Academic journal article American Journal of Psychotherapy

Contribution of Defensive Functioning to the Quality of Working Alliance and Psychotherapy Outcome

Academic journal article American Journal of Psychotherapy

Contribution of Defensive Functioning to the Quality of Working Alliance and Psychotherapy Outcome

Article excerpt

We analyzed whether defense mechanisms changed and/or predicted outcome during brief dynamic psychotherapy (N=43, max 40 sessions, Norwegian Multisite Study on Process and Outcome of Psychotherapy). Defenses were rated with the Defense Mechanism Rating Scales (DMRS, clinicianrated) and Defense Style Questionnaire (DSQ, self-rated). Overall defensivE functioning (ODF) as rated by DMRS changed significantly. We found that the initial ODF's neither predicted the quality of working alliance no? influenced the outcome. Symptoms improved most rapidly early in therapy, while defenses changed during the last half of therapy, consistent with the phase model of change.


We wanted to explore whether defenses changed over the course of brief dynamic psychotherapy (BDP, max 40 sessions). While defenses are expected to change in long-term treatment, one year of psychotherapy may be considered too short for such change. The patterns of defenses are assumed to be somewhat resistant to change. Any change in defenses during psychotherapy is, therefore, expected to be small to moderate, but may, nevertheless, reflect an increased capacity to tolerate internal and external stressors and the vicissitudes of life.

We also wanted to explore whether or not clinician-rated defenses are predictors of alliance and outcome in BDP, and whether the phase model of change over the course of therapy would be supported. A fairly rapid rate of improvement within the first nine sessions has been demonstrated, reflecting that clinically significant change occurs early in therapy, progressing from subjective well-being to symptom reduction, followed by gains in characterological, interpersonal, and social functioning (1). We used outcome variables corresponding to these categories, and also included coping styles.


Defense mechanisms may be helpful in understanding the patient's current distress and need for therapy, as assessments of symptoms and functioning are intrinsically more state dependent than the more traitlike defense mechanisms. Descriptive diagnoses do not yield information about the dynamics of the patients' symptoms. Assessment of defense mechanisms may therefore be useful for planning and conducting psychotherapy (2).

Defenses are seen as expressions of unconscious conflicts, needs, and motivations. They are often activated without conscious effort. Partial awareness of the defensive operation is possible. Freud saw defensive functioning as both adaptive and pathological. Later, Haan divided them into adaptive and maladaptive strategies. This labeling is now in common usage (3). There is a clear hierarchy of defenses in relation to their overall adaptiveness: defenses at the lower end are usually maladaptive, while those at the higher end are adaptive (4).

In a recent study, Perry found that patients with personality disorders had a high proportion of lower maladaptive (immature) defenses (49.3 %) (5). Higher overall defensive functioning (ODF) was associated with remaining in therapy after one year, whereas lower ODF was associated with dropping out. Some improvement in ODF was obtained after one year. Hoglend and Perry demonstrated that among subjects with major depression seeking help, mature defenses, such as anticipation and selfobservation, predicted better outcomes at six months after intake, whereas less mature defenses associated with depression, such as passive aggression, acting out, help-rejecting complaints, splitting of self-images, splitting of others' images, projective identifcation, projection, and devaluation, predicted worse outcomes, even after controlling for initial severity and the presence of a personality disorder (6). Defense mechanisms have previously been explored in a naturalistic follow-up study (7) and a single-case long-term treatment study (8). To our knowledge, no studies on the predictive validity of ODF in brief dynamic psychotherapy have been published. …

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