The Relationship Between Defense Mechanisms and Attachment as Measured by Observer-Rated Methods in a Sample of Depressed Patients: A Pilot Study

Development of a new observer-rated measure to assess the real relationship in psychotherapy sessions

OBJECTIVES

Real relationship (RR) refers to a genuine human relationship between client and therapist, that has been found to be positively related to treatment outcome, and to predict unique variance in outcome over and above the working alliance. However, thus far, the measurement of RR has been limited to self-report. We aimed to develop an observer-rated version of the RR measure (RR-O) to assess RR in therapy sessions.

METHODS

We adapted items from the self-report measures to an observer rated measure, which was reviewed by RR experts. The final 24-item RR-O was rated in 540 session transcripts from 27 psychoanalytic treatments that already had existing process and outcome scores.

RESULTS

The RR-O showed good internal consistency and good interrater reliability. In hierarchical EFA, items clustered into a general RR factor, and client realism, client genuineness, therapist genuineness, and therapist realism group factors. In addition, the RR-O was positively related to another RR measure and to the therapeutic alliance.

CONCLUSION

The RR-O shows initial reliability and validity as an observer-rated measure of the RR to be used in post-hoc psychotherapy research. Future research should clarify the relation between RR-O and treatment outcome.

Attachment style, emotional feedback, and neural processing: investigating the influence of attachment on the P200 and P400 components of event-related potentials

Understanding the interplay between attachment style, emotional processing, and neural responses is crucial for comprehending the diverse ways individuals function socially and emotionally. While previous research has contributed to our knowledge of how attachment style influences emotional processing, there is still a gap in the literature when it comes to investigating emotional feedback using event-related potentials (ERPs) within a cognitive framework. This study aims to address this gap by examining the effects of attachment style and feedback valence on ERP components, specifically focusing on the P200 and P400. The findings reveal significant effects of attachment style and feedback valence on both components. In insecure attachment styles, noticeable shifts in relative energy are observed during the transition from negative to positive feedback for both the P200 and P400. Conversely, individuals with secure attachment styles exhibit minimal to moderate variations in relative energy, consistently maintaining a lower P200 energy level. Additionally, both secure and insecure individuals demonstrate heightened intensity in the P400 component in response to positive feedback. These findings underscore the influential role of attachment style in shaping emotional reactivity and regulation, emphasizing the significance of attachment theory in understanding individual differences in social and emotional functioning. This study provides novel insights into the neural mechanisms underlying the influence of attachment style on emotional processing within the context of cognitive task performance. Future research should consider diverse participant samples, employ objective measures of attachment, and utilize longitudinal designs to further explore the neural processes associated with attachment.

Adjusting to a new reality: Consensual qualitative research on therapists' experiences with teletherapy

OBJECTIVE

In the wake of the COVID-19 pandemic, the use of teletherapy has become more pervasive than ever. Many therapists faced this move to a remote setting with little experience or training. We aimed to qualitatively examine therapists' subjective experience of providing teletherapy, including changes in technique, the therapeutic relationship, and the therapeutic process.

METHODS

Thirty-one psychotherapists participated in semistructured interviews. Interviews were recorded, then transcribed and analyzed using the Consensual Qualitative Research method.

RESULTS

Therapists typically reported a change in the therapeutic relationship in terms of an increased sense of disconnection as well as shifts in various aspects of the relational dynamics, and they also typically experienced differences in the therapy process due to changes in patient and therapist engagement in the therapeutic work. Additionally, some therapists also reported that they became more active and directive in sessions, took a more informal, personal, or relaxed approach to interacting with patients, and while the emotional connection changed and they missed the energy and intimacy of in-person sessions, the relationship in telesessions felt more authentic and human for some, and teletherapy also provided a way to discuss new dimensions in the process.

CONCLUSION

Overall, these results suggest great variability in therapists' subjective experiences with teletherapy, and present teletherapy as a distinct therapy format in many aspects. Further process-level research and subsequent training is needed to better equip therapists to navigate teletherapy's challenges and harness its unique opportunities.

