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Psychology and Psychotherapy: Theory, Research and Practice (2009), 82, 73–81 q 2009 The British Psychological Society
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Clinicians’ defences: An empirical study Jean-Nicolas Despland1*, Mathieu Bernard1, Nathalie Favre1, Martin Drapeau2, Yves De Roten1 and Friedrich Stiefel1 1 2
University of Lausanne, Prilly, Vaud, Switzerland McGill University, Montreal, Quebec, Canada Objective. Clinicians’ defence mechanisms are strategies used to manage the stress and the negative affects emerging during a therapy session. The first objective of the study is to adapt the defence mechanisms rating scales (DMRS), originally created by Perry for assessing patient defences, in order to evaluate clinician defences. The second objective is to explore the type of defence mechanisms used by clinicians in oncology. The third objective is to study the sensitivity of the instrument by assessing changes in defensive functioning after specific communication skills training (CST) in oncology. Design. Participants (N ¼ 20) were oncology clinicians participating in oncology CST. The defence mechanism rating scales for clinicians (DMRS-C) was used to assess the use of the clinicians’ defences before and after CST. Results. The instrument showed promising preliminary psychometric properties. Numerous and very varied defences were coded in each session and corresponding to a great variety of defences. After CST, the clinicians’ overall defensive functioning (ODF) increased. Considering the defences’ levels, a decrease in the use of immature defences was observed. Conclusions. Taking into consideration the importance of clinicians’ variables in treatment outcome, this instrument constitutes a promising way of assessing the clinician’s strategies used to face the emotional difficulties emerging during the therapeutic encounter.
The effects of clinician variables on the psychotherapeutic process have long been considered a promising area of research. Studies have shown that up to 10% of treatment variance are due to the clinician (Blatt, Sanislow, Zuroff, & Pilkonis, 1996; Kim, Wampold, & Bolt, 2006) and there is an increasing discussion of its possible influence (Crits-Christoph & Gallop, 2006; Elkin, Falconnier, Martinovitch, & Mahoney, 2006; Kim et al., 2006). Among the many clinician variables (Beutler et al., 2004), coping strategies were studied in regard to highly stressful areas such as therapeutic work with traumatized
* Correspondence should be addressed to Professor Jean-Nicolas Despland, Institut Universitaire de Psychothe´rapie, University of Lausanne, 1008 Prilly, Vaud, Switzerland (e-mail:
[email protected]). DOI:10.1348/147608308X324392
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74 Jean-Nicolas Despland et al.
children (Marriage & Marriage, 2005) or emergency care (Kleespies & Dettmer, 2000). These studies revealed supervision or support systems as effective regulation strategies. During the therapy session, less coping strategies were observed with better trained therapists (Dazord, Gerin, Davis, & Davis, 1994). We assume that defence mechanisms are a complementary way of analysing the clinicians’ strategies used to manage the stress and the negative affects emerging in the therapy session (Cramer, 2000). From a psychoanalytic perspective, a defence is a protective mental activity that mediates the individual’s needs and external reality. Defence mechanisms operate in response to internal and external stressors, without conscious effort, and follow specific patterns (Vaillant, 1992). Research has only focused on patient’s defences (Hentschel, Draguns, Ehlers, & Smith, 2004). In view of the high level of negative affects and stress that may emerge during the therapy session, we can hypothesize that clinicians use defence mechanisms to cope. This study is a step of a broader study aiming to evaluate the impact of the communication skills trainings (CST) on clinicians’ defences (Favre et al., 2007) and designed as a two parallel groups pre–post controlled trial, a group consisting of oncology clinicians who benefit from a training in communication skills and a control group consisting of oncology clinicians who did not benefit from this training. Interviews in oncology seem to be an adequate setting for mobilizing clinicians’ defences. The effects of disease, side-effects linked to chemotherapy, prognosis (whether the treatment is curative or palliative context), relational and familial implications are likely to trigger an heavy affective load by the patient. Using defence mechanisms allows clinicians to protect themselves from the emotional charge induced in the patient’s discourse. The hypothesis that clinicians’ defences may be modified by CST, thus allowing a more adequate way to relate to patients, is therefore plausible. The first objective of this study was to adapt a rating system, which had originally been created for assessing patient defences, so that it could also be used for the assessment of clinician defences. The second objective was to explore and to describe the defence mechanisms used by health care professionals in a difficult setting such as oncology. The third objective was to study the sensitivity of the instrument by assessing changes in defensive functioning, after oncology clinicians had undergone CST.
