University counseling services are increasingly recognized as effective interventions for promoting students' psychological well-being, yet the psychological mechanisms underlying their effectiveness are still poorly understood. The present study examined the role of epistemic stances (epistemic trust, mistrust, and credulity) and therapeutic alliance in predicting changes in psychological distress among students undergoing a brief psychodynamic counseling intervention. The sample included 93 university students who participated in a brief psychodynamic counseling intervention consisting of four sessions and a 3-month follow-up. Data were analyzed using hierarchical linear mixed-effects models. Psychological distress was assessed using the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at pre-treatment (T1), post-intervention (T2), and follow-up (T3). Epistemic stances were measured with the Epistemic Trust, Mistrust, and Credulity Questionnaire (ETMCQ) at T1, and therapeutic alliance was assessed at T2 with the Working Alliance Inventory - Short Form Revised (WAI-SR). Psychological distress significantly decreased from pretreatment to post-intervention and remained stable at follow-up. Higher baseline epistemic trust predicted lower levels of distress, whereas higher epistemic mistrust and credulity were associated with poorer outcomes. A stronger therapeutic alliance was associated with lower distress levels. Moreover, the therapeutic alliance moderated the relationship between epistemic mistrust and psychological distress, such that higher alliance was associated with lower distress. Findings suggest that both epistemic stances and the therapeutic alliance contribute to counseling effectiveness. A strong alliance may partially buffer the negative impact of epistemic mistrust, highlighting the importance of fostering a mentalizing environment in brief counseling interventions.
Relational skills and self-awareness are important aspects of psychotherapy training, shaping how trainees relate to clients, reflect on their experiences, and develop professionally. Despite their importance, little research has examined how these aspects are related during training. This cross-sectional study investigated the associations between relational skills and self-awareness outcomes in psychotherapy trainees and explored whether these variables differed according to stages of training, age, engagement in personal therapy, and self-reported mental health difficulties. The sample included 105 trainees (75.2% female, M age=29.71 years, SD=10.77), of whom 46% were in the beginning stage and 54% in the advanced stage of training. Relational styles were identified using exploratory factor analysis, and associations were examined using Pearson correlations and analyses of variance. Self-awareness outcomes were assessed with the Self-Awareness Outcomes Questionnaire (SAOQ). Exploratory factor analysis identified four relational styles: Warm, Guarded, Directive, and Intense. Warm, Directive, and Intense styles were positively associated with several self-awareness outcomes, whereas Guarded was associated with higher emotional costs of self-awareness. Older trainees (43+) reported greater emotional engagement, lower emotional strain, and higher scores on the Intense style than trainees aged 18-24. Trainees engaged in personal therapy tended to report lower emotional costs of self-awareness. Self-reported mental health difficulties were associated with higher emotional costs and more guarded, less warm relational styles. The results contribute to an understanding of how relational styles, self-awareness outcomes, and personal factors are interconnected in psychotherapy trainees and may help inform psychotherapy training by emphasizing individual differences in relational functioning.
Inflammatory bowel disease (IBD), encompassing Crohn’s disease (CD) and ulcerative colitis (UC), is a chronic immune-mediated gastrointestinal condition in which long-term care increasingly involves patient-reported health, emotional functioning, and psychological adaptation. Because psychological adaptation may not parallel clinical remission, this 5-year longitudinal study examined changes in psychopathological symptoms, alexithymia, coping strategies, and health-related quality of life (HR-QoL) in 73 outpatients receiving maintenance medical treatment. We expected no uniform mean-level improvement or deterioration and hypothesised that increases in depressive and anxiety symptoms, alexithymia, and avoidance coping would be associated with poorer HR-QoL outcomes and that increases in positive attitude coping would be associated with better outcomes. Participants were reassessed during clinical remission using validated measures, and psychological changes were analysed in relation to follow-up quality of life outcomes, adjusting for baseline levels and disease duration. Mean-level changes were limited across depressive symptoms, overall anxiety, alexithymia, most coping dimensions, and HR-QoL indices. Somatic anxiety increased over time (p=.03), whereas social support coping decreased consistently in the overall sample and within both diagnostic subgroups (p<.01). Increases in depressive symptoms were associated with poorer mental health and lower disease-specific HR-QoL (both p<.001), while increases in alexithymia were associated only with poorer disease-specific HR-QoL (p<.05). In the multivariate model, depressive change independently predicted follow-up physical health (p=.02), mental health (p<.001), and disease-specific HR-QoL (p<.001). These findings suggest that psychological vulnerability may remain clinically relevant even during remission and identify depressive symptoms as a key correlate of long-term patient-reported functioning. The results support the integration of psychological assessment and multidisciplinary care within routine gastroenterological follow-up and highlight the potential value of psychologically informed interventions aimed at preserving HR-QoL and long-term adaptation.
