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Clinical Psychology and PsychotherapyClin. Psychol. Psychother. 12, 288296 (2005)

Copyright 2005 John Wiley & Sons, Ltd.Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.444

Changes of Defensive Functioning.Does Interpretation Contribute

to Change?Anne Grete Hersoug,* Kjell-Petter Bgwald andPer HglendUniversity of Oslo, Norway

In this processoutcome study, we explored the changes of patientsdefensive functioning (rated with the Defence Mechanism RatingScales) over the course of brief dynamic psychotherapy (N = 39,maximum 40 sessions). We investigated whether therapists use ofinterpretation (rated with the Psychodynamic Intervention RatingScale) would influence the development of maladaptive defensivefunctioning. The proportion of maladaptive defences was reducedduring therapy. A higher proportion of interpretation was associatedwith less use of maladaptive defence after therapy, whereas the useof interpretation was not predictive of the change of adaptive defen-sive functioning. Therapists use of supportive interventions did notimpact the development of either maladaptive or adaptive defences.Copyright 2005 John Wiley & Sons, Ltd.

* Correspondence to: Anne Grete Hersoug, Department ofPsychiatry, University of Oslo, P.O. Box 85 Vinderen, N-0319Oslo, Norway. E-mail: [email protected]

In psychodynamic therapy, defensive functioningis one of the central issues. Defence mechanisms

are unconscious and automatic, although we mayhave some awareness of their impact on our behav-iour. Assessment of defence mechanisms may beused to indicate the patients level of functioning.Vaillant proposed a hierarchy of defences (1971,1986, 1992), from maladaptive (immature) on thelowest level, to adaptive defences on the highestlevel of the hierarchy. Maladaptive defences areassociated with less adaptive behaviour. Perrysreview (1990) supported a hierarchical relationship

between the maladaptiveness of defence mecha-nisms and psychiatric diagnoses, such as anxietyand affective disorders. The overall pattern was

that action and borderline defences were associ-ated with more anxiety and depressive symptoms,while more adaptive defences were associated

with their absence. Subsequent studies have con-sistently reported associations between maladap-

tive defences and severity of psychopathology,including signs of personality disorders (Axis II),and symptoms such as depression and anxiety(Axis I) (Hilsenroth, 2003; Perry, 2001; Perry &Hglend, 1998; Perry et al., 1998). In the study byHoli, Sammallahti, and Aalberg (1999), maladap-tive defence explained most of the variance insymptoms. Generally, maladaptive and adaptivedefences are associated with the presence versusabsence of psychopathology, whereas intermediatedefences do not predict pathology and do notchange much during treatment. Adaptive defencepredicted improvement of depressive symptoms

(Albucher, Abelson, & Nesse, 1998; Hglend &Perry, 1998). The study by Muris and Merkelbach(1996) indicated that patients use of more mal-adaptive defence was linked to less favourablepsychotherapy outcome. Reduction of maladap-tive defensive functioning over the course oftherapy was associated with improvement(Akkerman, Carr, & Lewin, 1992; Kneepkens &Oakley, 1996).

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Changes of Defensive Functioning 289

Copyright 2005 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 12, 288296 (2005)

Both maladaptive and adaptive defence mecha-nisms are expected to change over the course oftherapy. A previous study revealed that symptomimprovement took place in the early phase oftherapy, whereas change of defensive functioning,i.e. dynamic change, occurred in the last half of

treatment (Hersoug, Sexton, & Hglend, 2002).This is consistent with the phase model of changein therapy (Hilsenroth, Callahan, & Eudell, 2001;Howard, Lueger, Maling, & Martinovich, 1993;Lueger, Howard, & Martinovich, 2001). Akkerman,Lewin, and Carr (1999) demonstrated that patientsobtained a greater reduction in their use of mal-adaptive defence when therapy was continuedafter symptom recovery. In the psychodynamic tra-dition, it is commonly assumed that a certaindegree of regression may take place in the earlyphase of therapy. Patients demonstrate more mal-adaptive defence when this occurs.

