How to address patients' defences: a pilot study of the accuracy of defence interpretations and alliance

What Defense Mechanisms Do Therapists Interpret In-Session?

One of the key technical guidelines outlined by psychodynamic theorists and clinicians is for therapists to interpret a patient's most prominent defenses (Greenson, 1967; Langs, 1973). However, a debate exists about what constitutes a patient's most prominent defense and which defenses therapists actually choose to interpret in-session. This study aimed to shed light on this debate by examining 35 psychotherapy sessions (18 high alliance and 17 low alliance dyads) of individuals in therapy at a university counselling center. The analysis focused on comparing the patients' most prominent defenses and the range of defenses they utilized, and the therapists' most prominent interpretation level as well as the range of interpretation level. Paired sample t-tests showed no significant mean difference between sessions with low and high alliance scores in patient defense levels (e.g., frequency and range) and therapist interpretation levels (e.g., frequency and range). Significant differences were found between the range of patient defense levels and the range of therapist interpretation levels. Correlational analyses showed no significant relationship between patient defense levels and therapist interpretation levels on both the frequency and range levels. Clinical implications of these results, and directions for future research are discussed.

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

Interpreting or addressing defenses is an important aspect of psychoanalytic technique. Previous research has shown that therapist addressing defenses (TADs) can produce a positive effect on alliance. The potential value of TADs during the process of alliance rupture and resolution has not yet been documented. We selected patients (n = 17) undertaking a short-term dynamic psychotherapy in which the therapeutic alliance, measured with the Helping Alliance Questionnaire and monitored after each session, showed a pattern of rupture and resolution. Two control sessions (5 and 15) were also selected. Presence of TADs was examined in each therapist interpretation. Compared with control sessions, rupture sessions were characterized by fewer TADs and especially fewer TADs addressing specifically intermediate-essentially neurotic-defenses. Resolution sessions were characterized by more TADs addressing specifically intermediate defenses. This confirms the link between therapist technique and alliance process in psychodynamic psychotherapy.

Psychometric properties of the Helping Alliance Questionnaire-I in psychodynamic psychotherapy for major depression

The psychometric properties of the Helping Alliance Questionnaire-I were analyzed at two times in short-term psychoanalytic supportive psychotherapy for outpatient depression. Exploratory factor analysis conducted in 142 patients generated a model that was confirmed in a different validation sample (n=106) using confirmatory factor analysis. Two factors were found to have satisfactory psychometric properties and a consistent structure over time: relationship and internal change. The authors conclude that reporting on the HAQ-I with separate scores for these individual aspects of alliance offers a more precise assessment and is preferable to using a single general alliance score.

Therapist technique and patient defensive functioning in ultra-brief psychodynamic psychotherapy: a Lag sequential analysis

This study examined the association between therapist interventions, including interpretations, and patient defensive functioning. The first session of 32 (n = 32) Brief Psychodynamic Interventions were rated for therapist interventions and patient defensive functioning. Lag sequential analysis was used to determine if (a) there are organized sequences of therapist interventions; (b) there are predictable sequences in the patients' level of defensive functioning; (c) there are sequences of therapist interventions leading to change in the patients' defensive functioning; and (d) there are levels of patient defensive functioning leading to organized therapist response. Results suggested that there are organized sequences in the therapists' interventions and that patient in-session defensive functioning is relatively stable. However, no chain of therapist interventions led to a predictable response in the patients' defensive functioning or vice versa.