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Clinical Psychology and Psychotherapy Clin. Psychol. Psychother.

12, 288296 (2005)

Changes of Defensive Functioning. Does Interpretation Contribute to Change?

Anne Grete Hersoug,* Kjell-Petter Bgwald and Per Hglend
University of Oslo, Norway In this processoutcome study, we explored the changes of patients defensive functioning (rated with the Defence Mechanism Rating Scales) over the course of brief dynamic psychotherapy (N = 39, maximum 40 sessions). We investigated whether therapists use of interpretation (rated with the Psychodynamic Intervention Rating Scale) would inuence the development of maladaptive defensive functioning. The proportion of maladaptive defences was reduced during therapy. A higher proportion of interpretation was associated with less use of maladaptive defence after therapy, whereas the use of interpretation was not predictive of the change of adaptive defensive functioning. Therapists use of supportive interventions did not impact the development of either maladaptive or adaptive defences. Copyright 2005 John Wiley & Sons, Ltd.

In psychodynamic therapy, defensive functioning is one of the central issues. Defence mechanisms are unconscious and automatic, although we may have some awareness of their impact on our behaviour. Assessment of defence mechanisms may be used to indicate the patients level of functioning. Vaillant proposed a hierarchy of defences (1971, 1986, 1992), from maladaptive (immature) on the lowest level, to adaptive defences on the highest level of the hierarchy. Maladaptive defences are associated with less adaptive behaviour. Perrys review (1990) supported a hierarchical relationship between the maladaptiveness of defence mechanisms and psychiatric diagnoses, such as anxiety and affective disorders. The overall pattern was that action and borderline defences were associated with more anxiety and depressive symptoms, while more adaptive defences were associated

* Correspondence to: Anne Grete Hersoug, Department of Psychiatry, University of Oslo, P.O. Box 85 Vinderen, N-0319 Oslo, Norway. E-mail: a.g.hersoug@psykiatri.uio.no

with their absence. Subsequent studies have consistently reported associations between maladaptive defences and severity of psychopathology, including signs of personality disorders (Axis II), and symptoms such as depression and anxiety (Axis I) (Hilsenroth, 2003; Perry, 2001; Perry & Hglend, 1998; Perry et al., 1998). In the study by Holi, Sammallahti, and Aalberg (1999), maladaptive defence explained most of the variance in symptoms. Generally, maladaptive and adaptive defences are associated with the presence versus absence of psychopathology, whereas intermediate defences do not predict pathology and do not change much during treatment. Adaptive defence predicted improvement of depressive symptoms (Albucher, Abelson, & Nesse, 1998; Hglend & Perry, 1998). The study by Muris and Merkelbach (1996) indicated that patients use of more maladaptive defence was linked to less favourable psychotherapy outcome. Reduction of maladaptive defensive functioning over the course of therapy was associated with improvement (Akkerman, Carr, & Lewin, 1992; Kneepkens & Oakley, 1996).

Copyright 2005 John Wiley & Sons, Ltd.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.444

Changes of Defensive Functioning Both maladaptive and adaptive defence mechanisms are expected to change over the course of therapy. A previous study revealed that symptom improvement took place in the early phase of therapy, whereas change of defensive functioning, i.e. dynamic change, occurred in the last half of treatment (Hersoug, Sexton, & Hglend, 2002). This is consistent with the phase model of change in therapy (Hilsenroth, Callahan, & Eudell, 2001; Howard, Lueger, Maling, & Martinovich, 1993; Lueger, Howard, & Martinovich, 2001). Akkerman, Lewin, and Carr (1999) demonstrated that patients obtained a greater reduction in their use of maladaptive defence when therapy was continued after symptom recovery. In the psychodynamic tradition, it is commonly assumed that a certain degree of regression may take place in the early phase of therapy. Patients demonstrate more maladaptive defence when this occurs. The therapist gives defence interpretations, based on the assumption that this will contribute to enhanced self-exploration, insight, and change (Perry, 2001; Piper, Joyce, McCallum, & Azim, 1998). Defence interpretation addresses various aspects of defence mechanisms: patients affects, motives, and the specic defence mechanisms that are used (Bond, Banon, & Grenier, 1998; Milbrath et al., 1999; Perry, 1993). Research ndings consistently support that interpretation as a general mode of intervention can be helpful to patients (Orlinsky, Rnnestad, & Willutzki, 2003). The overview by Orlinsky et al. reported a signicant positive association between the use of interpretation and psychotherapy outcome in 24 accumulated ndings, whereas only three negative associations were reported. From the patients perspective, interpretation is among the most therapeutically signicant, positive factors (Bachelor, 1991). We have previously found that more interpretation was given to patients who displayed more maladaptive defence, whereas more supportive intervention was given to patients with more adaptive defence (Hersoug et al., 2003). Most interpretation was given when there was a high proportion of maladaptive defence combined with low quality of working alliance. A study on adjustment of therapists use of interpretation to patients level of defensive functioning yielded better quality of working alliance when therapists gave less interpretation to patients with higher overall defensive functioning (Hersoug, Hglend, & Bgwald, 2004). The main focus of this study is whether the therapists use of interpretation contributes to
Copyright 2005 John Wiley & Sons, Ltd.