Default defenses: the character defenses of attachment-anxiety and attachment-avoidance

Contemporary attachment researchers claim that attachment-anxiety is associated with a hyperactivating defense strategy while attachment-avoidance is associated with a deactivating defense strategy. However, to date, no study has comprehensively examined the basic patterns of specific defense expression in the two dimensions of attachment insecurity (anxiety/avoidance). To address this research gap, the current study aimed to assess the character defenses associated with attachment-avoidance and attachment-anxiety, incorporating a broad spectrum of psychological defenses. The main objective was to understand what differentiates attachment-avoidance and attachment-anxiety in defensive functioning. In this study of online questionnaire design (N = 250), university undergraduates aged between 17 to 65 completed the Experiences in Close Relationship Scale (ECR) and the Defense Style Questionnaire (DSQ-60). The results show that the two dimensions of insecure attachment exhibit different defensive patterns. Regarding the main findings, attachment-avoidance uniquely predicted defensive isolation, and attachment-anxiety uniquely predicted the defenses splitting, projective identification, anticipation, acting out, passive-aggression, reaction formation, and undoing. Overall, the results indicate that attachment-anxiety is a significant predictor of global defensive functioning, over and above that of attachment-avoidance. One implication of this study is that the two-dimensional model of adult attachment may offer a promising framework for organizing psychological defenses. We discuss the significance of this concerning the future of the empirical study of psychological defenses. The discussion also considers the clinical application and relevance to attachment-based psychotherapy.

An exploratory study on how attachment classifications manifest in group psychotherapy

Recently, attachment-informed researchers and clinicians have begun to show that attachment theory offers a useful framework for exploring group psychotherapy. However, it remains unclear whether patients with differing attachment classifications would behave and speak in distinct ways in group therapy sessions. In this study, we conducted an exploratory analysis of the discourse of patients in group therapy who had independently received different classifications with gold standard interview measures of attachment in adults. Each patient participant attended one of three mentalization-based parenting groups. Before treatment, the Adult Attachment Interview (AAI) or the Parent Development Interview (PDI) were administered to each patient, and interviews were transcribed and coded to obtain the patient's attachment classification. Groups included 2, 5, and 5 patients, respectively, and any session was led by at least two co-therapists. A total of 14 group sessions were transcribed verbatim. Sessions were analysed through a semi-inductive method, in order to identify markers that would typify patients of different attachment classifications in session. Through transcript excerpts and narrative descriptions, we report on the differing ways in which patients of different attachment classifications communicate in group psychotherapy, with the therapist and with each other. Our work provides useful information for group therapists and researchers regarding how differences in attachment status may play out in group sessions.

Assessing children's defense mechanisms with the Defense Mechanisms Rating Scales Q-sort for Children

Defense mechanisms are unconscious and automatic psychological processes that serve to protect the individual from painful emotions and thoughts. There is ample evidence from the adult psychotherapy and mental health literature suggesting the salience of defenses in the maintenance and amelioration of psychological distress. Although several tools for the assessment of children's defenses exist, most rely on projective and self-report tools, and none are based on the empirically derived hierarchy of defenses. This paper outlines the development of the defense mechanisms rating scale Q-sort for children (DMRS-Q-C), a 60-item, observer-rated tool for coding the use of defenses in child psychotherapy sessions. Modifications to the Defense Mechanisms Rating Scale Q-Sort for adults to create a developmentally relevant measure and the process by which expert child psychotherapists collaborated to develop the DMRS-Q-C are discussed. A clinical vignette describing the child's defensive functioning as assessed by the innovative DMRS-Q-C method is also reported. Finally, we provide an overview of forthcoming research evaluating the validity of the DMRS-Q-C.

COVID-19 Related Traumatic Distress in Psychotherapy Patients during the Pandemic: The Role of Attachment, Working Alliance, and Therapeutic Agency

The early months of the COVID-19 pandemic have been a challenging time for many psychotherapy patients. To understand why certain patients were more resilient, we examined the role of patients' attachment anxiety and attachment avoidance, as well as collaborative therapy experiences (perceived working alliance and therapeutic agency) in their online sessions on their COVID-related traumatic distress over a three-month period. A total of 466 patients in online psychotherapy completed a survey during the first weeks of the pandemic, and 121 of those completed a follow-up survey three months later. Lower distress at follow-up was predicted by patients' lower attachment anxiety and higher therapeutic agency in their online sessions after controlling for baseline distress and time of survey completion. Higher working alliance predicted less distress at follow-up only for patients with high attachment anxiety. For patients with low attachment avoidance (i.e., more securely attached), higher therapeutic agency predicted less distress. These findings suggest that patients' attachment anxiety and therapeutic agency may play significant roles also in online therapy during COVID-19 in patient's experienced traumatic distress, and that working alliance and therapeutic agency may be differentially important for patients with different levels of attachment anxiety and avoidance.