The therapist gives defence interpretations,based on the assumption that this will contributeto enhanced self-exploration, insight, and change(Perry, 2001; Piper, Joyce, McCallum, & Azim,1998). Defence interpretation addresses variousaspects of defence mechanisms: patients affects,motives, and the specific defence mechanisms thatare used (Bond, Banon, & Grenier, 1998; Milbrathet al., 1999; Perry, 1993). Research findings consis-tently support that interpretation as a generalmode of intervention can be helpful to patients(Orlinsky, Rnnestad, & Willutzki, 2003). Theoverview by Orlinsky et al. reported a significant

positive association between the use of interpreta-tion and psychotherapy outcome in 24 accu-mulated findings, whereas only three negativeassociations were reported. From the patients per-spective, interpretation is among the most thera-peutically significant, positive factors (Bachelor,1991). We have previously found that more inter-pretation was given to patients who displayedmore maladaptive defence, whereas more sup-portive intervention was given to patients withmore adaptive defence (Hersoug et al., 2003). Mostinterpretation was given when there was a highproportion of maladaptive defence combined with

low quality of working alliance. A study on adjust-ment of therapists use of interpretation to patientslevel of defensive functioning yielded betterquality of working alliance when therapists gaveless interpretation to patients with higher over-all defensive functioning (Hersoug, Hglend, &Bgwald, 2004).

The main focus of this study is whether thetherapists use of interpretation contributes to

the change of maladaptive defence. This has notpreviously been systematically investigated. Thepatients initial regression and increased use ofmaladaptive defence early in therapy may at timespresent the therapist with negative interpersonalpatterns and transference issues, which tends to

elicit a negative response from the therapist. Aben-eficial use of interpretation is more difficult ifnegative processes develop (Binder & Strupp,1997). Avoidance of negative processes may there-fore be important for the further progress oftherapy. Patients use of adaptive defence is neitherassociated with resistance in therapy nor the riskof developing negative processes.

In this processoutcome study, we investigatedwhether interpretation is favourable for patientswho demonstrate more maladaptive defence indynamic psychotherapy. We explored whether theproportion of interpretation would predict change

of patients maladaptive defensive functioning.Based on theory and previous research, weexpected to find that more interpretation would beassociated with less use of maladaptive defenceafter treatment. We did not expect any impact ofsupportive interventions on maladaptive defence.Furthermore, we did not expect that interpretationwould be predictive of more use of adaptivedefence.

METHODS

Setting, Therapists, and Therapy

This study was part of the naturalistic NorwegianMulticentre Study on Process and Outcome of Psy-chotherapy (NMSPOP, unpublished manuscript).A more detailed description of methods and mea-surements is presented elsewhere (Hersoug et al.,2002). The present site was the only site of theNMSPOP that had collected data on defencemechanisms and therapist interventions, in addi-tion to the core assessment instruments. Therefore,this study used data from that site. The sample (N= 39) was unselected. The seven therapists in thestudy had practiced psychodynamically oriented

individual therapy for a mean of 10 years (range417). Their mean age was 44. Six of the seventherapists were female. There was a time limit of40 sessions (mean number of sessions 35).

Procedure

After receiving information about the study andgiving their written consent, the patients com-

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290 A. G. Hersoug et al.


pleted the self-report questionnaires for demo-graphic data and symptoms, and then underwenta standardized diagnostic assessment using DSMIV Axis I and Axis II interviews, as well as a clini-cal assessment-dynamic interview, about 1 hour,followed by a clinical rating using the Psychody-

namic Functioning Scale, PFS (Hglend et al.,2000). After termination of treatment, the patientsunderwent a diagnostic assessment similar to thepre-therapy evaluation. The therapist group metevery second week with a supervisor and dis-cussed transcribed sessions in detail, with empha-sis on operationalization of defence mechanisms,interpretation of maladaptive defence and build-ing adaptive defence by supportive techniques.There were some expectations that the therapistsshould interpret patients defenses, especiallymaladaptive defences, although the design ofthe study did not demand consistent manual

adherence.