289 the change of maladaptive defence. This has not previously been systematically investigated. The patients initial regression and increased use of maladaptive defence early in therapy may at times present the therapist with negative interpersonal patterns and transference issues, which tends to elicit a negative response from the therapist. A benecial use of interpretation is more difcult if negative processes develop (Binder & Strupp, 1997). Avoidance of negative processes may therefore be important for the further progress of therapy. Patients use of adaptive defence is neither associated with resistance in therapy nor the risk of developing negative processes. In this processoutcome study, we investigated whether interpretation is favourable for patients who demonstrate more maladaptive defence in dynamic psychotherapy. We explored whether the proportion of interpretation would predict change of patients maladaptive defensive functioning. Based on theory and previous research, we expected to nd that more interpretation would be associated with less use of maladaptive defence after treatment. We did not expect any impact of supportive interventions on maladaptive defence. Furthermore, we did not expect that interpretation would be predictive of more use of adaptive defence.

Setting, Therapists, and Therapy
This study was part of the naturalistic Norwegian Multicentre Study on Process and Outcome of Psychotherapy (NMSPOP, unpublished manuscript). A more detailed description of methods and measurements is presented elsewhere (Hersoug et al., 2002). The present site was the only site of the NMSPOP that had collected data on defence mechanisms and therapist interventions, in addition to the core assessment instruments. Therefore, this study used data from that site. The sample (N = 39) was unselected. The seven therapists in the study had practiced psychodynamically oriented individual therapy for a mean of 10 years (range 417). Their mean age was 44. Six of the seven therapists were female. There was a time limit of 40 sessions (mean number of sessions 35).

After receiving information about the study and giving their written consent, the patients comClin. Psychol. Psychother. 12, 288296 (2005)

290 pleted the self-report questionnaires for demographic data and symptoms, and then underwent a standardized diagnostic assessment using DSM IV Axis I and Axis II interviews, as well as a clinical assessment-dynamic interview, about 1 hour, followed by a clinical rating using the Psychodynamic Functioning Scale, PFS (Hglend et al., 2000). After termination of treatment, the patients underwent a diagnostic assessment similar to the pre-therapy evaluation. The therapist group met every second week with a supervisor and discussed transcribed sessions in detail, with emphasis on operationalization of defence mechanisms, interpretation of maladaptive defence and building adaptive defence by supportive techniques. There were some expectations that the therapists should interpret patients defenses, especially maladaptive defences, although the design of the study did not demand consistent manual adherence.

