeneity within diagnostic types and comorbidity across diagnostic groups render a specific personality disorder anything but specific, leading researchers and clinicians to increasingly focus on the general severity of personality pathology. Personality pathology severity is reflected in one's level of personality organization (LPO) and research has demonstrated that LPO is a significant predictor of treatment response. This investigation examined the reliability and validity of the Psychodiagnostic Chart (PDC) in assessing the LPO dimension of the Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006). Among a sample of 88 urban-dwelling women seeking primary medical care, the LPO dimension of the PDC received fair to good interrater reliability among 6 psychodynamic psychologists. Convergent validity was demonstrated with contrast analysis and individual correlations that yielded statistically significant associations between LPO scores and conceptually related psychodynamic variables (e.g., defensive functioning, object relations) and self-reported personality pathology scores. Support for discriminant validity was limited by the modest power associated with the sample size. Exploratory analyses examining LPO scores and measures of physical health and intimate partner violence were conducted. Our results supported the reliability, validity, and practical use of the LPO dimension of the PDC.

Physicians' emotion regulation during communication with advanced cancer patients

OBJECTIVE

In cancer care, optimal communication between patients and their physicians is, among other things, dependent on physicians' emotion regulation, which might be related to physicians' as well as patients' characteristics. In this study, we investigated physicians' emotion regulation during communication with advanced cancer patients, in relation to physicians' (stress, training, and alexithymia) and patients' (sadness, anxiety, and alexithymia) characteristics.

METHODS

In this study, 134 real-life consultations between 24 physicians and their patients were audio-recorded and transcribed. The consultations were coded with the "Defence Mechanisms Rating Scale-Clinician." Physicians completed questionnaires about stress, experience, training, and alexithymia, while patients completed questionnaires about sadness, anxiety, and alexithymia. Data were analysed using linear mixed effect models.

RESULTS

Physicians used several defence mechanisms when communicating with their patients. Overall defensive functioning was negatively related to physicians' alexithymia. The number of defence mechanisms used was positively related to physicians' stress and alexithymia as well as to patients' sadness and anxiety. Neither physicians' experience and training nor patients' alexithymia were related to the way physicians regulated their emotions.

CONCLUSIONS

This study showed that physicians' emotion regulation is related to both physician (stress and alexithymia) and patient characteristics (sadness and anxiety). The study also generated several hypotheses on how physicians' emotion regulation relates to contextual variables during health care communication in cancer care.

Identifying indicators of defensive activity in narration about important interpersonal relations

<b>Background</b><br /> One of the main components of psychological conversation that influence communication is psychological defensiveness. 
In the paper I propose processual – situational understanding of defensiveness, and its measurement based on coding system. Preliminary results on link between personality traits and defensiveness in people’s narratives are presented as well.<br /> <br /> <b>Participants and procedure</b><br /> To test proposed coding system, study was conducted with participants presenting different levels of personality organization’s (borderline: n = 35, 20 women, M = 26.09, SD = 4.82, neurotic: n = 29, 24 women, M = 25.90, SD = 5.25, integrated: n = 31, 26 women, M = 21.94, SD = 1.69). Correlation method was applied (Borderline Personality Inventory, Neuroticism Scale, Emotion Control Inventory), as well as narrative’s interviews. Participants’ statements were coded by competent judges (defensiveness and coherence of narratives), and by automatic lexical analyses (descriptive indicators).<br /> <br /> <b>Results</b><br /> Results indicate that proposed defensiveness coding system is a set of heterogeneous indicators, and four groups of indicators could be extracted. Correlations between those indicators and expression control (positive relation), and coherence of narratives (negative relation). Moreover, differences between borderline participants and neurotic ones emerged.<br /> <br /> <b>Conclusions</b><br /> Proposed coding system seems to be a heterogeneous but useful tool for assessing defensiveness during psychological interviews. It could be applied as an element of a procedural control measures, directed to test the reliability of psychological conversation.