Patients

The patients were referred from their GPs to theirlocal outpatient clinics, and were consecutivelyadmitted for individual psychotherapy. Theirmean age was 36.7 years (SD 8.1, range 2452), and87% were female. The most frequent DSM IV(American Psychiatric Association, 1994) Axis Idiagnoses were depressive disorders (67%) andanxiety disorders (65%), and 65% had a personal-ity disorder. The mean sum of personality disordercriteria, using the SCID II interview, was 11.7.Mean GAS (current GAS) (Endicott, Spitzer, Fleiss,& Cohen, 1976) for the sample was 56 (SD. 5.1), andmean symptom severity, GSI (Global SeverityIndex, SCL-90-R; Derogatis, 1983), was 1.34 (SD.0.55). The data indicate that the sample of patientswas moderately disturbed (Tingey, Lambert, &Burlingame, 1996).

Measurements

Defence Mechanism Rating Scales (DMRS)DMRS was developed by J. C. Perry (Perry,

unpublished manuscript). DMRS is a criterion-based system of operationalization of defencemechanisms, and allows for systematic quantita-tive and qualitative studies of defence mechanismsand their influence on the therapy process andoutcome. It is an observer-rated method, con-structed with seven levels of defensive function-

ing, which distinguishes between mature/adaptive, neurotic, and immature/maladaptivedefences. Defence mechanisms are unconscious,

but one may have some degree of awareness oftheir impact on ones behaviour. The DMRS is com-prised of 28 defence mechanisms, in a hierarchical

scale of seven levels, from maladaptive (oftenreferred to as immature) to most adaptive (oftenreferred to as mature): action, major image distort-ing (borderline), disavowal, minor image dis-torting (narcissictic), neurotic, obsessional andadaptive (mature) defence. Several studies havesupported the validity of the method (Perry,Kardos, & Pagano, 1993), and satisfactory inter-rater reliability for the overall defensive function-ing (ODF) score has been documented (Perry &Ianni, 1998). The ODF is a summary score calcu-lated from the DMRS scores, yielding a weightedaverage of the individual defence scores, to deter-

mine the level of defensive functioning. In thisstudy, we also examined the impact of interpreta-tion on the highest and lowest adaptive defencelevels. We computed a combined score for levels13, maladaptive defence (Maldef), calculated as aproportion of the total number of defences in thesame session, and a combined score for the twohighest adaptive defence levels, adaptive defence(Adapdef). Maladaptive defence includes actingout, borderline (splitting and projective identifica-tion) and disavowal defences. Subjects who usesuch defenses usually become inflexible to theenvironmental realities and may be perceived by

others as unpredictable and irrational.Two raters, who were trained by the developer

of the DMRS manual for quantitative scoring, ratedcomplete transcripts of the dynamic interviews

before and after therapy. The dynamic interviewsattempted to capture the patients characteristicpatterns of defence mechanisms. Two therapy ses-sions per patient were also rated. The patientsdefensive functioning during therapy was rated inthe same sessions as the ratings of therapist inter-ventions were made. The defence mechanismswere rated according to the counting signs method,i.e. each occurrence of a defence in the complete

transcripts of sessions was rated. The limitedresources for transcription of sessions, and the verytime-consuming rating procedure, allowed for fourtranscripts to be rated for each patient, includingthe dynamic interviews before and after therapy.The seventh and 16th sessions were selected

because it was deemed most appropriate to startthe rating of interpretation in the seventh session,after the initial phase, allowing the patient and

