Psychiatric News September 17, 2004
Volume 39 Number 18
© 2004 American Psychiatric Association
p. 28
Psychodynamic Therapy Alters Maladaptive Defense Styles
Mark Moran
Open-ended therapy may be essential for patients with personality
disorder who may leave therapy early if a time limit is imposed.
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>.
Am J Psychiatry 2004 161 1665[Abstract/Free Full Text]
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