How does addressing patient's defenses help to repair alliance ruptures in psychodynamic psychotherapy?: An exploratory study

Interpreting or addressing defenses is an important aspect of psychoanalytic technique. Previous research has shown that therapist addressing defenses (TADs) can produce a positive effect on alliance. The potential value of TADs during the process of alliance rupture and resolution has not yet been documented. We selected patients (n = 17) undertaking a short-term dynamic psychotherapy in which the therapeutic alliance, measured with the Helping Alliance Questionnaire and monitored after each session, showed a pattern of rupture and resolution. Two control sessions (5 and 15) were also selected. Presence of TADs was examined in each therapist interpretation. Compared with control sessions, rupture sessions were characterized by fewer TADs and especially fewer TADs addressing specifically intermediate-essentially neurotic-defenses. Resolution sessions were characterized by more TADs addressing specifically intermediate defenses. This confirms the link between therapist technique and alliance process in psychodynamic psychotherapy.

Development of a Q-sort version of the Defense Mechanism Rating Scales (DMRS-Q) for clinical use

This report focuses on the need to provide clinicians with a reliable and valid measure for detecting patient defense mechanisms "inside psychotherapy." To avoid the limitations of existing methods, we designed a Q-sort based on the theoretical definitions and criteria of the Defense Mechanisms Rating Scales (DMRS-Q), but one that does not require transcripts of clinical interviews or sessions and may be applied without specific training on defenses. The DMRS-Q is sensitive to changes in psychotherapy and its scores correlate significantly with various aspects of mental functioning, making it potentially available for the psychotherapy process and outcome research as well. We report the results of using the DMRS-Q on a systematic single case study with the aim of detecting changes in defense mechanisms during a long-term psychodynamic psychotherapy. The DMRS-Q reveals change both in quantitative scores and in the literary Defensive Profile Narrative.

Change in defense mechanisms and coping patterns during the course of 2-year-long psychotherapy and psychoanalysis for recurrent depression: a pilot study of a randomized controlled trial

Very little research has been conducted so far to study the potential mechanisms of change in long-term active psychological treatments of recurrent depression. The present pilot randomized controlled trial aimed to determine the feasibility of studying the change process occurring in patients during the course of 2-year-long dynamic psychotherapy, psychoanalysis, and cognitive therapy, as compared with clinical management. In total, eight outpatients presenting with recurrent depression, two patients per treatment arm, were included. All patients were randomly assigned to one of the four treatment conditions. Defense mechanisms and coping patterns were assessed using validated observer-rated methodology based on transcribed, semistructured follow-along independent dynamic interviews. The results indicated that, whereas some patients in the active treatments changed on the symptomatic levels, some others remained unchanged during the course of their 2-year-long treatment. However, with regard to potential mechanisms of change in these patients, changes in defense mechanisms and coping patterns were revealed to be important processes over time in successful therapies and, to a lesser extent, in less successful treatments. No change was found either on outcome or on the process measure for the control condition, that is, clinical management. These results are discussed along with previous data comparing change in defense mechanisms and coping during the course of treatments.

Oncology clinicians' defenses and adherence to communication skills training with simulated patients: an exploratory study