Empirical research has suggested the association between interpersonal dysfunctions and anxiety disorders. However, no previous meta-analysis has estimated the extent to which these relational issues are related to negative mental health in anxiety disorders. This study aimed to conduct a systematic review and meta-analysis to evaluate the correlation between interpersonal distress and negative mental health outcomes in people with a diagnosed anxiety disorder. We performed a systematic search in PsycINFO and PubMed, based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria, including studies reporting estimates of the associations between interpersonal distress and negative (non-relational) mental health outcomes in people with diagnosed anxiety disorders. Using multilevel meta-analytic models, we estimated a pooled correlational (r) effect size, accounting for variability at the within-effect-size, between-effect-size, and between-study level. We identified 18 eligible articles, reporting 43 effect sizes from 2,998 subjects. The multilevel models showed a significant association between interpersonal distress and mental health in people with a diagnosed anxiety disorder (r=0.37, 95% confidence interval [CI] [0.28, 0.52], d=0.84). We found significant heterogeneity around the estimations (Q(42)=463.29, p<.001) but failed to find significant moderators of the association. Interpersonal distress has a moderate-to-large correlation with non-relational mental health outcomes in people with diagnosed anxiety disorders. More research would be necessary to determine putative moderators of this association.
Baseline personality pathology may shape both everyday functioning and engagement in psychotherapy. This study tested whether maladaptive personality trait domains and borderline symptom severity were associated with psychosocial functioning at intake and whether these variables were related to subsequent psychotherapy dropout within the same clinical pathway. Participants were 124 young adults (M age = 20.81, SD=2.30; 51.6% male and 48.4% female) assessed at intake in a youth mental health early intervention service in Milan, Italy (2024-2025). Measures included the Personality Inventory for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PID-5), the Borderline Symptom List-23 (BSL-23), and the Social and Occupational Functioning Assessment Scale (SOFAS). SOFAS was examined using stepwise multiple linear regression including PID-5 domains, BSL-23, sex, and age. Dropout was examined using Bayesian logistic regression and model comparison in the psychotherapy-only subsample (n=63; 13 dropouts, 20.6%). In the full sample, the final regression model retained only BSL-23, F(1, 122)=5.57, p=.020, R2=.04, indicating that higher borderline symptom severity was associated with lower functioning (B=-2.86, β=-.21, 95% CI [-5.27, -0.46]). For dropout, inclusion evidence was strongest for disinhibition (Bayes factor for inclusion [BF_inclusion] = 3.36), followed by BSL-23 (2.39) and SOFAS (2.23), although model-averaged 95% credible intervals (CrIs) included zero for all predictors. Clinically, these findings suggest that disinhibition and borderline severity may be better understood as markers of relational intensity requiring a structured yet reflective therapeutic stance rather than as straightforward dropout risks.
Despite the recognition of emotional experiencing as a key change factor in psychotherapy, gaps remain regarding how clinical training influences this dimension, particularly in brief interventions conducted by trainees, and preliminary process data on this phenomenon in Portuguese clinical training contexts are scarce. This study examined emotional experiencing in brief psychotherapy conducted by trainee psychologists undergoing structured experiential training with deliberate practice, analyzing whether patients show a progressive increase in experiential depth across sessions, whether higher levels of emotional experiencing are associated with stronger therapeutic alliance and greater symptom reduction, and whether therapists' persuasiveness predicts patients' emotional experiencing at different session moments. A quantitative repeated measures design was adopted with 5 trainee psychologists and 15 adult patients in a university clinic. Four sessions per patient were analyzed by three independent researchers using standardized measures: the Outcome Questionnaire-45 (OQ-45), the Working Alliance Inventory-Short Revised (WAI-SR), the Experiencing Scale (EXP), and the Therapist Persuasiveness Rating Scale (TPRS). Mixed linear models were then applied to assess longitudinal changes and relationships among variables. A significant reduction in psychological distress and an increase in therapeutic alliance indices, particularly in the tasks and bond dimensions, were observed. No significant changes were found in the depth of emotional experiencing, nor robust associations of this variable with symptom improvement or alliance, except for a marginal negative relationship between goal consensus and modal emotional experiencing. These findings suggest a stability of emotional experiencing in brief intervention contexts, highlighting the central role of collaborative processes in clinical change.