Methods Instrument development To develop a new measure to assess the clinicians’ defences, we adapted the defence mechanisms rating scales (DMRS; Perry, 1990), one of the most reliable method of assessing patient’s defence mechanisms. The original defence mechanisms rating scales The DMRS is an observer-rated method that evaluates the use of defence mechanisms using therapy sessions transcripts. It includes 30 defences assigned to seven hierarchical levels of functioning, including mature, obsessional, other neurotic, narcissistic, disavowal, borderline, and action level defences (see Table 1). Each level includes 3–8 individual defences, which can be weighted according to its level of maturity and summed up to an overall defensive functioning score (ODF) ranging from 1 (most immature) to 7 (most mature). They can also be assigned to one of three broader levels (Vaillant, Bond, & Vaillant, 1986). Both the seven- and the three-level defence
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hierarchies were examined in this study. Numerous studies have shown the validity and reliability of the DMRS (Despland, Despars, De Roten, Stigler, & Perry, 2001; Drapeau, De Roten, Perry, & Despland, 2003; Herzoug, Sexton, & Hoglend, 2002; Perry, 2001; Perry et al., 1998). Table 1. Description of the levels and defence mechanisms Defence’s classification Vaillant
Perry
Mature
Mature
Neurotic
Obsessive Other neurotic Minor image-distorting
Immature
Disavowal Major image-distorting Action
Defence mechanisms Affiliation, altruism, anticipation, humour, self-assertion, self-observation, sublimation, suppression Isolation, intellectualization, undoing Repression, dissociation, reaction formation, displacement Omnipotence, idealization (self, object), devaluation (self, object) Neurotic denial, projection, rationalization, autistic fantasy Splitting of other, splitting of self, projective identification Acting out, passive aggression, help-rejecting complaining
The adaptation of the DMRS for clinicians The purpose of this adaptation is to allow trained coders to evaluate clinicians’ defences. The adaptation procedure followed four steps: (1) four coders evaluated clinicians’ defences using the DMRS in two interviews; (2) meetings were organized between the coders to discuss the ratings; (3) difficulties in coding were identified; and (4) specific rules were added to avoid misunderstanding. They refer to the fact that the clinicians’ defences are induced by the emotional content in the patient’s discourse. The emotional content may be marked by three different types of markers: the direct or indirect expression of affects; the presence of representations linked to emotionally charged themes; and the patient’s defence mechanisms. The basic assumption is to remain faithful to the Perry’s original definitions. The specific rules were added only for an optimal application of the instrument. This four-steps process was repeated six times until adequate inter-rater reliability was reached (. .70). Independent raters then coded 30 more interviews in order to obtain specific examples for each defence mechanism. An appendix, the defence mechanism rating scales for clinician (DMRS-C) was added to the original method (Despland et al., 2006). DMRS-C provides: (1) a rating procedure and (2) for each defence a summary of the DMRS definition, an additional explanation for its application to the clinician if necessary, and at least two commented examples of coding (see Appendix A for an example). Finally for the purpose of face validity, the DMRS-C was submitted to three experts with at least 20 years of experience in psychodynamic psychotherapy and a prior knowledge of the DMRS.