The aim of this exploratory study was to assess the impact of clinicians' defense mechanisms-defined as self-protective psychological mechanisms triggered by the affective load of the encounter with the patient-on adherence to a communication skills training (CST). The population consisted of oncology clinicians (N=31) who participated in a CST. An interview with simulated cancer patients was recorded prior and 6 months after CST. Defenses were measured before and after CST and correlated with a prototype of an ideally conducted interview based on the criteria of CST-teachers. Clinicians who used more adaptive defense mechanisms showed better adherence to communication skills after CST than clinicians with less adaptive defenses (F(1, 29) =5.26, p=0.03, d=0.42). Improvement in communication skills after CST seems to depend on the initial levels of defenses of the clinician prior to CST. Implications for practice and training are discussed. Communication has been recognized as a central element of cancer care [1]. Ineffective communication may contribute to patients' confusion, uncertainty, and increased difficulty in asking questions, expressing feelings, and understanding information [2, 3], and may also contribute to clinicians' lack of job satisfaction and emotional burnout [4]. Therefore, communication skills trainings (CST) for oncology clinicians have been widely developed over the last decade. These trainings should increase the skills of clinicians to respond to the patient's needs, and enhance an adequate encounter with the patient with efficient exchange of information [5]. While CSTs show a great diversity with regard to their pedagogic approaches [6, 7], the main elements of CST consist of (1) role play between participants, (2) analysis of videotaped interviews with simulated patients, and (3) interactive case discussion provided by participants. As recently stated in a consensus paper [8], CSTs need to be taught in small groups (up to 10-12 participants) and have a minimal duration of at least 3 days in order to be effective. Several systematic reviews evaluated the impact of CST on clinicians' communication skills [9-11]. Effectiveness of CST can be assessed by two main approaches: participant-based and patient-based outcomes. Measures can be self-reported, but, according to Gysels et al. [10], behavioral assessment of patient-physician interviews [12] is the most objective and reliable method for measuring change after training. Based on 22 studies on participants' outcomes, Merckaert et al. [9] reported an increase of communication skills and participants' satisfaction with training and changes in attitudes and beliefs. The evaluation of CST remains a challenging task and variables mediating skills improvement remain unidentified. We recently thus conducted a study evaluating the impact of CST on clinicians' defenses by comparing the evolution of defenses of clinicians participating in CST with defenses of a control group without training [13]. Defenses are unconscious psychological processes which protect from anxiety or distress. Therefore, they contribute to the individual's adaptation to stress [14]. Perry refers to the term "defensive functioning" to indicate the degree of adaptation linked to the use of a range of specific defenses by an individual, ranging from low defensive functioning when he or she tends to use generally less adaptive defenses (such as projection, denial, or acting out) to high defensive functioning when he or she tends to use generally more adaptive defenses (such as altruism, intellectualization, or introspection) [15, 16]. Although several authors have addressed the emotional difficulties of oncology clinicians when facing patients and their need to preserve themselves [7, 17, 18], no research has yet been conducted on the defenses of clinicians. For example, repeated use of less adaptive defenses, such as denial, may allow the clinician to avoid or reduce distress, but it also diminishes his ability to respond to the patient's emotions, to identify and to respond adequately to his needs, and to foster the therapeutic alliance. Results of the above-mentioned study [13] showed two groups of clinicians: one with a higher defensive functioning and one with a lower defensive functioning prior to CST. After the training, a difference in defensive functioning between clinicians who participated in CST and clinicians of the control group was only showed for clinicians with a higher defensive functioning. Some clinicians may therefore be more responsive to CST than others. To further address this issue, the present study aimed to evaluate the relationship between the level of adherence to an "ideally conducted interview", as defined by the teachers of the CST, and the level of the clinician' defensive functioning. We hypothesized that, after CST, clinicians with a higher defensive functioning show a greater adherence to the "ideally conducted interview" than clinicians with a lower defensive functioning.

The impact of level of personality organization on treatment response: a systematic review

This paper provides a systematic review of extant research concerning the association between level of personality organization (PO) and psychotherapy response. Psychotherapy studies that reported a quantifiable association between level of PO and treatment outcome were examined for eligibility. Based on stringent inclusion and exclusion criteria, we identified 18 studies from 13 original data sources. Participants in these studies had a variety of mental disorders, of which mood, anxiety, and personality disorders were the most common. The results of this systematic review converge to suggest that higher initial levels of PO are moderately to strongly associated with better treatment outcome. Some studies indicate that level of PO may interact with the type of intervention (i.e., interpretive versus supportive) in predicting treatment outcome, which suggests the importance of tailoring the level of interpretive work to the level of PO. Yet, at the same time, the limited number of studies available and the heterogeneity of measures used to assess PO in existing research stress the need for further research. Potential implications for clinical practice and guidelines for future research are discussed.

