Research in Psychotherapy-Psychopathology Process and Outcome最新文献

Mature defense mechanisms support patients' engagement in psychotherapy. The Overall Defensive Functioning (ODF) scale of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Defensive Functioning Scale (DFS) is a measure of the maturity of patients' defenses. Immature defenses (e.g., splitting) and poor emotion regulation are hallmarks of borderline personality organization, and both can interfere with positive treatment engagement. We predicted that ODF would significantly and negatively correlate with the Personality Assessment Inventory Borderline (PAI-BOR) scales, PAI Treatment Rejection (PAI-RXR) scale, and the PAI Treatment Process Index (PAI-TPI). To our knowledge, no studies have examined the relationship between ODF scores, as measured by the DFS rating of Thematic Apperception Test (TAT) narratives, and defense levels, PAI-BOR Full Scale (PAI-BOR-FS), PAI-RXR, and PAI-TPI scales. The sample included 73 outpatients from an academic hospital. Patients were administered the PAI and a TAT protocol. Two psychologists independently rated 40 TAT protocols with the observer-rated DFS for reliability. Healthy defenses showed significant negative correlations with PAI-BOR-FS (r=-.27), PAI-BOR Negative Relationships (PAI-BOR-N) (r=-.38), and PAI-RXR (r=.30). The pathological defenses had positive correlations with four of the five PAI-BOR scales and the PAI-TPI. There were significant correlations between ODF and the treatment related scales, PAIRXR (r=.37, p<.01) and PAI-TPI (r=-.32, p<.01). ODF significantly and negatively correlated with the PAI BOR-FS (r=-.36, p<.01) and its subscales, Affective Instability (r=-.35, p<.01) and Negative Relationships (r=-.39, p<.01). High and low ODF groups had significant and meaningful differences on all seven PAI scales. Overall, these findings provide support for the construct validity and clinical utility of the DFS defense levels (healthy, neurotic, and pathological) and the global ODF.

This longitudinal observational study investigates the relationship between patients' defense mechanisms before outpatient therapy and their interpersonal problems during early treatment, exploring how specific defense mechanisms are associated with interpersonal problems, a clinically relevant factor for therapy planning. Participants (N=286) from a German outpatient sample completed baseline assessments prior to their first therapy session, including self-report measures of defense styles (Defense Style Questionnaire [DSQ]), emotion regulation (Difficulties in Emotion Regulation Scale - Short Form [DERS-SF]), structural integration (Operationalized Psychodynamic Diagnosis - Structure Questionnaire Short Version [OPD-SQS]), and interpersonal problems (Inventory of Interpersonal Problems [IIP-32]). Follow-up assessments were conducted at approximately 6 and 12 months. Linear mixed models were used to examine longitudinal changes in interpersonal problems and their association with baseline defense styles and defense mechanisms, adjusting for age, sex, therapy duration, structural integration, and emotion regulation difficulties. Particularly, the intermediate (neurotic) defense style was associated with higher levels of interpersonal problems across timepoints. However, defense styles did not significantly predict changes in interpersonal problems over time. In contrast, a more nuanced analysis at the level of defense mechanisms revealed that projection, undoing, and reaction formation were associated with greater interpersonal difficulties, while anticipation was associated with fewer difficulties. Projection showed a robust interaction with time, indicating its relevance for predicting individual change trajectories. These findings suggest that individual defense mechanisms provide added predictive value over aggregated defense styles when assessing interpersonal functioning in early outpatient therapy. From a clinical perspective, the differentiated assessment of specific defenses may improve treatment planning in psychodynamic therapy, although further research is warranted.

This cross-sectional, questionnaire-based study examined the role of psychological (i.e., defenses and reflective functioning) and contextual variables (i.e., LGBTQ+ identity, clinical experience, and LGBTQ+-specific training) in contributing to professional burnout among 51 Italian psychologists and psychotherapists (mean age 40.12, standard deviation [SD]=9.86) working with LGBTQ+ patients. Preliminary correlational analyses showed that mature defenses were negatively associated with emotional exhaustion and depersonalization, and positively with personal accomplishment. Conversely, immature defenses correlated positively with emotional exhaustion and depersonalization, and negatively with personal accomplishment. Neurotic defenses were linked specifically to reduced personal accomplishment. Lower certainty about mental states - an indicator of diminished reflective functioning - was also associated with higher burnout. In line with the study's main hypothesis, regression analyses revealed that lower overall defensive functioning (ODF), reduced certainty about mental states, and fewer years of clinical experience significantly predicted higher burnout levels. These findings underscore the importance of both intrapsychic resources and professional development in protecting therapists from burnout. Adaptive defenses and strong reflective functioning appear particularly protective in LGBTQ+ clinical contexts, where therapists often encounter emotionally complex, identity-related challenges. Therapists who can mentalize effectively and regulate internal responses through mature defenses may be better equipped to sustain therapeutic engagement and mitigate emotional exhaustion. These results suggest that clinical training and supervision should prioritize the enhancement of reflective capacity and adaptive defenses. Supporting these intrapsychic skills may be key to promoting therapist well-being and ensuring affirming, competent care for LGBTQ+ patients.