Sample The clinicians (N ¼ 20) were 7 oncology physicians and 13 nurses who were randomly chosen from a pool of participants in a workshop on CST, which took place between 2000 and 2004 in the French-speaking part of Switzerland. Seventeen of the participants
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76 Jean-Nicolas Despland et al.
were women and three were men. The mean age for the sample was 38.20 (SD ¼ 8:5) and the mean number of years of clinical experience was 11.33 (SD ¼ 6:6). CST consists of a 2-day retreat for up to 10 oncology clinicians (nurses or physicians oncologists), where participants are trained by means of case supervisions, role play, and video analyses of simulated patient interview, followed by 4–6 individual supervisions and another half-day training session 6 months later. CST for oncology clinicians have been widely developed over the last decade in order to increase effective communication in oncology clinicians (Butler, Degner, Baile, & Landry, 2005; Gysels, Richardson, & Higginson, 2005; Merckaert et al., 2005). The training exercises the adequate use of focused, open and leading questions and the ability for clarifying medical information. During the supervisions, the participants can discuss cases that have challenged them from a communicational point of view. Procedure Each clinician conducted two simulated interviews, one at the beginning of the CST, and one at the end of the training session 6 months later (2-days retreat, individual supervisions, and half-day training). The patient was played by three professional actors (one woman and two men) experienced in playing patients in medical settings. Short instructions were given to both the clinician and the actor prior to the interview specifying the type of cancer (five different scenarios), the age of the patient (between 30 and 40 years of age), and the type of treatment (curative or palliative). The simulated interviews allowed for the control of the level of stress induced by the patient and the type of treatment. The interviews were videotaped, and then transcribed. For this study, the 40 verbatim transcripts (20 before and 20 after training) were randomly distributed to four coders (three authors of the DMRS-C and one trained coder) and were coded using the DMRS-C.
Results Inter-rater reliability Reliability was calculated on 11 interviews (27.5% of all interviews). The mean intraclass coefficient for defence levels was good with an ICC ð2; 1Þ ¼ :81 (SD ¼ 0:17). Clinician defence mechanisms At time 1, the number of defence mechanisms found in each session ranged from 10 to 35, with a mean of 21.1 defences (SD ¼ 5:6). All seven levels were found. The most prevalent defensive levels were disavowal (26.8%), other neurotic (26.6%), and obsessional (23.6%). Among the 30 possible types of defence mechanisms, 23 were coded at least once. The three most common mechanisms were displacement (19.6%), intellectualization (17.1%), and rationalization (16.7%). The following defences were never rated: repression; self-observation; sublimation; suppression; dissociation; autistic fantasy; and splitting. The ODF score was independent from the type of scenario (palliative or curative; t ¼ 21:584, p . :05). The influence of the actor was not assessable (14 interviews with the first actor, 5 with the second, and 1 with the third actor). At time 2, the number of defence mechanisms found in each session ranged from 10 to 35 (M ¼ 20:9; SD ¼ 5:9). All seven levels were represented. The most prevalent
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defence levels were other neurotic (29.6%), obsessional (27.3%), and disavowal (23.5%). Among the 30 possible types of defences, 23 defence mechanisms were coded at least once. The three most common mechanisms were intellectualization (22.1%), displacement (21%), and rationalization (15.5%). The non-observed defence mechanisms were similar to time one. ODF was not influenced by the type of scenario (palliative or curative; t ¼ 1:466, p . :05). The influence of the actor was not assessable (18 interviews with the first actor and two with the third actor) The Q–Q plot of ODF scores at time 1 and time 2 suggested a normal distribution with homogeneous variance (F ¼ 0:61, p . :05). Change in defences As seen in Table 2, the mean ODF scores increased by 0.38 (SD ¼ 0:5; range ¼ 20:40 to 1:67) from time 1 to time 2. Immature defences (using Vaillant’s classification) decreased. Effect sizes were moderate for the obsessional and disavowal levels and large for action defences (using Perry’s classification). Results did not indicate any association between the clinicians’ individual characteristics (profession and experience) and change in ODF.
