Psychodynamic Therapy Alters Maladaptive Defense Styles

Psychodynamic psychotherapy produces long-term changes in maladaptive defense styles as measured by a standardized scale. And those changes appear to correlate with improvement in symptoms.

“Changes in defense styles predict improvement in symptoms, so they seem to go together,” said researcher Michael Bond, M.D., psychiatrist in chief at Sir Mortimer B. Davis Jewish General Hospital in Quebec and an associate professor of psychiatry at McGill University Faculty of Medicine.

Bond and co-author J. Christopher Perry, M.D., M.P.H., acknowledged in their report in the September American Journal of Psychiatry that the naturalistic nature of their study of psychodynamic psychotherapy and the lack of a manualized therapy are limitations, and that causation of change is not possible to determine. They noted as well that some patients received medication treatment in addition to psychotherapy.

But Bond emphasized that the study's use of standardized measures of defense styles, symptoms, and function administered longitudinally is a unique model for measuring aspects of change that have traditionally proven difficult or impossible to measure.

“The fact that it was a naturalistic study where the patients were not highly selected and the therapists were not using manuals allowed us to look at what actually goes on in patients who come for psychodynamic psychotherapy,” Bond told Psychiatric News. “And because the treatment and the follow-up were over a course of three to five years, it allowed us to look at the ups and downs that patients undergo in therapy. This is in contrast to a study of 16 weeks that may show that someone gets better, but doesn't record whether [the patient has] a relapse one year later.”

Bond said that he and Perry were “interested in symptomatic improvement, but also in structural or dynamic changes. It is not easy to measure these kinds of things. Defense mechanisms are the ways in which people mediate internal and external stress, and we wanted to know whether psychodynamic psychotherapy can change those toward a more adaptive way.”

In the study, 53 subjects were referred from an outpatient clinic to the Long-Term Dynamic Psychotherapy Research Project at Jewish General Hospital. The project offered a minimum of three years of free dynamic psychotherapy to subjects who had a depressive disorder, anxiety disorder, and/or personality disorder. Patients with psychosis, organic brain disorders, or significant substance abuse were excluded.

Of the 53 subjects, 41 were women. A substantial number of the subjects (40) had personality disorders, including borderline, self-defeating, avoidant, and narcissistic, while eight had “significant personality disorder traits” that were not severe enough to qualify for a diagnosis of personality disorder. Every six months during therapy, patients completed the Defense Style Questionnaire, an 88-item self-report designed to measure defense styles. These include maladaptive, image-distorting, self-sacrificing, and adaptive styles. After sessions 3, 5, 7, 9, and 11, the patients completed the California Psychotherapy Alliance Scale. The Global Assessment of Functioning and SCL-90-R (a measure of distress) was administered every six months, and patients with depression completed the Hamilton Rating Scale for Depression.

Of the 29 patients who completed the study, those with high initial scores on maladaptive and self-sacrificing defense styles showed statistically significant improvement on those scales over the course of the study.

Initial symptom scores on the Global Severity Index of the SCL-90-R, Hamilton, and Global Assessment of Functioning correlated significantly with initial scores on the Defense Style Questionnaire: higher defensive functioning was associated with fewer symptoms and better adjustment.

Over the course of the follow-up period, which was from three to five years, subjects showed statistically significant improvement in overall mean scores on the Global Assessment of Functioning and the Global Severity Index of the SCL-90-R. The scores of subjects with depression on the Hamilton Rating Scale for Depression were statistically significantly improved after the subjects had the psychodynamic psychotherapy.

Moreover, regression analysis showed that change in overall defensive functioning predicted change in symptoms and functioning. “[A]lthough we cannot determine whether defense change causes symptom change or visa versa, or whether both change as a function of some third factor, change in overall defensive functioning was a potent predictor of change in symptoms and functioning,” the authors stated in their report.

Bond also noted that among the patients with personality disorder, staying in treatment appeared to be essential to improvement. He speculated that open-ended treatment may be critical to such patients, who may for conscious and unconscious reasons leave therapy early if a time limit is established.

The study, “Long-Term Changes in Defense Styles With Psychodynamic Psychotherapy for Depressive, Anxiety, and Personality Disorders,” is posted online at<http://ajp.psychiatryonline.org/cgi/content/full/161/9/1665>.▪