Relational competence is a key determinant of psychotherapy outcomes, yet its development during training remains insufficiently understood. The present study adopts a qualitative, trainee-centered approach to examine how psychotherapy trainees conceptualize relational competences, evaluate their strengths and limitations, and identify the experiences most influential in their development. Forty-nine trainees from a four-year psychotherapy training program completed a structured interview, and data were analyzed using inductive qualitative content analysis. Findings revealed four main themes: i) the conceptualization of relational competence as a foundational and multidimensional component of clinical practice; ii) a predominantly external, patient-driven locus of validation for perceived strengths; iii) the context-dependent and relationally situated nature of perceived limitations; and iv) the central role of experiential learning contexts in fostering relational development. Overall, relational competence emerged as a dynamic and developmental construct, shaped by the integration of personal dispositions, experiential learning, and evolving professional identity. These findings highlight the need for training models that more effectively integrate experiential and reflective components, while supporting the development of more internalized standards of professional competence.
Virtually delivered psychotherapy is a widely adopted means of providing mental health interventions. There is little research on patients' perspectives on this mode of delivering therapy, and their perspectives are important given that patient factors predict a large proportion of mental health outcomes. This study explores patients' experiences with online psychotherapy to help inform best practices. Thirty-three patients who were currently receiving synchronous, virtually delivered psychotherapy were interviewed. The interview focused on patient experiences, both positive and negative, and their recommendations for improving virtually delivered therapy. Interviews were audio-recorded and transcribed. We used an inductive approach to thematic analysis in coding the transcripts. Audit trails and reflexive and independent coding ensured the trustworthiness and fidelity of the identified themes. Themes reflecting positive patient experiences included convenience, accessibility, and connection with the therapist. Themes of negative experiences included technology-related challenges, perceived disconnection due to not being physically present with a therapist, concerns about safety, and privacy issues. Patient characteristics and personal circumstances interacted with the online modality to affect their experiences. Patients recommended enhancing privacy and safety, utilizing online tools effectively, and encouraging therapists to be more deliberate in their non-verbal communication. For clinicians and researchers, this study outlines patients' perspectives on the aspects of virtual care that work effectively and those that could benefit from further improvement.
The 40-item Defense Style Questionnaire (DSQ-40) is frequently used to measure defense mechanisms in adults with depression because of its brevity and efficient assessment. However, previous research has yielded inconsistent results concerning its factor structure, with one- (overall defensive functioning), three- (mature, neurotic, immature), and four- (mature, neurotic, immature, image-distorting) factor solutions being reported. Therefore, we examined the DSQ-40’s latent structure across different samples. Using multigroup confirmatory factor analysis (CFA), we tested the one-, three-, and four-factor solutions using baseline data from three research projects of psychodynamic psychotherapy for depressed adults (N=667; mean age 33.9; standard deviation [SD]=9.3; 79.0% female). Configural invariance across samples was evaluated, and model fit was compared using multiple fit indices. Across samples, the three- and four-factor models outperformed the one-factor model, with the four-factor model providing the best relative fit; however, it fell short of conventional model fit thresholds. Separate CFAs found the four-factor model showing the best relative fit in two samples, and the three-factor model in one, but all models failed to meet acceptable fit criteria. Several defense mechanisms showed weak standardized loadings, high inter-factor correlations, and cross-loadings. These findings indicate that the DSQ-40 lacks a stable factor structure in adults with depression and raise important questions about the instrument’s construct validity, suggesting that its subscale scores cannot be assumed to validly represent the theorized defense categorizations in this population. Further psychometric refinement and evaluation are needed to determine the DSQ-40’s suitability for both clinical and research applications.