Table 2. Evolution of clinicians defences Time 1 M (SD) ODF 4.29 (0.5) Defensive levels according to Vaillant (mean %) Mature 4.64 (0.8) Neurotic 50.15 (1.4) Immature 45.21 (1.3) Defensive levels according to Perry (mean %) Mature 4.64 (0.8) Obsessional 23.61 (1.2) Other neurotic 26.54 (1.0) Minor image-distorting 7.32 (0.5) Disavowal 26.74 (0.9) Major image-distorting 1.24 (0.2) Action 9.91 (0.9)
Time 2 M (SD)
W
g
4.67 (0.4)
2.97*
0.81
6.55 (0.6) 56.99 (1.0) 36.46 (1.1)
1.05 2.27 2.84*
0.27 0.51 0.70
6.55 (0.6) 27.36 (0.8) 29.64 (1.2) 8.19 (0.7) 23.49 (0.9) 0.40 (0.5) 4.38 (0.5)
1.05 1.12 0.89 0.56 1.88 1.15 2.46
0.27 0.35 0.27 0.14 0.36 0.19 0.73
Note. ODF, overall defensive score; W, Wilcoxon signed-rank test; g, Hedge’s g effect size. Cohen (1988) considered: g ¼ 0:20 as a small effect size; g ¼ 0:50 as a medium effect size; and g ¼ 0:80 as a large effect size; *significance test when p , :05 with Bonferroni correction (*p , :05=3 ¼ :016 for Vaillant’s classification and p , :05=7 ¼ :007 for Perry’s classification).
Discussion Preliminary psychometric properties of the DMRS-C appeared promising, with a good inter-rater reliability and a high face validity. A high number and a great variety of defences were observed in oncology clinicians. The three most common defences (representing 56% of all defences) belong to the most often used defensive levels: displacement (neurotic level); intellectualization (obsessive
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78 Jean-Nicolas Despland et al.
level); and rationalization (disavowal level). In view of the therapeutic context, the neurotic level may have resulted from a distancing in relation to the emotional content evoked during the patient’s discourse. In most cases, the clinicians’ defence mechanisms occurred when they were explaining care processes, such as therapeutic procedures. Intellectualization was observed when the clinician gave a diagnosis for example, where common medical terms were replaced by scientific terms or explanation to lessen the induced anxiety perceptible in the patient or the clinician. Displacement was used to evoke a third party rather than directly dealing with a highly emotional problem, for example information of possibilities to meet a psycho-oncologist or a social-worker. Rationalization might be interpreted as the clinician’s need to accomplish his mission without being overinvolved in the patient’s feelings. This consists of reassuring the patient about the usefulness and advantages of the suggested treatment or at justifying a painful treatment. In this sense, the use of rationalization may be a sign of the clinician’s difficulty in establishing an empathetic bond with the patient or a lack of training in this area. The results indicated that clinicians are likely to change their defensive functioning after relatively short training in communication skills. These results were congruent with previous research, which demonstrated that patients’ defences can change in terms of the evolution of their ODF scores (Drapeau et al., 2003; Perry & Cooper, 1989). ODF increased towards more mature defences (increase in neurotic level), while immature defence mechanisms decreased (particularly for action defences). Referring to the normal distribution of the ODF scores, our results indicated that some clinicians did not benefit from the CST, at least by considering the defence mechanisms area. An evaluation of the impact of low clinician defences on the patient (i.e. satisfaction) or the relationship (i.e. therapeutic alliance) is needed to better understand how the defences displayed by the clinician influence the therapeutic process. The evolution of the ODF raises the question of defences as trait-like rather that statelike mechanisms (Beutler et al., 2004; Hentschel et al., 2004). The fact that defences in clinicians changed after communication training would suggest that defences are sensitive to specific contexts such as communication training. A plausible explanation would be that improvable professional ability should be considered as an intermediary variable between inflexible traits and behaviour patterns resulting exclusively from contextual parameters. This positive evolution in a 6-months interval is not a guarantee of a stable change in a long-term. Recent studies have shown that consolidation workshops are necessary to really induce an adequate clinician’s adjustment to the patient’s level of distress (Merckaert et al., 2005, 2008). The study is limited regarding several points. The results were based on only 23 of the possible 30 defence mechanisms. The reported high effect sizes are not significant because of the small sample size used. A larger sample would have allowed a more thorough study of specific defence mechanisms. Future research should also include more evidence on criterion validity (concurrent and predictive) by including other instruments such as coping scales for example. The study of clinicians’ defence mechanisms as a process variable during treatment may allow for a better understanding of how medical clinicians deal with emotional issues and how this influences therapeutic outcomes. This is particularly important given that indices of burnout and psychological distress among clinicians are linked to the suffering of patients, particularly in oncology (Ramirez et al., 1995; Sherman, Edwards, Simonton, & Mehts, 2006).