Cognitive coping and defense styles in patients with personality disorders

This study investigates the associations between cognitive coping (as measured with the Cognitive Emotion Regulation Questionnaire; CERQ), defense mechanisms (as measured with the Defense Style Questionnaire-60; DSQ-60) and personality disorders (PDs; as measured with the SIDP-IV interview) in a large sample of patients with PDs (n = 1,435). Explorative factor analyses indicated that the nine CERQ subscales can be clustered into three higher-order factors (adaptive coping, non-adaptive coping and external attribution style). When compared to a general population sample, the PD sample particularly scored higher on nonadaptive coping styles. A higher number of PDs was related to a particularly higher level of nonadaptive coping and less mature defensive functioning, but also to lower levels of adaptive coping and external attribution. This study is the first to suggest that three higher-order coping styles can be identified among PD patients, and that these coping styles are related to the presence and number of PDs.

Change in defense mechanisms during short-term dynamic and cognitive therapy in patients with cluster C personality disorders

The aims of this study were to examine whether a change in overall defensive functioning during treatment a) would predict change in symptom distress during the course of treatment and follow-up and b) would be greater in short-term dynamic therapy than in cognitive therapy. Patients (N = 50) who met criteria for cluster C personality disorders were randomized to 40 weekly sessions of short-term dynamic therapy or cognitive therapy. Video recordings of a pretreatment interview and therapy session 36 were evaluated using the Defense Mechanisms Rating Scales. Symptom distress was measured using the revised version of Symptom Checklist-90. Change in overall defensive functioning during treatment predicted change in symptom distress from pretreatment to 2 years after treatment. Both treatment groups showed significant changes in defensive functioning toward greater adaptability but without any significant differences between the short-term dynamic therapy and cognitive therapy groups in a sample of patients with cluster C personality disorders.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Defensive Functioning Scale: a validity study

OBJECTIVE

We assess the convergent and predictive validity of the Defensive Functioning Scale (DFS) with measures of life events, including childhood abuse and adult partner victimization; dimensions of psychopathology, including axis I (depressive) and axis II (borderline personality disorder) symptoms; and quality of object relations.

METHOD

One hundred and ten women from a university-based urban primary care clinic completed a research interview from which defense mechanisms were assessed. The quality of object relations was also assessed from interview data. The women completed self-report measures assessing depression, borderline personality disorder symptoms, childhood physical and sexual abuse, and adult partner physical and sexual victimization.

RESULTS

Inter-rater reliability of the scoring of the DFS levels was good. High adaptive defenses were positively correlated with the quality of object relations and pathological defenses were positively correlated with childhood and adult victimization and symptom measures. Although major image distorting defenses were infrequently used, they were robustly correlated with all study variables. In a stepwise multiple regression analysis, major image distorting defenses, depressive symptoms, and minor image distorting defenses significantly predict childhood victimization, accounting for 37% of the variance. In a second stepwise multiple regression analysis, borderline personality disorder symptoms and disavowal defenses combined to significantly predict adult victimization, accounting for 16% of the variance.

CONCLUSIONS

The DFS demonstrates good convergent validity with axis I and axis II symptoms, as well as with measures of childhood and adult victimization and object relations. The DFS levels add nonredundant information to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition beyond axis I and axis II.

Defensive flexibility and its relation to symptom severity, depression, and anxiety

Numerous studies have examined which individual defense mechanisms are related with mental health, and which are linked with psychopathology. However, the idea that a flexible use of defensive mechanisms is related to psychological wellbeing remained a clinical assumption, which this study sought to test empirically. A total of 62 (N = 62) outpatients participated in the study and were assessed with the Symptom Checklist-90R and the Social Adjustment Self-rated Scale. A subsample of 40 participants was further assessed using the Hamilton Depression (HAMD-21) and Anxiety scales (HAMA-21). The first therapy session of all participants was transcribed and rated using the Defense Mechanisms Ratings Scales (), and the Overall Defensive Functioning (ODF) score, which indicates the maturity of one's defensive functioning, was computed. An indicator of flexible use of defenses was also calculated based on the Gini Concentration C measure. Results showed that defensive flexibility, but not ODF, could predict anxiety scores. Symptom severity was predicted by both ODF and defensive flexibility, although in directions opposite to our predictions. Results suggest that defensive flexibility captures another aspect of an individual's functioning not assessed by the ODF, and that it is a promising new way of documenting defensive functioning.