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therapist a few sessions to establish a workingalliance (the patient and therapist did not meetuntil the assessment procedure was completed).The 16th session was selected because it wasexpected to be within the active treatment phase,

before issues related to termination became the

focus of attention for patients. We computed theproportion of Maldef in the seventh session and16th session: Maldef 7 and Maldef 16. Based on theprevious finding that changes of defensive func-tioning take place after the 16th session, we calcu-lated the mean proportion of Maldef (meanMaldef) from initial Maldef, Maldef 7 and Maldef16, and used this as the independent variable in thestatistical analyses, to control for the impact of theearly proportion of Maldef on the further develop-ment of maladaptive defence. In a similar manner,we computed the proportion of adaptive defence,Adapdef: initial, in the seventh session, in the 16th

session, and after therapy. For the statistical analy-ses, we calculated the mean proportion of Adapdefup to session 16 (mean Adapdef) and used this asthe independent variable.

The raters first made independent ratings of eachoccurrence of defence mechanisms in all the tran-scripts for all patients in the sample. Based on theseratings, their intraclass correlation (ICC 2, 2) wascalculated, according to Shrout and Fleiss (1979).The mean ICC for the ODF in the rated transcriptsover the four time points was 0.83. The meanintraclass correlations for Adapdef and Maldefover the four time points were ICC(2, 2) 0.70 (range

0.640.77) and 0.75 (range 0.680.84), respectively.The mean intraclass correlations for neuroticdefence and narcissistic defence (ICC 2, 2) were0.61 (range 0.530.68) and 0.57 (range 0.440.62),respectively. After the independent ratings, theraters met for consensus ratings of each occurrenceof defence mechanisms. The consensus ratingswere used in the statistical analyses.

Psychodynamic Intervention Rating Scales (PIRS)PIRS is a categorical rating scale (Cooper & Bond,

unpublished manuscript), with two main cate-gories: interpretation (non-transference and

transference) and supportive interventions(clarification, reflection, question, work-enhancingstrategy, support, association, acknowledgment,and contractual arrangement). For a statement to

be rated as a defence interpretation, it must belinked to unconscious processes, e.g. keeping anaffect out of awareness or an affect itself that is outof consciousness. Defence interpretation is broadlydefined, and includes patients affects, motives,

and the specific mechanisms of defence that areused (Milbrath et al, 1999; Perry, 1993). Transfer-ence interpretation is defined broadly, including alloccurrences of addressing the patienttherapistrelationship. Defence and transference interpreta-tions were rated on levels from one to five, accord-

ing to completeness or depth. The highest levelwas rated when both defence mechanism andunconscious motives were specified. Interpretationon level one specifies e.g. an affect being wardedoff or the method used to diminish affect or diffusemeaning. Interpretation on level three inquiresabout a possible motive for the defence mecha-nism. On level five, the therapist addresses boththe motives and the reason why the affect is beingavoided or mitigated. Interpretation on level one isassumed to reflect the therapists emotional attune-ment with the patients affects. The total numberof interpretive interventions, i.e. defence and trans-

ference interpretations combined, was analyzed,relative to the total number of interventions. Thisyielded the proportion of interpretation (Int). In asimilar manner, the proportion of supportive inter-ventions (Sup) was calculated.

Two independent raters, who were trainedaccording to the PIRS manual, scored each thera-pist intervention in complete transcripts (session 7and session 16) for all patients in the sample. First,they made independent ratings, from which theintraclass correlation for each intervention cate-gory was calculated. In the seventh session, theintraclass correlation coefficient for Int (ICC 2, 2)

was 0.79. In the 16th session, the intraclass corre-lation coefficient for Int (ICC 2, 2) was 0.78. In asimilar manner, the intraclass correlation for Supwas calculated. The mean ICC(2, 2) for Sup in theseventh session was 0.97, and in the 16th sessionICC(2, 2) for Sup was 0.98. After the independentratings, the raters met for consensus ratings of eachtherapist intervention. In the statistical analyses,the mean proportion of interpretation from theconsensus ratings in the seventh session and 16thsession was used.