Treatment studies of major depression commonly focus on symptoms rather than changes in psychological risk factors. This pilot study examines the relationship between changes in eight defenses specifically related to depression, called depressive defenses, and depressive symptoms. Thirty adults with acute, recurrent major depression were given antidepressant medications (ADM) and randomized to up to 18 months of either cognitive behavioral therapy (CBT), dynamic, or supportive psychotherapy and followed for 4.5 years. Defenses were assessed using the observer-rated Defense Mechanism Rating Scales (DMRS) at intake and 18 months. The Hamilton Rating Scale for Depression-17 item version (HRSD-17) and the Beck Depression Inventory-2nd version (BDI-II) assessed depression periodically. Depressive symptoms decreased significantly on both the HRSD-17 (effect size [ES]=-1.03) and BDI (ES=-1.90). Overall defensive functioning (ODF) increased significantly (ES=.85), improving in 76% of participants. Similarly, the mean proportion of depressive defenses decreased significantly by termination (ES=-.62), although the overall mean remained above that generally seen in healthy adults. Twenty-four percent of participants attained this threshold at termination. After controlling for initial levels, at termination depressive defenses correlated significantly with HRSD-17 (rs=.44, p=.02), and BDI (rs=.33, p=.095). Although causal relationships were not established, depressive defenses were consistently related to changes in depressive symptoms, suggesting that they are promising mediators of treatment effects for major depression. Clinically, defenses are readily identifiable and can serve as important foci in treatment. Finally, levels of depressive defenses that exceed healthy norms may reflect a continuing level of risk for current or future depressive symptoms or episodes.

Defense mechanisms are automatic psychological processes that regulate emotional conflicts and modulate adaptation to internal and external stressors. As implicit components of emotion regulation, they play a transdiagnostic role across psychological and physical domains of health. Among the available instruments, the Defense Mechanisms Rating Scales-Self-Report-30 (DMRS-SR-30) directly operationalizes the hierarchical model of defenses, widely considered the gold standard framework for their empirical assessment. This systematic review aimed to synthesize findings from all studies that had employed the DMRS-SR-30 to date, summarizing its psychometric properties, domains of application, and clinical implications. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was conducted across PubMed, Scopus, and Web of Science databases. Eligible studies were full-text peer-reviewed articles written in English employing the DMRS-SR-30. Risk of bias was assessed according to study design using an established quality appraisal tool. Twenty-six studies met the inclusion criteria. The main domains of application were medical conditions, mental health and psychopathology, personality, and stress-related adjustment. Across these research areas, mature defenses were consistently associated with adaptive functioning and resilience, whereas immature and neurotic defenses predicted higher psychological distress, maladjustment, and psychopathology. The findings from the validation studies demonstrated that the scale exhibited robust reliability, construct validity, and clinical sensitivity. The DMRS-SR-30 provides a valid, efficient, and clinically meaningful method to assess the full hierarchy of defense mechanisms through a self-report tool. Its overall defensive functioning (ODF) index may offer an integrative measure of adaptive capacity that can complement standard psychodiagnostic and medical evaluations. Incorporating the assessment of defensive functioning can enhance the holistic understanding of patients, improve compliance with treatment, and promote person-centered care within mind-body health contexts.

Premature termination of psychotherapy is a challenging reality for both research and practice. This study aimed to contribute to a more comprehensive understanding of psychotherapy dropout by aggregating and synthesizing findings across dropout cases. A qualitative meta-synthesis was conducted on case studies from the Single Case Archive (SCA), a representative sample of published, peer-reviewed single-case psychotherapy studies. This meta-synthesis aggregated and synthesized the 11 case studies in the SCA published in English that described dropout substantively. The meta-synthesis identified 7 themes that influenced dropout: misattunement, inert therapeutic relationships, unmanaged therapist responses, unmanaged therapist interventions, rigid protocol adherence, readiness for change, and repeating interpersonal dynamics. These themes were arranged into the interrelated patient, therapist, and interactional clusters. The findings of the meta-synthesis were comprehensively represented by the metaphor of tango dancing, in which both partners co-create the dynamic that produces a (un)successful dance. One additional theme not fitting this structure includes instances in which dropout was a positive act on the part of the patient. The meta-synthesis revealed the complex and multifarious nature of psychotherapy dropout, a phenomenon that requires a sufficiently multifaceted conceptual framework for adequate comprehension. It was found that patients, therapists, and their dynamic interaction must be incorporated to account for the complex processes underlying psychotherapy dropout.