Toward developing a scale to empirically measure psychotic defense mechanisms

In recent years, research on psychological processes has greatly advanced our understanding of various psychopathologies. Defense mechanisms, for example, have been described as observable phenomena, and studies have shown meaningful relationships among these processes and other measurable dimensions of health and illness. Despite some notable exceptions, one area that has been overlooked is the empirical study of defenses in psychotic disorders. This is in part due to the lack of valid instruments measuring psychotic-level defenses. Propadeutic to creating an empirical scale for measuring psychotic defenses, the psychoanalytic and empirical literature on psychotic defenses is reviewed, after which the concept of psychotic defenses as measured by the P-DMRS (Psychotic-Defense Mechanism Rating Scales)--which can be used independently or in combination with the current DMRS (Defense Mechanism Rating Scales)--is operationalized. Finally, current research directions applying the P-DMRS to the clinical setting are presented, as well as its implications for guiding current clinical practice.

Communication skills training and clinicians' defenses in oncology: an exploratory, controlled study

OBJECTIVE

The underlying mechanisms modifying clinician's communication skills by means of communication skills training (CST) remain unknown. Defense mechanisms, defined as psychological processes protecting the individual against emotional stress, may be a mediating factor of skills improvement.

METHODS

Using an adapted version of the Defense Mechanism Rating Scale-Clinician, this study evaluated clinicians' defense mechanisms and their possible modification after CST. Interviews with simulated patients of oncology clinicians (N=57) participating in CST (pre-/post-CST with a 6-month interval) were compared WITH interviews with the same simulated patients of oncology clinicians (N=56) who did not undergo training (T1 and T2 with a 6-month interval).

RESULTS

Results showed (i) a high number (mean=16, SD=6) and variety of defenses triggered by the 15-min interviews, (ii) no evolution difference between groups, and (iii) an increase in mature defenses after CST for clinicians with an initial higher level of defensive functioning.

CONCLUSIONS

This is the first study describing clinicians' defensive functioning; results indicate a possible mediating role of defenses in clinician-patient communication.

Early change in defence mechanisms and coping in short-term dynamic psychotherapy: relations with symptoms and alliance

Several patient-related variables have already been investigated as predictors of change in psychodynamic psychotherapy. Defensive functioning is one of them. However, few studies have investigated adaptational processes, encompassing defence mechanisms and coping, from an integrative or comparative viewpoint. This study includes 32 patients, mainly diagnosed with adjustment disorder and undergoing time-limited psychodynamic psychotherapy lasting up to 40 sessions, and will focus on early change in defence and coping. Observer-rater methodology was applied to the transcripts of two sessions of the first part of the psychotherapeutic process. It is assumed that the contextual-relational variable of therapeutic alliance intervenes as moderator on change in adaptational processes. Results corroborated the hypothesis, but only for coping, whereas for defences, overall functioning remained stable over the first 20 sessions of psychotherapy. These results are discussed within the framework of disentangling processes underlying adaptation, i.e., related to issues on trait and state aspects, as well as the role of the therapeutic alliance.

Defense mechanisms and Major Depressive Disorder in African American women

This study explored differences in defense use between a group of predominantly African American women diagnosed with Major Depressive Disorder (MDD; n = 20) and a healthy control sample (n = 20), both from a primary care medical clinic. Patients completed the Patient Health Questionnaire to assess DSM-IV diagnoses and underwent video-recorded interviews, which were assessed for defenses using the Defensive Functioning Scale from the DSM-IV. Groups were compared for differences in overall defensive functioning, defense levels, and individual defenses using independent samples t tests. Results showed that the MDD group scored higher on mental inhibition, minor image distorting, and major image distorting defense levels as well as the individual defenses devaluation, dissociation, and isolation. The control group scored higher on the overall defensive functioning and the individual defense anticipation. The results also showed a trend toward the MDD group scoring higher on the disavowal defense level and the individual defense splitting.