Data Analysis

We investigated the associations between the pro-portion of interpretation (Int) and patients mal-adaptive defensive functioning (Maldef) at the endof treatment, performing a hierarchical multipleregression analysis (HMR) (Cohen & Cohen, 1983).The HMR analysis yielded the amount of variancein maladaptive defence after therapy that was

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accounted for by the proportion of interpretation.The procedure was as follows. On the first step, weentered mean Maldef, to control for the impact ofthe proportion of Maldef before the improvementstarted, on the proportion of Maldef after therapy.On the second step, we entered Int. In a similar

manner, we performed an HMR anlysis of theimpact of interpretation on the development ofadaptive defensive functioning (Adapdef). Theproportion of supportive interventions (Sup) is theinverse value of the proportion of interpretation.Since the results would be the inverse of the find-ings with the HMR analyses of Int, separate HMRanalyses with Sup were not performed. We usedSPSS version 11.0 (SPSS Inc, 2002) in the statisticalanalyses. A significance level of p < 0.05 waschosen. The analyses were two tailed.

RESULTS

Patient use of defence mechanisms changed duringtherapy and became more adaptive, as reflected inthe ODF score. ODF was 4.41 pre-therapy andincreased to 4.87 post-treatment (p < 0.01; ES =0.77). Descriptive data on the development of theseven levels of defence mechanisms over thecourse of therapy are presented in Table 1.

The initial proportion of the outcome variable,Maldef, was 28.7. Maldef in the seventh sessionwas 29.6%. In the 16th session Maldef was 30.4%,and Maldef at the end of treatment was 22.7%,

which is a significant reduction. The initial pro-portion of Adapdef was 25.2%, in the seventhsession 28.3%, in the 16th session 25.6%, and aftertherapy Adapdef was 40.8%, which is a significantincrease. We observed a small increase of Maldefin the early phase of treatment. Maldef improvedafter session 16, i.e. after the mid-phase, which isconsistent with the assumption in the psychody-namic tradition. The findings are presented inTable 2. Effect sizes for the change in defensivefunctioning are computed using Cohens d withpooled SD for pre-therapy and post-therapymeasures.

Descriptive values of the PIRS ratings indicatethat defence interpretation was moderately used(mean 14.8 per session) and transference interpre-tation used with caution (mean 3.3 per session).The mean number of interpretations rated on levelone was 10.4 per session; fewer were rated on levelthree (mean 3.7 per session), and level five wasrarely used. The PIRS criteria indicate that defenceinterpretation should be rated on level one when

Table 1. Development of defence mechanisms preposttherapy

Defence level Proportion of defences

Pre-therapy Session 16 Post-therapy

Level VIIa

Mature 2.4 1.6 13.3Level VIb

Obsessional 22.8 24.0 26.9Level Vc

Other neurotic 30.9 29.5 25.2Level IVd

Minor image 14.9 14.7 13.0distorting

Level IIIe

Disavowal 18.3 22.6 15.3Level IIf

Major image 6.6 4.5 3.6distorting

Level Ig

Action 3.9 3.3 3.2

DMRS defence mechanisms:a Affiliation, altruism, anticipation, humor, self-observation, self-assertiveness, sublimation, suppression.b Isolation, intellectualization, undoing.c Repression, dissociation, reaction formation, displacement.d Omnipotence, idealization, devaluation.e Denial, projection, rationalization, fantasy.fSplitting others images, splitting self-images, projectiveidentification.g Acting out, passive aggression, hypochondriasis (help-rejectingcomplaining).