Overweight and obesity are linked with binge eating disorder (BED). Traditionally, cognitive behavioral therapy (CBT) is the therapeutic approach indicated for both inpatient and outpatient treatment of BED. Eye movement desensitization and reprocessing (EMDR) could be more effective for the treatment of BED, in particular with patients who have experienced one or more traumatic experiences. A two-arm randomized controlled trial (RCT) was thus run to test the hypothesis that a 4-week EMDR intervention was more effective than a parallel CBT intervention in the treatment of inpatients with obesity and BED who experienced at least a traumatic event. The sample included 31 inpatients, who were randomly assigned to EMDR (n=16) or CBT (n=15). Outcomes were the reduction of binge eating symptoms, emotional eating, psychological distress, and trauma-related variables, and the improvement of emotion regulation from baseline to treatment completion. Results showed no statistically significant difference between the two treatment conditions, while statistically significant improvements were observed in the whole sample and in several outcome variables: depression, anxiety, stress, emotional eating, binge eating, two Difficulties in Emotion Regulation Scale (DERS) domains (Clarity and Strategies), and the DERS total score, two Impact of Event Scale-Revised (IES-R) sub-scales (Intrusion and Hyperarousal) and the IES-R total score, but with small standardized sizes of improvements (Cohen’s d). Both interventions may have yielded similar benefits; however, the absence of a control group prevented a clear attribution of these improvements to the interventions, as all participants were concurrently undergoing a structured residential multidisciplinary treatment. Future studies should include larger samples, longer treatment protocols, and follow-up assessments, as well as comparison groups of inpatients not receiving experimental treatments, to better isolate the specific effects of EMDR and CBT.
While a substantial number of studies investigate the nuances and clinical relevance of attachment styles and defense mechanisms separately, relatively few studies have explored the relationship between attachment styles and defense mechanisms. We aimed to provide a narrative review of empirical studies that used validated measures to assess the relationship between defense mechanisms and attachment styles in adolescents or adults. Twenty peer-reviewed studies published over the past 30 years were included. Except for one study involving high school students, all others focused on adults, mostly from community samples, with a few including clinical populations. Most studies employed various self-report questionnaires, though several used observer-rated or interview-based methods, with the majority using a cross-sectional design; a few studies used experimental and longitudinal designs as well. The studies’ findings indicate an association between insecure attachment and greater use of immature defenses, while secure attachment is associated with more mature defenses. Anxious attachment was particularly linked to defenses such as projection, splitting, and devaluation, whereas avoidant attachment was associated with emotional suppression and denial. A subset of studies examined changes in these constructs during psychotherapy, suggesting that both defense mechanisms and attachment security may improve over time, and indicating the potential importance of reflective functioning as a mediator, as well as depressive immature defenses as obstacles to change. These results underscore the clinical relevance of assessing both attachment and defensive functioning and highlight the importance of addressing them as potential mechanisms of change in clinical contexts.
Treatment studies of major depression commonly focus on symptoms rather than changes in psychological risk factors. This pilot study examines the relationship between changes in eight defenses specifically related to depression, called depressive defenses, and depressive symptoms. Thirty adults with acute, recurrent major depression were given antidepressant medications (ADM) and randomized to up to 18 months of either cognitive behavioral therapy (CBT), dynamic, or supportive psychotherapy and followed for 4.5 years. Defenses were assessed using the observer-rated Defense Mechanism Rating Scales (DMRS) at intake and 18 months. The Hamilton Rating Scale for Depression-17 item version (HRSD-17) and the Beck Depression Inventory-2nd version (BDI-II) assessed depression periodically. Depressive symptoms decreased significantly on both the HRSD-17 (effect size [ES]=-1.03) and BDI (ES=-1.90). Overall defensive functioning (ODF) increased significantly (ES=.85), improving in 76% of participants. Similarly, the mean proportion of depressive defenses decreased significantly by termination (ES=-.62), although the overall mean remained above that generally seen in healthy adults. Twenty-four percent of participants attained this threshold at termination. After controlling for initial levels, at termination depressive defenses correlated significantly with HRSD-17 (rs=.44, p=.02), and BDI (rs=.33, p=.095). Although causal relationships were not established, depressive defenses were consistently related to changes in depressive symptoms, suggesting that they are promising mediators of treatment effects for major depression. Clinically, defenses are readily identifiable and can serve as important foci in treatment. Finally, levels of depressive defenses that exceed healthy norms may reflect a continuing level of risk for current or future depressive symptoms or episodes.