A. G. Hersoug et al. ing, which distinguishes between mature/ adaptive, neurotic, and immature/maladaptive defences. Defence mechanisms are unconscious, but one may have some degree of awareness of their impact on ones behaviour. The DMRS is comprised of 28 defence mechanisms, in a hierarchical scale of seven levels, from maladaptive (often referred to as immature) to most adaptive (often referred to as mature): action, major image distorting (borderline), disavowal, minor image distorting (narcissictic), neurotic, obsessional and adaptive (mature) defence. Several studies have supported the validity of the method (Perry, Kardos, & Pagano, 1993), and satisfactory interrater reliability for the overall defensive functioning (ODF) score has been documented (Perry & Ianni, 1998). The ODF is a summary score calculated from the DMRS scores, yielding a weighted average of the individual defence scores, to determine the level of defensive functioning. In this study, we also examined the impact of interpretation on the highest and lowest adaptive defence levels. We computed a combined score for levels 13, maladaptive defence (Maldef), calculated as a proportion of the total number of defences in the same session, and a combined score for the two highest adaptive defence levels, adaptive defence (Adapdef). Maladaptive defence includes acting out, borderline (splitting and projective identication) and disavowal defences. Subjects who use such defenses usually become inexible to the environmental realities and may be perceived by others as unpredictable and irrational. Two raters, who were trained by the developer of the DMRS manual for quantitative scoring, rated complete transcripts of the dynamic interviews before and after therapy. The dynamic interviews attempted to capture the patients characteristic patterns of defence mechanisms. Two therapy sessions per patient were also rated. The patients defensive functioning during therapy was rated in the same sessions as the ratings of therapist interventions were made. The defence mechanisms were rated according to the counting signs method, i.e. each occurrence of a defence in the complete transcripts of sessions was rated. The limited resources for transcription of sessions, and the very time-consuming rating procedure, allowed for four transcripts to be rated for each patient, including the dynamic interviews before and after therapy. The seventh and 16th sessions were selected because it was deemed most appropriate to start the rating of interpretation in the seventh session, after the initial phase, allowing the patient and
Clin. Psychol. Psychother. 12, 288296 (2005)

The patients were referred from their GPs to their local outpatient clinics, and were consecutively admitted for individual psychotherapy. Their mean age was 36.7 years (SD 8.1, range 2452), and 87% were female. The most frequent DSM IV (American Psychiatric Association, 1994) Axis I diagnoses were depressive disorders (67%) and anxiety disorders (65%), and 65% had a personality disorder. The mean sum of personality disorder criteria, using the SCID II interview, was 11.7. Mean GAS (current GAS) (Endicott, Spitzer, Fleiss, & Cohen, 1976) for the sample was 56 (SD. 5.1), and mean symptom severity, GSI (Global Severity Index, SCL-90-R; Derogatis, 1983), was 1.34 (SD. 0.55). The data indicate that the sample of patients was moderately disturbed (Tingey, Lambert, & Burlingame, 1996).

Measurements Defence Mechanism Rating Scales (DMRS)

DMRS was developed by J. C. Perry (Perry, unpublished manuscript). DMRS is a criterionbased system of operationalization of defence mechanisms, and allows for systematic quantitative and qualitative studies of defence mechanisms and their inuence on the therapy process and outcome. It is an observer-rated method, constructed with seven levels of defensive functionCopyright 2005 John Wiley & Sons, Ltd.

Changes of Defensive Functioning therapist a few sessions to establish a working alliance (the patient and therapist did not meet until the assessment procedure was completed). The 16th session was selected because it was expected to be within the active treatment phase, before issues related to termination became the focus of attention for patients. We computed the proportion of Maldef in the seventh session and 16th session: Maldef 7 and Maldef 16. Based on the previous nding that changes of defensive functioning take place after the 16th session, we calculated the mean proportion of Maldef (mean Maldef) from initial Maldef, Maldef 7 and Maldef 16, and used this as the independent variable in the statistical analyses, to control for the impact of the early proportion of Maldef on the further development of maladaptive defence. In a similar manner, we computed the proportion of adaptive defence, Adapdef: initial, in the seventh session, in the 16th session, and after therapy. For the statistical analyses, we calculated the mean proportion of Adapdef up to session 16 (mean Adapdef) and used this as the independent variable. The raters rst made independent ratings of each occurrence of defence mechanisms in all the transcripts for all patients in the sample. Based on these ratings, their intraclass correlation (ICC 2, 2) was calculated, according to Shrout and Fleiss (1979). The mean ICC for the ODF in the rated transcripts over the four time points was 0.83. The mean intraclass correlations for Adapdef and Maldef over the four time points were ICC(2, 2) 0.70 (range 0.640.77) and 0.75 (range 0.680.84), respectively. The mean intraclass correlations for neurotic defence and narcissistic defence (ICC 2, 2) were 0.61 (range 0.530.68) and 0.57 (range 0.440.62), respectively. After the independent ratings, the raters met for consensus ratings of each occurrence of defence mechanisms. The consensus ratings were used in the statistical analyses.