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In conclusion, the adaptation of the DMRS for evaluating clinicians’ defences seems promising in light of the frequency and diversity of the mechanisms identified. These preliminary results in this specific context encourage us to extend its application to other contexts of care or psychotherapy sessions. Studies of defence mechanisms represent a promising way of taking into consideration clinicians’ characteristics, which account for great variance in treatment outcome (Kim et al., 2006).
Acknowledgements This study was supported by OncoSuisse, grant 01595-08-2004.
References Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., Talebi, H., Noble, S., et al. (2004). Clinicians variables. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 227–306). New York: Wiley. Blatt, S. J., Sanislow, C. A., Zuroff, D. C., & Pilkonis, P. A. (1996). Characteristics of effective clinicians: Further analyses of data from the National Institute of mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology, 64, 1276–1284. Butler, L., Degner, L., Baile, W., & Landry, M. (2005). Developing communication competency in the context of cancer: A critical interpretive analysis of provider training programs. PsychoOncology, 14, 861–872. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale: Lawrence Earlbaum Associates. Cramer, P. (2000). Defense mechanisms in psychology today. Further processes for adaptation. American Psychologist, 66, 637–646. Crits-Christoph, P., & Gallop, R. (2006). Therapist effect in the National Institute of Mental Health Treatment of Depression Collaborative Research Program and other psychotherapy studies. Psychotherapy Research, 16, 173–177. Dazord, A., Gerin, P., Davis, J. D., & Davis, M. L. (1994). Influence of psychoanalytical training on professional performance in a sample of French speaking psychoclinicians. European Psychiatry, 9, 211–220. Despland, J. N., Despars, J., De Roten, Y., Stigler, M., & Perry, J. C. (2001). Contribution of patient defense mechanisms and clinician interventions to the development of early therapeutic alliance in a brief psychodynamic intervention. Journal of Psychotherapy Practice and Research, 10, 155–164. Despland, J. N., Favre, N., Drapeau, M., de Roten, Y., Beretta, V., & Bernard, M., et al. (2006). Echelles d’e´valuation des me´canismes de defense: Manuel d’application au clinicien [Defense mechanism rating scales: Clinician’s application manual]. Unpublished manuscript, University of Lausanne. Drapeau, M., De Roten, Y., Perry, J. C., & Despland, J. N. (2003). A study of stability and change in defense mechanisms during a brief psychodynamic investigation. Journal of Nervous and Mental Disease, 191, 496–502. Elkin, I., Falconnier, L., Martinovich, Z., & Mahoney, C. (2006). Therapist effect in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Psychotherapy Research, 16, 161–172. Favre, N., Despland, J. N., De Roten, Y., Drapeau, M., Bernard, M., & Stiefel, F. (2007). Psychodynamic aspects of communication skills training: A pilot study. Supportive Care in Cancer, 15, 333–337.
