How does addressing patient's defenses help to repair alliance ruptures in psychodynamic psychotherapy?: An exploratory study

Understanding Defense Mechanisms

Understanding defense mechanisms is an important part of psychotherapy. In this article, we trace the history of the concept of defense, from its origin with Freud to current views. The issue of defense as an unconscious mechanism is examined. The question of whether defenses are pathological, as well as their relation to pathology, is discussed. The effect of psychotherapy on the use of defenses, and their relation to a therapeutic alliance is explored. A series of empirical research studies that demonstrate the functioning of defense mechanisms and that support the theory is presented. Research also shows that as part of normal development, different defenses emerge at different developmental periods, and that gender differences in defense use occur.

Patient satisfaction and alliance as a function of the physician's self-regulation, the physician's stress, and the content of consultation in cancer care

OBJECTIVE

To investigate which characteristics of the physician and of the consultation are related to patient satisfaction with communication and working alliance.

METHODS

Real-life consultations (N = 134) between patients (n = 134) and their physicians (n = 24) were audiotaped. All of the patients were aware of their cancer diagnosis and consulted their physician to discuss the results of tests (CT scans, magnetic resonance imaging, or tumor markers) and the progression of their cancer. The consultations were transcribed and coded with the "Defense Mechanisms Rating Scale-Clinician." The patients and physicians completed questionnaires about stress, satisfaction, and alliance, and the data were analyzed using robust linear modeling.

RESULTS

Patient satisfaction with communication and working alliance was high. Both were significantly (negatively) related to the physician's neurotic and action defenses-in particular to the defenses of displacement, self-devaluation, acting out, and hypochondriasis-as well as to the physician's stress level. The content of the consultation was not significantly related to the patient outcomes.

CONCLUSIONS

Our study shows that patient satisfaction with communication and working alliance is not influenced by the content of the consultation but is significantly associated with the physician's self-regulation (defense mechanisms) and stress. The results of this study might contribute to optimizing communication skills training and to improving communication and working alliance in cancer care.

Emotional Control in Psychotherapy Discourse

Emotional control may be observed to be (1) too excessive as in avoidant behaviors during psychotherapy, (2) suitable to a frank expression of feelings, or (3) lacking in regulation causing too intense affective experiences. This article offers a theory that may help clinicians make observations about this range of possible states, formulate the patient's defensive processes, and choose if, how, and when to act. The observations and formulations presented focus on specific and present moment situations rather than habitual defense mechanisms.

"Spinning one's wheels": Nonimproved patients view their psychotherapy

OBJECTIVE

To explore psychotherapy experiences among nonimproved young adults in psychoanalytic psychotherapy.

METHOD

A two-stage, mixed-method design was used. Twenty patients in the clinical range at pretreatment were identified as either with reliable deterioration or with no reliable change at termination. Interviews at termination and 3-year follow-up were analyzed with grounded theory methodology.

RESULTS

"Spinning One's Wheels" emerged as a core category. The patients described the therapeutic relationship as distanced and artificial. While they saw active components in therapy and their own activities in life as beneficial, therapy itself was experienced as overly focused on problem insight and past history.

CONCLUSIONS

When the therapist does not contribute to the achievement of the patient's treatment goals--even when the patient gains some benefit--the patient does not fully profit from the therapy.