Therapist technique and patient defensive functioning in ultra-brief psychodynamic psychotherapy: a Lag sequential analysis

This study examined the association between therapist interventions, including interpretations, and patient defensive functioning. The first session of 32 (n = 32) Brief Psychodynamic Interventions were rated for therapist interventions and patient defensive functioning. Lag sequential analysis was used to determine if (a) there are organized sequences of therapist interventions; (b) there are predictable sequences in the patients' level of defensive functioning; (c) there are sequences of therapist interventions leading to change in the patients' defensive functioning; and (d) there are levels of patient defensive functioning leading to organized therapist response. Results suggested that there are organized sequences in the therapists' interventions and that patient in-session defensive functioning is relatively stable. However, no chain of therapist interventions led to a predictable response in the patients' defensive functioning or vice versa.

Changes in defensive functioning in completed psychoanalyses: the penn psychoanalytic treatment collection

Theory predicts that patients completing psychoanalysis should improve in their dynamic functioning. The aim of this naturalistic study is to examine whether a sample of 17 subjects from the Penn Psychoanalytic Treatment Collection with completed, tape-recorded psychoanalyses demonstrated improvement in one dynamic aspect: their defense mechanisms. The pre-post effect size for the change in overall defensive functioning (ODF) of the sample was large (.76) and statistically significant (p = .01). The percentage of subjects who improved in their ODF (71%) was similar to that found by others who studied the same sample using general functioning measures. These findings provide the first empirical evidence to support a trait-like change in dynamic personality functioning in patients who have undergone psychoanalysis. Randomized controlled studies with homogeneous samples are needed to further confirm these findings.

Clinicians' defences: An empirical study

OBJECTIVE

Clinicians' defence mechanisms are strategies used to manage the stress and the negative affects emerging during a therapy session. The first objective of the study is to adapt the defence mechanisms rating scales (DMRS), originally created by Perry for assessing patient defences, in order to evaluate clinician defences. The second objective is to explore the type of defence mechanisms used by clinicians in oncology. The third objective is to study the sensitivity of the instrument by assessing changes in defensive functioning after specific communication skills training (CST) in oncology.

DESIGN

Participants (N=20) were oncology clinicians participating in oncology CST. The defence mechanism rating scales for clinicians (DMRS-C) was used to assess the use of the clinicians' defences before and after CST.

RESULTS

The instrument showed promising preliminary psychometric properties. Numerous and very varied defences were coded in each session and corresponding to a great variety of defences. After CST, the clinicians' overall defensive functioning (ODF) increased. Considering the defences' levels, a decrease in the use of immature defences was observed.

CONCLUSIONS

Taking into consideration the importance of clinicians' variables in treatment outcome, this instrument constitutes a promising way of assessing the clinician's strategies used to face the emotional difficulties emerging during the therapeutic encounter.

An overview of issues related to categorical and dimensional models of personality disorder assessment

Despite long-standing efforts to improve the current diagnostic system for Axis II, problems remain with the categorical conceptualization of personality disorders (PDs). Due in part to these problems, interest has developed in dimensional models of PD classification. In this article, we discuss four issues relevant to categorical vs. dimensional assessment of PDs: (a) problems with self-reports in PD patients, (b) methodological issues in behavioral and clinician assessment of PDs, (c) challenges that arise when dimensional models are applied to patient and nonpatient samples, and (d) clinical implications of categorical and dimensional PD models. We suggest that researchers and clinicians address these concerns to avoid implementing a new PD assessment model that-although different from the current system-would otherwise remain fraught with difficulties.