291 and the specic mechanisms of defence that are used (Milbrath et al, 1999; Perry, 1993). Transference interpretation is dened broadly, including all occurrences of addressing the patienttherapist relationship. Defence and transference interpretations were rated on levels from one to ve, according to completeness or depth. The highest level was rated when both defence mechanism and unconscious motives were specied. Interpretation on level one species e.g. an affect being warded off or the method used to diminish affect or diffuse meaning. Interpretation on level three inquires about a possible motive for the defence mechanism. On level ve, the therapist addresses both the motives and the reason why the affect is being avoided or mitigated. Interpretation on level one is assumed to reect the therapists emotional attunement with the patients affects. The total number of interpretive interventions, i.e. defence and transference interpretations combined, was analyzed, relative to the total number of interventions. This yielded the proportion of interpretation (Int). In a similar manner, the proportion of supportive interventions (Sup) was calculated. Two independent raters, who were trained according to the PIRS manual, scored each therapist intervention in complete transcripts (session 7 and session 16) for all patients in the sample. First, they made independent ratings, from which the intraclass correlation for each intervention category was calculated. In the seventh session, the intraclass correlation coefcient for Int (ICC 2, 2) was 0.79. In the 16th session, the intraclass correlation coefcient for Int (ICC 2, 2) was 0.78. In a similar manner, the intraclass correlation for Sup was calculated. The mean ICC(2, 2) for Sup in the seventh session was 0.97, and in the 16th session ICC(2, 2) for Sup was 0.98. After the independent ratings, the raters met for consensus ratings of each therapist intervention. In the statistical analyses, the mean proportion of interpretation from the consensus ratings in the seventh session and 16th session was used.

Psychodynamic Intervention Rating Scales (PIRS)

PIRS is a categorical rating scale (Cooper & Bond, unpublished manuscript), with two main categories: interpretation (non-transference and transference) and supportive interventions (clarication, reection, question, work-enhancing strategy, support, association, acknowledgment, and contractual arrangement). For a statement to be rated as a defence interpretation, it must be linked to unconscious processes, e.g. keeping an affect out of awareness or an affect itself that is out of consciousness. Defence interpretation is broadly dened, and includes patients affects, motives,
Copyright 2005 John Wiley & Sons, Ltd.

Data Analysis
We investigated the associations between the proportion of interpretation (Int) and patients maladaptive defensive functioning (Maldef) at the end of treatment, performing a hierarchical multiple regression analysis (HMR) (Cohen & Cohen, 1983). The HMR analysis yielded the amount of variance in maladaptive defence after therapy that was
Clin. Psychol. Psychother. 12, 288296 (2005)

292 accounted for by the proportion of interpretation. The procedure was as follows. On the rst step, we entered mean Maldef, to control for the impact of the proportion of Maldef before the improvement started, on the proportion of Maldef after therapy. On the second step, we entered Int. In a similar manner, we performed an HMR anlysis of the impact of interpretation on the development of adaptive defensive functioning (Adapdef). The proportion of supportive interventions (Sup) is the inverse value of the proportion of interpretation. Since the results would be the inverse of the ndings with the HMR analyses of Int, separate HMR analyses with Sup were not performed. We used SPSS version 11.0 (SPSS Inc, 2002) in the statistical analyses. A signicance level of p < 0.05 was chosen. The analyses were two tailed.

A. G. Hersoug et al.
Table 1. Development of defence mechanisms prepost therapy Defence level Proportion of defences Pre-therapy Level VII Mature Level VIb Obsessional Level Vc Other neurotic Level IVd Minor image distorting Level IIIe Disavowal Level IIf Major image distorting Level Ig Action

Session 16 1.6 24.0 29.5 14.7 22.6 4.5 3.3

Post-therapy 13.3 26.9 25.2 13.0 15.3 3.6 3.2

2.4 22.8 30.9 14.9 18.3 6.6 3.9

Patient use of defence mechanisms changed during therapy and became more adaptive, as reected in the ODF score. ODF was 4.41 pre-therapy and increased to 4.87 post-treatment (p < 0.01; ES = 0.77). Descriptive data on the development of the seven levels of defence mechanisms over the course of therapy are presented in Table 1. The initial proportion of the outcome variable, Maldef, was 28.7. Maldef in the seventh session was 29.6%. In the 16th session Maldef was 30.4%, and Maldef at the end of treatment was 22.7%, which is a signicant reduction. The initial proportion of Adapdef was 25.2%, in the seventh session 28.3%, in the 16th session 25.6%, and after therapy Adapdef was 40.8%, which is a signicant increase. We observed a small increase of Maldef in the early phase of treatment. Maldef improved after session 16, i.e. after the mid-phase, which is consistent with the assumption in the psychodynamic tradition. The ndings are presented in Table 2. Effect sizes for the change in defensive functioning are computed using Cohens d with pooled SD for pre-therapy and post-therapy measures. Descriptive values of the PIRS ratings indicate that defence interpretation was moderately used (mean 14.8 per session) and transference interpretation used with caution (mean 3.3 per session). The mean number of interpretations rated on level one was 10.4 per session; fewer were rated on level three (mean 3.7 per session), and level ve was rarely used. The PIRS criteria indicate that defence interpretation should be rated on level one when
Copyright 2005 John Wiley & Sons, Ltd.