Table 2. Development of defensive functioning over thecourse of therapy

Defence Proportionlevel of defences

Pre-therapy Post-therapya ES

Adaptive 67 25.3% 40.8%* 0.95defence

Neurotic 5 30.9% 25.2%* 0.54defence

Narcissistic 4 14.9% 13.0% NS 0.20defence

Maladaptive 13 28.7% 22.2%* 0.42defence

*p < 0.05, two tailed.

a The change in defensive functioning is assessed with a paired-samples T-test prepost therapy.

an affect is warded off and when a specification ismade regarding the method used to diminishaffect/diffuse meaning. Transference interpreta-tion on level one includes all occurrences ofaddressing the patienttherapist relationship. De-scriptive data on therapist interventions are pre-

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sented in Table 3, which indicates that the thera-pists use of defence and transference interpreta-tion was predominantly rated on level one.

Impact of Interpretation onMaladaptive Defence

The HMR analysis of the association between inter-pretation and the development of Maldef, control-ling for the impact of the early proportion, yielded

a significant impact of interpretation on the devel-opment of Maldef (b = -0.30, DR2 = 0.09,F= 6.72,dfs 1, 36,p< 0.05). The proportion of interpretationexplained 9% of variance in the outcome of Maldef.More interpretation was associated with lessmaladaptive defensive functioning at the end oftreatment. The findings are presented in Table 4.The association between supportive interventions(Sup) and the outcome of Maldef is the inverse ofthe finding with interpretation; i.e., the sameamount of variance was explained, but in theopposite direction.

Impact of Interpretation on Adaptive Defence

The HMR analysis of the association between inter-pretation and the development of Adapdef, con-trolling for the impact of the early proportion,yielded a nonsignificant finding (p = 0.34). Since theimpact of supportive interventions is the inverse ofinterpretation, Sup did not predict the develop-

ment of Adapdef. A separate investigation of theimpact of interpretation on the highest level ofdefence (mature, level 7) revealed a nonsignificantfinding.

DISCUSSION

The general finding was that those patientswho received more interpretation had a morefavourable outcome, i.e. less use of maladaptive

defence after termination of therapy (9% of vari-ance was accounted for), whereas patients whoreceived more supportive interventions did notimprove, and used a higher proportion of Maldef.We observed a considerable increase of Adapdef(from 25.2 to 40.8%), but neither the therapists useof interpretation nor the use of supportive inter-ventions contributed to the change. The resultssupported the hypotheses: only interpretation hasa favourable impact, and the therapists use ofinterpretation is only associated with the change ofMaldef. The development of defence mechanismsoccurred according to the phase model of change

in therapy: the reduction of Maldef took placein the last half of treatment, after symptomimprovement.

A closer look at the change of maladaptivedefence mechanisms indicates that the improve-ment of action and major image-distortingdefences (levels one and two) started before themid-phase of therapy (session 16). Disavowaldefence (level three) increased in the same phase,

Table 3. Descriptive data for the Psychodynamic Inter-vention Rating Scale

Proportion of M SDinterpretation (%)

20 0.10

Number of

inter-pretationsT.I. (level 1) 2.50 (range 020) 3.7T.I. (level 3) 0.40 (range 06) 0.7T.I. (level 5) 0.05 (range 01) 0.3D.I. (level 1) 10.50 (range 025) 4.9D.I. (level 3) 3.80 (range 015) 2.8D.I. (level 5) 0.75 (range 05) 0.8

Supportiveinterventions 73.9 (range 33116) 23.3

Total number ofinterventions 91.8 (range 52135) 20.9

T.I. = transference interpretation.D.I. = defence interpretation.Mean values are combined for the seventh and 16th sessions.

Table 4. Hierarchical multiple regression for interpreta-tion and outcome

Variables entered b DR2 F dfs

DependentMaldef2

IndependentStep 1Maldefm 0.69 0.42*** 27.00 1, 37Step 2Interpretation -0.30 0.09* 6.72 1, 36

Total 0.51*** 18.95 1, 36

b = standardized coefficient beta.*p< 0.05; **p 0.01; ***p< 0.001.Maldef2 = the proportion of maladaptive defence after termina-tion of therapy.Maldefm = the mean proportion of maladaptive defence early intreatment: initial, seventh session and 16th session.

