Therapist Judgment of Defense Styles and Therapeutic Technique Related to Outcome in Psychodynamic Psychotherapy for Depression

We hypothesized that expressive technique would be associated with a better outcome when utilized in patients with stronger ego capacities, operationalized as a more mature defense style. The study involved secondary analyses of a randomized controlled trial comparing psychotherapy and combined therapy for depression. The total sample consisted of 191 patients with depression at two outpatient clinics of Arkin Mental Health Care [20–22] , of whom 106 patients were allocated to psychotherapy and 85 to combined therapy (psychotherapy and medication). Written informed consent was obtained from all patients. The study group consisted of 147 patients for whom the measure of interest (therapist evaluation form, TEF) was available. This group did not differ from the total sample. There were no differences with regard to sociodemographic variables, symptom severity or study dropout between the groups with or without medication. The majority of patients (70%) was female, 70% was younger than 39 years, 31% suffered from a recurrent depression and half of the patients were highly educated. The mean baseline Hamilton Depression Rating Scale (HAM-D) score was 18 (SD = 3.4). The outcome measure was the HAM-D-17 [23] . The TEF assessed the therapist’s appraisal of the patient’s personality structure based on Kernberg’s structural model [9] (5 categories from normal to severe borderline personality structure), the patient’s defense style based on Valliant’s hierarchy of ego defense mechanisms [24] (immature, neurotic or mature) and applied technique during treatment (5 categories from solely supportive to solely expressive). Test-retest reliability was assessed using Cohen’s for categorical data [25] . It was satisfactory for technique (0.60; p ! 0.01) and defense (0.74; p ! 0.01) but not for the appraisal of personality structure (0.36; p = 0.03), which was therefore removed from the final analyses. Last observation carried forward analysis was applied to the outcome measure. Stepwise hierarchical regression analysis with forced entry was performed to determine which variables were associated with outcome: first HAM-D baseline, next technique, defense style and the interaction technique ! defense. The variable technique was coded from 1 (solely supportive) to 5 (solely expressive), and the variable defense style was coded from 1 (immature) to 3 (mature). The tests were two-tailed. According to the therapists, 15% of the patients received solely supportive interventions, 42.9% mainly supportive, 34.7% equally supportive and expressive, 7.5% mainly expressive and no patient received solely expressive interventions. Patients’ defense style was appraised as mainly neurotic in 50%, immature in 35% and mature in 12%. Table 1 shows the predictors of outcome. Expressive therapeutic technique was significantly related to therapy outcome in the second step. After adding defense style to the model in the third There is a lively debate regarding the elements that may optimize outcome in psychodynamic therapies [1–4] . These elements can be studied from different perspectives. In this article, we explore the predictive value of therapeutic technique and personality. Psychodynamic technique can be placed on a continuum from supportive to expressive. Expressive interventions are related to better outcome across diagnostic groups, even for patients with poor object relational functioning [5, 6] , but supportive interventions might be as effective [7, 8] . From a psychoanalytic viewpoint, depression is understood in the context of one’s personality structure [9, 10] . Personality pathology has a negative impact on the course, duration and outcome of treatment [11, 12] . Defense style is a promising concept in this domain and appears to be related to the course and outcome of treatment for depression [13–15] . The interplay between these factors is unclear. In addition, in daily practice, clinicians practice ‘intuitive psychometrics’ to guide their interventions [16] . Clinical judgment may be useful in tailoring treatment protocols to the individual patient [17, 18] , but it has received little attention in psychotherapy research. In this study, we applied short-term psychoanalytic supportive psychotherapy [19] . As this approach is characterized by the explicit possibility to intervene on a continuum from solely supportive to more expressive technique, it enabled us to investigate the relationship between the type of intervention style and outcome. Received: April 15, 2010 Accepted: January 11, 2011 Published online: September 28, 2011