The observer-rated Q-sort based on the gold-standard Defense Mechanisms Rating Scales (DMRS-Q) allows the investigation of defense mechanisms based on one session as a whole. The present study analyzed the reliability and validity of the DMRS-Q applied to three types of clinical interactions other than therapy sessions. Transcripts of three different clinical interviews, including a total of 233 adults (50 cancer patients who completed Mayman's Early Memory Interview [EMI], 93 individuals without clinical diagnosis who completed McAdams' Life Story Interview [LSI], and 90 pregnant women who completed the Working Model of the Child Interview [WMCI]), have already been coded on the DMRS. Our research team of expert raters conducted the DMRS-Q coding on these same transcripts and assessed the inter-rater reliability and the concurrent, convergent, and discriminant validity of DMRS-Q in these clinical interactions. Results showed good inter-rater reliability (intraclass correlation coefficient [ICC]=.70) for the Overall Defensive Functioning (ODF), although lower than reported using transcripts of psychotherapy sessions. Large correlations were found between ODF scales assessed with the DMRS-Q and the DMRS among the three samples (r=.43 to .59; p<.001), while small to moderate correlations were found between the DMRS-Q, sociodemographic, and psychological measures. The DMRS-Q ODF scale might be a valid and reliable measure to assess the overall maturity of defensive functioning in brief interviews. Its ease of use, supported by open-source software, enables the application of the gold-standard DMRS theory across a wide range of contexts beyond psychotherapy research.

While a substantial number of studies investigate the nuances and clinical relevance of attachment styles and defense mechanisms separately, relatively few studies have explored the relationship between attachment styles and defense mechanisms. We aimed to provide a narrative review of empirical studies that used validated measures to assess the relationship between defense mechanisms and attachment styles in adolescents or adults. Twenty peer-reviewed studies published over the past 30 years were included. Except for one study involving high school students, all others focused on adults, mostly from community samples, with a few including clinical populations. Most studies employed various self-report questionnaires, though several used observer-rated or interview-based methods, with the majority using a cross-sectional design; a few studies used experimental and longitudinal designs as well. The studies' findings indicate an association between insecure attachment and greater use of immature defenses, while secure attachment is associated with more mature defenses. Anxious attachment was particularly linked to defenses such as projection, splitting, and devaluation, whereas avoidant attachment was associated with emotional suppression and denial. A subset of studies examined changes in these constructs during psychotherapy, suggesting that both defense mechanisms and attachment security may improve over time, and indicating the potential importance of reflective functioning as a mediator, as well as depressive immature defenses as obstacles to change. These results underscore the clinical relevance of assessing both attachment and defensive functioning and highlight the importance of addressing them as potential mechanisms of change in clinical contexts.

Grandiose narcissism is increasingly conceptualized as encompassing two dimensions: admiration and rivalry. Clarifying how these aspects are shaped requires attention to the intrapsychic regulators and interpersonal motivational systems that organize narcissistic functioning. A total of 478 participants completed an online survey including the Narcissistic Admiration and Rivalry Questionnaire (NARQ), the Defense Mechanisms Rating Scale-Self Report-30 (DMRS-SR-30), and the Social Mentalities Scale (SMS). Rivalry showed a stronger negative association with overall defensive functioning (ODF; r=-0.34, p<.001) compared to admiration (r=-0.09, p<.05). At the interpersonal level, rivalry was positively associated with insecurity (r=0.25, p<.001) and agonism (r=0.48, p<.001), and negatively with prosociality (r=-0.30, p<.001), belongingness (r=-0.28, p<.001), and playfulness (r=-0.23, p<.001). Admiration, in contrast, was positively associated with agonism (r=0.42, p<.001) and sexuality (r=0.23, p<.001). The mediation analysis (moderated by gender) indicated that defensive functioning impacted narcissistic expression through specific interpersonal motivational systems: insecurity (βmales=0.036, p=.040; βfemales=0.055, p=.009), prosociality (βmales=-0.033, p=.033; βfemales=-0.085, p=.002), and agonism (βmales=-0.163, p=<.001; βfemales=-0.132, p=.001). The study expands theoretical and clinical knowledge of the underlying motivations and defense mechanisms involved in grandiose narcissism, shedding light on specific intrapsychic and relational processes underpinning narcissistic dynamics.

The paper revisits defense mechanisms as central regulators of emotional life and self-coherence in contemporary clinical practice, showing how a classical psychodynamic construct has evolved into an empirically measurable, transdiagnostic dimension of functioning. After outlining the historical development of the concept, the authors present the hierarchical model of defenses, operationalized through the Defense Mechanisms Rating Scale (DMRS), as the current reference framework for assessment of thirty individual defenses across seven levels of adaptiveness. Empirical studies using the DMRS - also in its observer-rated Q-sort and self-report versions - indicate that shifts toward more mature defenses predict better outcomes across different treatment orientations, suggesting that changes in defensive functioning may represent a common factor underlying psychotherapeutic change. These advances are integrated with dimensional and transdiagnostic approaches, including the Psychodynamic Diagnostic Manual, Third Edition (PDM-3), in which defenses play a pivotal role in evaluating personality organization on Axis P and mental capacities on Axis M, thereby complementing symptom-focused systems such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) and the International Classification of Diseases (ICD-11). The paper also discusses conceptual overlaps with coping and emotion regulation, the limitations of cross-sectional and self-report methodologies, and the need for longitudinal, cultural, and neuro-psychodynamic research, proposing defense mechanisms as a unifying language that links psychodynamic theory, empirical psychology, and neuroscience.