The observer-rated Q-sort based on the gold-standard Defense Mechanisms Rating Scales (DMRS-Q) allows the investigation of defense mechanisms based on one session as a whole. The present study analyzed the reliability and validity of the DMRS-Q applied to three types of clinical interactions other than therapy sessions. Transcripts of three different clinical interviews, including a total of 233 adults (50 cancer patients who completed Mayman's Early Memory Interview [EMI], 93 individuals without clinical diagnosis who completed McAdams' Life Story Interview [LSI], and 90 pregnant women who completed the Working Model of the Child Interview [WMCI]), have already been coded on the DMRS. Our research team of expert raters conducted the DMRS-Q coding on these same transcripts and assessed the inter-rater reliability and the concurrent, convergent, and discriminant validity of DMRS-Q in these clinical interactions. Results showed good inter-rater reliability (intraclass correlation coefficient [ICC]=.70) for the Overall Defensive Functioning (ODF), although lower than reported using transcripts of psychotherapy sessions. Large correlations were found between ODF scales assessed with the DMRS-Q and the DMRS among the three samples (r=.43 to .59; p<.001), while small to moderate correlations were found between the DMRS-Q, sociodemographic, and psychological measures. The DMRS-Q ODF scale might be a valid and reliable measure to assess the overall maturity of defensive functioning in brief interviews. Its ease of use, supported by open-source software, enables the application of the gold-standard DMRS theory across a wide range of contexts beyond psychotherapy research.
This longitudinal observational study investigates the relationship between patients' defense mechanisms before outpatient therapy and their interpersonal problems during early treatment, exploring how specific defense mechanisms are associated with interpersonal problems, a clinically relevant factor for therapy planning. Participants (N=286) from a German outpatient sample completed baseline assessments prior to their first therapy session, including self-report measures of defense styles (Defense Style Questionnaire [DSQ]), emotion regulation (Difficulties in Emotion Regulation Scale - Short Form [DERS-SF]), structural integration (Operationalized Psychodynamic Diagnosis - Structure Questionnaire Short Version [OPD-SQS]), and interpersonal problems (Inventory of Interpersonal Problems [IIP-32]). Follow-up assessments were conducted at approximately 6 and 12 months. Linear mixed models were used to examine longitudinal changes in interpersonal problems and their association with baseline defense styles and defense mechanisms, adjusting for age, sex, therapy duration, structural integration, and emotion regulation difficulties. Particularly, the intermediate (neurotic) defense style was associated with higher levels of interpersonal problems across timepoints. However, defense styles did not significantly predict changes in interpersonal problems over time. In contrast, a more nuanced analysis at the level of defense mechanisms revealed that projection, undoing, and reaction formation were associated with greater interpersonal difficulties, while anticipation was associated with fewer difficulties. Projection showed a robust interaction with time, indicating its relevance for predicting individual change trajectories. These findings suggest that individual defense mechanisms provide added predictive value over aggregated defense styles when assessing interpersonal functioning in early outpatient therapy. From a clinical perspective, the differentiated assessment of specific defenses may improve treatment planning in psychodynamic therapy, although further research is warranted.