Impact of defense style on brief psychotherapy of postpartum depression

In this study, we evaluated the impact of defense style (DS) on outcome and its relation to the therapeutic alliance. Women with postpartum depression were allocated to a brief psychotherapeutic intervention. To evaluate DS and the therapeutic alliance, the Defense Style Questionnaire and the Working Alliance Inventory were employed. The main outcome was the Edinburgh Postnatal Depression Scale score at end point; anxiety and retention in treatment were also evaluated. Fifty-nine patients were included; 46 completed the therapy and 65.4% responded (Edinburgh Postnatal Depression Scale score <10). Intense use of immature defenses was related to persistence of depression and anxiety symptoms at end point, even when controlled for potential confounders. Results tended to confirm a hierarchy of DSs independently of the alliance. Clinicians should be aware of possible differential responses to brief psychotherapies related to DS.

Psychodynamic aspects of communication skills training: a pilot study

GOALS OF WORK

Communication between patients and oncology clinicians is a key element of cancer care. Emotionally charged consultations may trigger clinicians' defense mechanisms, protecting them from painful emotions. Defense mechanisms, however, may also hamper the recognition of patients' suffering. This pilot study aims to explore clinicians' defense mechanisms observed in communication skills training (CST).

PATIENTS AND METHODS

A verbatim transcription of videotaped interviews with simulated patients were evaluated before (N=10) and after CST (N=10) with the defense mechanism rating scales (DMRS).

MAIN RESULTS

A wide variety of defense mechanisms were observed such as obsessional (e.g. intellectualisation) or disavowal (e.g. denial or projection). Immature defense mechanisms decreased after CST.

CONCLUSIONS

A wide variety of defense mechanisms are operant in oncology clinicians facing challenging interviews with simulated patients. Defense mechanisms may be modified by CST.

The History and Empirical Status of Key Psychoanalytic Concepts

Over the past century, the ideas set out in psychoanalytic theory have permeated the field of psychology as well as literature, art, and culture. Despite this popularity, analytic theory has only recently received empirical support. In this chapter, we seek to highlight several fundamental concepts of analytic theory (the unconscious, drives, defenses, object relations, Oedipus complex) and psychodynamic treatments (transference, countertransference, interpretations, resistance). The first section of the chapter offers a comprehensive definition and historical background for each concept. This foundation is followed by a review of the empirical evidence supporting the reliability and validity of these concepts, their impact on treatment, and their broader influence on the future of psychology.

Seven institutionalized children and their adaptation in late adulthood: the children of Duplessis (Les Enfants de Duplessis)

War, societal and familial upheaval, disease, and natural disasters have resulted in orphaned children throughout time. One societal response to providing care for orphans has been institutionalization or the orphanage. We studied a sample of adults, known as les enfants de Duplessis or Duplessis's children, who were raised in Quebec institutions from birth onward and followed up in late adulthood. Systematic study indicated a high prevalence of adverse outcomes and found high levels of gross psychological trauma and adversity which, moderated by the childhood strengths of the individuals, had adverse effects on adult outcome (Sigal, Perry, Rossignol, & Ouimet, 2003; Perry, Sigal, Boucher, Paré, & Ouimet, 2005a; Perry, Sigal, Boucher, Paré, Ouimet, Norman, & Henry, 2005b). This report describes the experiences of seven individuals in the institutions and their subsequent life history and current functioning. The individual cases reflect a wide range of childhood strengths and experiences of trauma and other adversity in relationship to adult caretakers. While the group overall appears to have had seriously diminished functioning in late adulthood, several individuals had positive outcomes. We hope that by highlighting the potentially adverse effects of institutional rearing on subsequent development into late adulthood, these stories may inform those concerned with the care of orphans.