DMRS defence mechanisms: a Afliation, altruism, anticipation, humor, self-observation, selfassertiveness, sublimation, suppression. b Isolation, intellectualization, undoing. c Repression, dissociation, reaction formation, displacement. d Omnipotence, idealization, devaluation. e Denial, projection, rationalization, fantasy. f Splitting others images, splitting self-images, projective identication. g Acting out, passive aggression, hypochondriasis (help-rejecting complaining).

Table 2. Development of defensive functioning over the course of therapy Defence level Proportion of defences Pre-therapy Post-therapya ES Adaptive defence Neurotic defence Narcissistic defence Maladaptive defence 67 5 4 13 25.3% 30.9% 14.9% 28.7% 40.8%* 25.2%* 13.0% NS 22.2%* 0.95 0.54 0.20 0.42

* p < 0.05, two tailed. a The change in defensive functioning is assessed with a pairedsamples T-test prepost therapy.

an affect is warded off and when a specication is made regarding the method used to diminish affect/diffuse meaning. Transference interpretation on level one includes all occurrences of addressing the patienttherapist relationship. Descriptive data on therapist interventions are preClin. Psychol. Psychother. 12, 288296 (2005)

Changes of Defensive Functioning

Table 3. Descriptive data for the Psychodynamic Intervention Rating Scale Proportion of interpretation (%) Number of inter-pretations T.I. (level 1) T.I. (level 3) T.I. (level 5) D.I. (level 1) D.I. (level 3) D.I. (level 5) Supportive interventions Total number of interventions M 20 SD 0.10

Table 4. Hierarchical multiple regression for interpretation and outcome Variables entered Dependent Maldef2 Independent Step 1 Maldefm Step 2 Interpretation Total b DR2 F dfs

2.50 (range 020) 0.40 (range 06) 0.05 (range 01) 10.50 (range 025) 3.80 (range 015) 0.75 (range 05) 73.9 (range 33116) 91.8 (range 52135)

3.7 0.7 0.3 4.9 2.8 0.8 23.3 20.9

0.69 -0.30

0.42*** 0.09* 0.51***

27.00 6.72 18.95

1, 37 1, 36 1, 36

b = standardized coefcient beta. * p < 0.05; ** p 0.01; *** p < 0.001. Maldef2 = the proportion of maladaptive defence after termination of therapy. Maldefm = the mean proportion of maladaptive defence early in treatment: initial, seventh session and 16th session.

T.I. = transference interpretation. D.I. = defence interpretation. Mean values are combined for the seventh and 16th sessions.

sented in Table 3, which indicates that the therapists use of defence and transference interpretation was predominantly rated on level one.

ment of Adapdef. A separate investigation of the impact of interpretation on the highest level of defence (mature, level 7) revealed a nonsignicant nding.

Impact of Interpretation on Maladaptive Defence

The HMR analysis of the association between interpretation and the development of Maldef, controlling for the impact of the early proportion, yielded a signicant impact of interpretation on the development of Maldef (b = -0.30, DR2 = 0.09, F = 6.72, dfs 1, 36, p < 0.05). The proportion of interpretation explained 9% of variance in the outcome of Maldef. More interpretation was associated with less maladaptive defensive functioning at the end of treatment. The ndings are presented in Table 4. The association between supportive interventions (Sup) and the outcome of Maldef is the inverse of the nding with interpretation; i.e., the same amount of variance was explained, but in the opposite direction.