This cross-sectional, questionnaire-based study examined the role of psychological (i.e., defenses and reflective functioning) and contextual variables (i.e., LGBTQ+ identity, clinical experience, and LGBTQ+-specific training) in contributing to professional burnout among 51 Italian psychologists and psychotherapists (mean age 40.12, standard deviation [SD]=9.86) working with LGBTQ+ patients. Preliminary correlational analyses showed that mature defenses were negatively associated with emotional exhaustion and depersonalization, and positively with personal accomplishment. Conversely, immature defenses correlated positively with emotional exhaustion and depersonalization, and negatively with personal accomplishment. Neurotic defenses were linked specifically to reduced personal accomplishment. Lower certainty about mental states - an indicator of diminished reflective functioning - was also associated with higher burnout. In line with the study's main hypothesis, regression analyses revealed that lower overall defensive functioning (ODF), reduced certainty about mental states, and fewer years of clinical experience significantly predicted higher burnout levels. These findings underscore the importance of both intrapsychic resources and professional development in protecting therapists from burnout. Adaptive defenses and strong reflective functioning appear particularly protective in LGBTQ+ clinical contexts, where therapists often encounter emotionally complex, identity-related challenges. Therapists who can mentalize effectively and regulate internal responses through mature defenses may be better equipped to sustain therapeutic engagement and mitigate emotional exhaustion. These results suggest that clinical training and supervision should prioritize the enhancement of reflective capacity and adaptive defenses. Supporting these intrapsychic skills may be key to promoting therapist well-being and ensuring affirming, competent care for LGBTQ+ patients.
Mature defense mechanisms support patients' engagement in psychotherapy. The Overall Defensive Functioning (ODF) scale of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Defensive Functioning Scale (DFS) is a measure of the maturity of patients' defenses. Immature defenses (e.g., splitting) and poor emotion regulation are hallmarks of borderline personality organization, and both can interfere with positive treatment engagement. We predicted that ODF would significantly and negatively correlate with the Personality Assessment Inventory Borderline (PAI-BOR) scales, PAI Treatment Rejection (PAI-RXR) scale, and the PAI Treatment Process Index (PAI-TPI). To our knowledge, no studies have examined the relationship between ODF scores, as measured by the DFS rating of Thematic Apperception Test (TAT) narratives, and defense levels, PAI-BOR Full Scale (PAI-BOR-FS), PAI-RXR, and PAI-TPI scales. The sample included 73 outpatients from an academic hospital. Patients were administered the PAI and a TAT protocol. Two psychologists independently rated 40 TAT protocols with the observer-rated DFS for reliability. Healthy defenses showed significant negative correlations with PAI-BOR-FS (r=-.27), PAI-BOR Negative Relationships (PAI-BOR-N) (r=-.38), and PAI-RXR (r=.30). The pathological defenses had positive correlations with four of the five PAI-BOR scales and the PAI-TPI. There were significant correlations between ODF and the treatment related scales, PAIRXR (r=.37, p<.01) and PAI-TPI (r=-.32, p<.01). ODF significantly and negatively correlated with the PAI BOR-FS (r=-.36, p<.01) and its subscales, Affective Instability (r=-.35, p<.01) and Negative Relationships (r=-.39, p<.01). High and low ODF groups had significant and meaningful differences on all seven PAI scales. Overall, these findings provide support for the construct validity and clinical utility of the DFS defense levels (healthy, neurotic, and pathological) and the global ODF.
Grandiose narcissism is increasingly conceptualized as encompassing two dimensions: admiration and rivalry. Clarifying how these aspects are shaped requires attention to the intrapsychic regulators and interpersonal motivational systems that organize narcissistic functioning. A total of 478 participants completed an online survey including the Narcissistic Admiration and Rivalry Questionnaire (NARQ), the Defense Mechanisms Rating Scale-Self Report-30 (DMRS-SR-30), and the Social Mentalities Scale (SMS). Rivalry showed a stronger negative association with overall defensive functioning (ODF; r=−0.34, p<.001) compared to admiration (r=−0.09, p<.05). At the interpersonal level, rivalry was positively associated with insecurity (r=0.25, p<.001) and agonism (r=0.48, p<.001), and negatively with prosociality (r=−0.30, p<.001), belongingness (r=−0.28, p<.001), and playfulness (r=−0.23, p<.001). Admiration, in contrast, was positively associated with agonism (r=0.42, p<.001) and sexuality (r=0.23, p<.001). The mediation analysis (moderated by gender) indicated that defensive functioning impacted narcissistic expression through specific interpersonal motivational systems: insecurity (βmales=0.036, p=.040; βfemales=0.055, p=.009), prosociality (βmales=−0.033, p=.033; βfemales=−0.085, p=.002), and agonism (βmales=−0.163, p=<.001; βfemales=−0.132, p=.001). The study expands theoretical and clinical knowledge of the underlying motivations and defense mechanisms involved in grandiose narcissism, shedding light on specific intrapsychic and relational processes underpinning narcissistic dynamics.