Personal strengths and traumatic experiences among institutionalized children given up at birth (Les Enfants de Duplessis--Duplessis' children): II: Adaptation in late adulthood

In a companion article, we retrospectively examined the childhood strengths and adverse experiences of a group of orphans given up at or near birth and raised in Quebec institutions. This article examines the relationship of their early experiences to functioning and symptoms in later adulthood. The same follow-up interview of 81 adults (41 women, 40 men) at a mean age of 59.2 years included assessments of their current symptoms and functioning. The mean adult Social and Occupational Functioning Score (57.8; 95% CI, 54.7-61.0) indicated moderate difficulty. Psychiatric symptoms were significantly higher than in a matched population survey sample from Quebec. Mean overall defensive functioning indicated a neurotic (inhibited) level. Total trauma and childhood strengths predicted adult outcomes, but childhood strengths moderated the effects of trauma. Institutionalization of children--if unavoidable--must build in effective safeguards against adverse experiences, especially among children with few strengths, and foster children's strengths to avoid impaired adult outcomes.

How to address patients' defences: a pilot study of the accuracy of defence interpretations and alliance

This pilot study examined the accuracy of therapist defence interpretations (TAD) in high-alliance patients (N = 7) and low-alliance patients (N = 8). TAD accuracy was assessed in the two subgroups by comparing for each case the patient's most frequent defensive level with the most frequent defensive level addressed by the therapist when making defence interpretations. Results show that in high-alliance patient-therapist dyads, the therapists tend to address accurate or higher (more mature) defensive level than patients most frequent level. On the other hand, the therapists address lower (more immature) defensive level in low-alliance dyads. These results are discussed along with possible ways to better assess TAD accuracy.

Clinical significance and patients' perceived change in four sessions of brief psychodynamic intervention: characteristics of early responders

This study investigated Tingey, Lambert, Burlingame, and Hansen's (1996) extension of Jacobson, Follette and Revenstorf's (1984) proposal for assessing clinical significance. Seventy (N=70) outpatients with/without Cluster C personality disorders treated with a brief psychodynamic intervention (BDI) were included in the study. Results showed that 33% of patients demonstrated clinically significant change on the Global Severity Index. Patients who improved reported more perceived subjective change, greater satisfaction with the treatment, and greater improvement on the Social Adjustment Scale than patients who did not improve (60%) or deteriorated (7%). Further analyses showed that clinical significance achieved in a four session ultra-brief therapy is associated with patient characteristics such as co-morbid personality disorders, level of defensive functioning, and specific interpersonal problems. Results were maintained at 3 month and 6 month follow-ups. Findings are discussed in reference to Howard's suggestions on remoralization and remission.

Childhood sexual abuse and adult defensive functioning

Differences in defensive functioning between those who reported a history of childhood sexual abuse (CSA) and those who did not was examined in a naturalistic treatment-seeking sample of adult outpatients (N = 67). Defensive functioning and childhood sexual abuse history were rated by clinicians and external raters utilizing the DSM-IV Defensive Functioning Scale and the Abuse Dimensions Inventory, respectively, based on information gathered as part of a larger therapeutic assessment. Individuals reporting a history of CSA were found to use more major image-distorting level defenses than the non-CSA group, and abuse severity was also related to greater use of major image-distorting level defenses. Those reporting a history of CSA relied more on defenses indicative of impairment in realistic perception of self and others. This defensive style likely contributes to the greater difficulties in interpersonal functioning and psychological problems in adulthood.

Assessment of Therapists' and Patients' Personality: Relationship to Therapeutic Technique and Outcome in Brief Dynamic Psychotherapy

My first focus of this study was to explore therapists' personal characteristics as predictors of the proportion of interpretation in brief dynamic psychotherapy (N=39; maximum 40 sessions). In this study, I used data from the Norwegian Multicenter Study on Process and Outcome of Psychotherapy (1995). The main finding was that therapists who had experienced good parental care gave less interpretation (28% variance was accounted for). Therapists who had more negative introjects used a higher proportion of interpretation (16% variance was accounted for). Patients' pretreatment characteristics were not predictive of therapists' use of interpretation. The second focus was to investigate the impact of therapists' personality and the proportion of interpretation on the development of patients' maladaptive defensive functioning over the course of therapy. Better parental care and less negative introjects in therapists were associated with a positive influence and accounted for 5% variance in the reduction of patients' maladaptive defense.