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80 Jean-Nicolas Despland et al. Gysels, M., Richardson, A., & Higginson, I. J. (2005). Communication training for health professionals who care for patients with cancer: A systematic review of training methods. Supportive Care in Cancer, 13, 356–366. Hentschel, U., Draguns, J. G., Ehlers, W., & Smith, G. (2004). Defense mechanisms: Current approaches to research and measurement. In U. Hentschel, J. G. Draguns, W. Ehlers, & G. Smith (Eds.), Advances in psychology. Defense mechanisms: Theoretical, research and clinical perspectives (pp. 3–28). Amsterdam: Elsevier. Herzoug, A. J., Sexton, H. C., & Hoglend, P. A. (2002). Contribution of defensive functioning to the quality of working alliance and psychotherapy outcome. American Journal of Psychotherapy, 56, 539–554. Kim, D. M., Wampold, B. E., & Bolt, D. M. (2006). Clinicians effects in psychotherapy: A randomeffects modeling of the National Institute of Mental Health Treatment of Depression Collaborative Research Program data. Psychotherapy Research, 16, 161–172. Kleespies, P. M., & Dettmer, E. L. (2000). The stress of patient emergencies for the clinician: Incidence, impact and means of coping. Journal of Clinical Psychology, 56, 1353–1369. Marriage, S., & Marriage, K. (2005). Too many sad stories: Clinician stress and coping. Canadian Child and Adolescent Psychiatry Review, 14, 114–117. Merckaert, I., Libert, Y., Delvaux, N., Lie´nard, A., Marchal, S., Boniver, J., et al. (2008). Factors influencing physicians’ detection of cancer patients’ and relatives’ distress: Can a communication skills training program improve physicians’ detection? Psycho-Oncology, 17, 260–269. Merckaert, I., Libert, Y., Delvaux, N., Marchal, S., Boniver, J., Etienne, A.-M., et al. (2005). Factors that influence physicians’ detection of distress in patients with cancer: Can a communication skills program improve physicians’ detection? Cancer, 104, 411–421. Perry J. C. (1990). Defense Mechanism Rating Scale, Unpublished manuscript, Harvard Medical School of Boston. Perry, J. C. (2001). A pilot study of defenses in psychotherapy of personality disorders entering psychotherapy. Journal of Nervous and Mental Disease, 189, 651–660. Perry, J. C., & Cooper, S. (1989). An empirical study of defense mechanisms: I clinical interview and life vignette ratings. Archives of General Psychiatry, 46, 444–452. Perry, J. C., Hoglend, P., Shear, K., Vaillant, G. E., Horowitz, M. J., Kardos, M. E., et al. (1998). Field trial of a diagnostic axis for defense mechanisms for DSM-IV. Journal of Personality Disorders, 12, 1–13. Ramirez, A. J., Graham, J., Richards, M. A., Cull, A., Gregory, W. M., Leaning, M. S., et al. (1995). Burnout and psychiatric disorder among cancer clinicians. British Journal of Cancer, 71, 1263–1269. Sherman, A. C., Edwards, D., Simonton, S., & Mehta, P. (2006). Caregiver stress and burnout in a oncology unit. Palliative and Supportive Care, 4, 65–81. Vaillant, G. E. (1992). Ego mechanisms of defense. Washington, DC: American Psychiatric Press. Vaillant, G. E., Bond, M., & Vaillant, C. O. (1986). An empirically validated hierarchy of defense mechanisms. Archives of General Psychiatry, 43, 786–794. Received 30 October 2007; revised version received 10 April 2008
Appendix A Example of defence mechanism in the DMRS-C: Displacement Definition according to the DMRS The individual deals with emotional conflicts or internal or external stressors, by generalizing or redirecting a feeling about or a response to an object on to another,
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usually less threatening, object. The person using displacement may or may not be aware that the affect or impulse expressed towards the displaced object was really meant for someone else. Adaptation to the clinician The evocation of a third party when an emotional content is clearly identifiable is considered as a displacement. The clinician feels an affect that he is unable to cope with, and manages it by displacing it on to a third person or a less troubled theme. Example#1 Because : : : the cells which are still there can’t be removed! So I’m going to die : : : T: Yeah : : : Did he talk about a curative treatment? Or palliative? P: palliative! If I am not mistaken. T: mhm mhm How do you understand the term palliative? P: (sighs) euh (sighs) prevention or accompaniment euh I don’t know exactly. T: OK. How did you feel during these 15 days? between the announcement that this tumour couldn’t be totally removed and this consultation?
P:
Commentary The patient is speaking about his risk of dying and informs the clinician that he didn’t understand very well the term palliative. The clinician displaces the affect on a less troubled theme, that is on the patient’s affects during the last weeks. Example#2 P:
As you said, everyone reacts differently to medication. May be it will be necessary to change the medication or something like that : : : If we consider the extremes, with your experience and your practice, what does it mean? it’s one year? three years? It’s six months? Four years? C: For me : : : I really understand your question. As you said you are a self-employed worker isn’t it? : : : Commentary The patient wants to know how long he will live; the clinician considers the object but by displacing the connected affect on to another less threatening object, that is the professional situation of the patient.