Defense mechanisms are automatic psychological processes that regulate emotional conflicts and modulate adaptation to internal and external stressors. As implicit components of emotion regulation, they play a transdiagnostic role across psychological and physical domains of health. Among the available instruments, the Defense Mechanisms Rating Scales-Self-Report-30 (DMRS-SR-30) directly operationalizes the hierarchical model of defenses, widely considered the gold standard framework for their empirical assessment. This systematic review aimed to synthesize findings from all studies that had employed the DMRS-SR-30 to date, summarizing its psychometric properties, domains of application, and clinical implications. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was conducted across PubMed, Scopus, and Web of Science databases. Eligible studies were full-text peer-reviewed articles written in English employing the DMRS-SR-30. Risk of bias was assessed according to study design using an established quality appraisal tool. Twenty-six studies met the inclusion criteria. The main domains of application were medical conditions, mental health and psychopathology, personality, and stress-related adjustment. Across these research areas, mature defenses were consistently associated with adaptive functioning and resilience, whereas immature and neurotic defenses predicted higher psychological distress, maladjustment, and psychopathology. The findings from the validation studies demonstrated that the scale exhibited robust reliability, construct validity, and clinical sensitivity. The DMRS-SR-30 provides a valid, efficient, and clinically meaningful method to assess the full hierarchy of defense mechanisms through a self-report tool. Its overall defensive functioning (ODF) index may offer an integrative measure of adaptive capacity that can complement standard psychodiagnostic and medical evaluations. Incorporating the assessment of defensive functioning can enhance the holistic understanding of patients, improve compliance with treatment, and promote person-centered care within mind-body health contexts.
The paper revisits defense mechanisms as central regulators of emotional life and self-coherence in contemporary clinical practice, showing how a classical psychodynamic construct has evolved into an empirically measurable, transdiagnostic dimension of functioning. After outlining the historical development of the concept, the authors present the hierarchical model of defenses, operationalized through the Defense Mechanisms Rating Scale (DMRS), as the current reference framework for assessment of thirty individual defenses across seven levels of adaptiveness. Empirical studies using the DMRS - also in its observer-rated Q-sort and self-report versions - indicate that shifts toward more mature defenses predict better outcomes across different treatment orientations, suggesting that changes in defensive functioning may represent a common factor underlying psychotherapeutic change. These advances are integrated with dimensional and transdiagnostic approaches, including the Psychodynamic Diagnostic Manual, Third Edition (PDM-3), in which defenses play a pivotal role in evaluating personality organization on Axis P and mental capacities on Axis M, thereby complementing symptom-focused systems such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) and the International Classification of Diseases (ICD-11). The paper also discusses conceptual overlaps with coping and emotion regulation, the limitations of cross-sectional and self-report methodologies, and the need for longitudinal, cultural, and neuro-psychodynamic research, proposing defense mechanisms as a unifying language that links psychodynamic theory, empirical psychology, and neuroscience.
Premature termination of psychotherapy is a challenging reality for both research and practice. This study aimed to contribute to a more comprehensive understanding of psychotherapy dropout by aggregating and synthesizing findings across dropout cases. A qualitative meta-synthesis was conducted on case studies from the Single Case Archive (SCA), a representative sample of published, peer-reviewed single-case psychotherapy studies. This meta-synthesis aggregated and synthesized the 11 case studies in the SCA published in English that described dropout substantively. The meta-synthesis identified 7 themes that influenced dropout: misattunement, inert therapeutic relationships, unmanaged therapist responses, unmanaged therapist interventions, rigid protocol adherence, readiness for change, and repeating interpersonal dynamics. These themes were arranged into the interrelated patient, therapist, and interactional clusters. The findings of the meta-synthesis were comprehensively represented by the metaphor of tango dancing, in which both partners co-create the dynamic that produces a (un)successful dance. One additional theme not fitting this structure includes instances in which dropout was a positive act on the part of the patient. The meta-synthesis revealed the complex and multifarious nature of psychotherapy dropout, a phenomenon that requires a sufficiently multifaceted conceptual framework for adequate comprehension. It was found that patients, therapists, and their dynamic interaction must be incorporated to account for the complex processes underlying psychotherapy dropout.