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followed by improvement in the last half of treat-ment. This may reflect a trend that defences lowerin the hierarchy improve prior to defence mecha-nisms at higher levels. At the top of the hierarchy,increase of obsessive defence mechanisms (levelsix) precedes the increase of mature defense (level

7). Further research should include ratings ofdefensive functioning towards the end of therapy,in order to investigate whether there is a generalpattern that the most adaptive defence (mature)improves after the defence mechanisms lower inthe hierarchy have changed.

How do therapist factors influence the outcomeof Maldef? We have previously found that moreexperienced therapists gave more interpretation(Hersoug et al., 2003), and included an additionalinvestigation of whether therapist experiencewould contribute to the development of Maldef.In an extended model of the HRM analysis we

entered therapist experience on the third step, afterearly Maldef and Int, but found no association

between this therapist factor and the change ofMaldef over the course of therapy. A GLM multi-variate analysis yielded no difference betweentherapists; i.e., the therapists were equally effectivein regard to the change of patients maladaptivedefensive functioning. A study on the relationship

between therapists personality (such as negativeintrojects), therapeutic technique and outcomeindicates that therapists personal characteristicsare an important area for further investigation(Hersoug, 2004).

In this study, interpretation was used mainly onlevel one: the therapist specifies the methods usedto mitigate or diminish affect or diffuse meaning,or points out an affect which is warded off. Alowerproportion of interpretation was made on levelthree and few interpretations were made on levelfive. For investigation of the the impact of thelevel of interpretation, i.e. completeness, or depth,a larger sample size is desirable. In forthcomingqualitative analyses, the impact of level three andlevel five interpretations will be investigated.

A clinical implication is that education to recog-nize patients maladaptive defence may enhance

therapists effective use of interpretation. This mayfacilitate a positive therapeutic processes and helpavoiding negative processes. The operationaliza-tion according to the DMRS criteria makes defencemechanisms easier to identify than underlyingconflicts and motives, e.g. wishes and fears, whichusually require more inference. Our sample ofpatients is close to the clinical practice of outpatientclinics with treatment of primarily less healthy, i.e.

moderately to severely disturbed, patients, whichmay increase the generalizability of the findings.

Limitations

This study was naturalistic and observational, with

no control group or experimental variation intherapist interventions. The limited sample sizeindicates that the findings in this study should beregarded as preliminary. The PIRS is a relativelynew rating system, with few published studies. Itdoes not allow for rating the valence of transfer-ence interpretations as either positive or negative.Only two therapy sessions were rated for defencemechanisms and therapist interventions. Withmore resources for transcriptions and ratings,scoring of more sessions per patient would bedesirable. The sample of patients and therapistswas predominantly female, 87 and 85%, respec-tively, i.e. an uneven gender distribution.

Suggestions for Further Research

A controlled study with experimental manipula-tion of defence interpretation versus supportiveinterventions is warranted, to explore whether thetwo categories of interventions influence the devel-opment of maladaptive defence differently.

CONCLUSION

We explored the development of maladaptivedefensive functioning over the course of briefdynamic psychotherapy. Patients use of maladap-tive defence was reduced during therapy. Weobserved an association between therapists use ofinterpretation and improvement in maladaptivedefence, whereas more use of supportive tech-niques had the opposite effect. Neither intepreta-tion nor supportive interventions were predictiveof the development of adaptive defence.

ACKNOWLEDGMENTSThe authors acknowledge Professor J. C. Perry forthe training of raters for the assessment of defencemechanisms and therapist interventions.

The study has used data from the NorwegianMulticentre study of Process and Outcome inPsychotherapy, which was supported by grantsfrom Medicine and Health, Norwegian Council ofMental Health, Health and Rehabilitation.

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