The general nding was that those patients who received more interpretation had a more favourable outcome, i.e. less use of maladaptive defence after termination of therapy (9% of variance was accounted for), whereas patients who received more supportive interventions did not improve, and used a higher proportion of Maldef. We observed a considerable increase of Adapdef (from 25.2 to 40.8%), but neither the therapists use of interpretation nor the use of supportive interventions contributed to the change. The results supported the hypotheses: only interpretation has a favourable impact, and the therapists use of interpretation is only associated with the change of Maldef. The development of defence mechanisms occurred according to the phase model of change in therapy: the reduction of Maldef took place in the last half of treatment, after symptom improvement. A closer look at the change of maladaptive defence mechanisms indicates that the improvement of action and major image-distorting defences (levels one and two) started before the mid-phase of therapy (session 16). Disavowal defence (level three) increased in the same phase,
Clin. Psychol. Psychother. 12, 288296 (2005)

Impact of Interpretation on Adaptive Defence

The HMR analysis of the association between interpretation and the development of Adapdef, controlling for the impact of the early proportion, yielded a nonsignicant nding (p = 0.34). Since the impact of supportive interventions is the inverse of interpretation, Sup did not predict the developCopyright 2005 John Wiley & Sons, Ltd.

294 followed by improvement in the last half of treatment. This may reect a trend that defences lower in the hierarchy improve prior to defence mechanisms at higher levels. At the top of the hierarchy, increase of obsessive defence mechanisms (level six) precedes the increase of mature defense (level 7). Further research should include ratings of defensive functioning towards the end of therapy, in order to investigate whether there is a general pattern that the most adaptive defence (mature) improves after the defence mechanisms lower in the hierarchy have changed. How do therapist factors inuence the outcome of Maldef? We have previously found that more experienced therapists gave more interpretation (Hersoug et al., 2003), and included an additional investigation of whether therapist experience would contribute to the development of Maldef. In an extended model of the HRM analysis we entered therapist experience on the third step, after early Maldef and Int, but found no association between this therapist factor and the change of Maldef over the course of therapy. A GLM multivariate analysis yielded no difference between therapists; i.e., the therapists were equally effective in regard to the change of patients maladaptive defensive functioning. A study on the relationship between therapists personality (such as negative introjects), therapeutic technique and outcome indicates that therapists personal characteristics are an important area for further investigation (Hersoug, 2004). In this study, interpretation was used mainly on level one: the therapist species the methods used to mitigate or diminish affect or diffuse meaning, or points out an affect which is warded off. A lower proportion of interpretation was made on level three and few interpretations were made on level ve. For investigation of the the impact of the level of interpretation, i.e. completeness, or depth, a larger sample size is desirable. In forthcoming qualitative analyses, the impact of level three and level ve interpretations will be investigated. A clinical implication is that education to recognize patients maladaptive defence may enhance therapists effective use of interpretation. This may facilitate a positive therapeutic processes and help avoiding negative processes. The operationalization according to the DMRS criteria makes defence mechanisms easier to identify than underlying conicts and motives, e.g. wishes and fears, which usually require more inference. Our sample of patients is close to the clinical practice of outpatient clinics with treatment of primarily less healthy, i.e.
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A. G. Hersoug et al. moderately to severely disturbed, patients, which may increase the generalizability of the ndings.

This study was naturalistic and observational, with no control group or experimental variation in therapist interventions. The limited sample size indicates that the ndings in this study should be regarded as preliminary. The PIRS is a relatively new rating system, with few published studies. It does not allow for rating the valence of transference interpretations as either positive or negative. Only two therapy sessions were rated for defence mechanisms and therapist interventions. With more resources for transcriptions and ratings, scoring of more sessions per patient would be desirable. The sample of patients and therapists was predominantly female, 87 and 85%, respectively, i.e. an uneven gender distribution.

Suggestions for Further Research

A controlled study with experimental manipulation of defence interpretation versus supportive interventions is warranted, to explore whether the two categories of interventions inuence the development of maladaptive defence differently.

We explored the development of maladaptive defensive functioning over the course of brief dynamic psychotherapy. Patients use of maladaptive defence was reduced during therapy. We observed an association between therapists use of interpretation and improvement in maladaptive defence, whereas more use of supportive techniques had the opposite effect. Neither intepretation nor supportive interventions were predictive of the development of adaptive defence.

The authors acknowledge Professor J. C. Perry for the training of raters for the assessment of defence mechanisms and therapist interventions. The study has used data from the Norwegian Multicentre study of Process and Outcome in Psychotherapy, which was supported by grants from Medicine and Health, Norwegian Council of Mental Health, Health and Rehabilitation.
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Changes of Defensive Functioning

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