The mental health of migrants living in limbo: A mixed-methods systematic review with meta-analysis.

The number of forcibly displaced people has more than doubled over the past decade. Many people fleeing are left in limbo without a secure pathway to citizenship or residency. This mixed-methods systematic review reports the prevalence of mental disorders in migrants living in limbo, the association between limbo and mental illness, and the experiences of these migrants in high income countries. We searched electronic databases for quantitative and qualitative studies published after January 1, 2010, on mental illness in precarious migrants living in HICs and performed a meta-analysis of prevalence rates. Fifty-eight articles met inclusion criteria. The meta-analysis yielded prevalence rates of 43.0 % for anxiety disorders (95 % CI 29.0-57.0), 49.5 % for depression (40.9-58.0) and 40.8 % for posttraumatic stress disorder (30.7-50.9). Having an insecure status was associated with higher rates of mental illness in most studies comparing migrants in limbo to those with secure status. Six themes emerged from the qualitative synthesis: the threat of deportation, uncertainty, social exclusion, stigmatization, social connection and religion. Clinicians should take an ecosocial approach to care that attends to stressors and symptoms. Furthermore, policymakers can mitigate the development of mental disorders among migrants by adopting policies that ensure rapid pathways to protected status.

The COVID-19 pandemic as traumatic stressor: Distress in older adults is predicted by childhood trauma and mitigated by defensive functioning.

OBJECTIVE: It has been broadly anticipated that COVID-19 pandemic-related experiences may constitute traumatic stressors, and that older adults' might be especially at risk of experiencing mental health symptoms during the pandemic. The present study aimed to examine older adults' psychological distress: posttraumatic stress, Covid-related fears, anxiety, and depression during the pandemic, and the relationship between present distress, defensive functioning, and childhood trauma. We also explored potential differences between older adults (between 65 and 74 years), and older-older adults (75 years and above). METHOD: A large-scale online survey was conducted during the early months of the pandemic, for the present study, we included participants above 65 years old (N = 1,225) mainly from the United States and Canada. RESULTS: Results showed that age, adverse childhood experiences, and overall defensive functioning were significantly related to posttraumatic stress, anxiety, and depression. Specifically, younger age and more reported childhood adversity were related to higher distress, whereas the use of more adaptive defenses was related to less distress. Covid-related fears were not associated with age. Our final model showed that defensive functioning mediated the relationship between childhood trauma and distress. CONCLUSIONS: Our results support the relative resilience of older-older adults compared to older adults, as well as the long-lasting impact of childhood adversity through defensive functioning later in life, specifically in times of heightened stress, such as the COVID-19 pandemic. Future studies are warranted to identify further factors affecting defensive functioning as adults age, as well as processes that are associated with resilience in response to stressors in older adulthood. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Defense mechanisms are associated with mental health symptoms across six countries.

Defense mechanisms are adaptative processes that are related to mental health and psychological functioning and may play an important role in adaptation to distress, as well as in mental health interventions. The present study aimed to compare the use of defense mechanisms and their relationship to mental health symptoms across six countries. In a large-scale descriptive study, we collected data from community- based individuals (N=19,860) in the United States, Australia, Canada, Germany, Italy, and the United Kingdom about the use of defense mechanisms and experienced mental health symptoms during the early phase of the pandemic. We found that the use of defense mechanism categories was similar across countries. Moreover, lower defensive functioning, specifically, neurotic and immature defenses were related to experiencing higher distress across countries, whereas mature defenses were generally inversely related to symptoms. Furthermore, these findings were relatively similar across the six countries. Cross-cultural research on defense mechanisms and mental health has important clinical implications. Our results are consistent with the goal of promoting more adaptive defensive functioning to increase psychological well-being and mitigate the detrimental impact of situational stress.

Psychometric Properties of the Defense Mechanisms Rating Scales-Self-Report-30 (DMRS-SR-30): Internal Consistency, Validity and Factor Structure.

Assessment of defense mechanisms has a longstanding history within the clinical psychology and psychopathology literature. Despite their centrality to clinical practice, there are few self-report measures that assess defenses and, those that do exist, have limitations in addressing individual defenses and levels of defensive functioning. To address this need, we investigated the psychometric properties of the Defense Mechanisms Rating Scale - Self-Report - 30 item (DMRS-SR-30) with a global, community sample of 1,539 participants who responded to an online survey about distress and coping. Exploratory factor analysis found a three-factor model for the DMRS-SR-30 - mature, mental inhibition and avoidance, and immature-depressive. Internal consistency was high for the Overall Defensive Functioning (ODF) and the three extracted factors with coefficient alphas ranging from .75 to .90. Examination of concurrent validity with a commonly used measure of defensive functioning found significant relationships in the predicted directions. The group of immature defenses had the strongest concurrent validity (r = .50). Finally, correlations with external criteria - including psychological distress and adverse childhood experiences - supported the convergent and discriminant validity of the DMRS-SR-30. The three factor structure of the DMRS-SR-30 has good psychometric properties. Limitations and directions for future research, as well as clinical implications, are described.

The Hierarchy of Defense Mechanisms: Assessing Defensive Functioning With the Defense Mechanisms Rating Scales Q-Sort.

The psychodynamic concept of defense mechanisms is nowadays considered by professionals with various theoretical orientations of great importance in the understanding of human development and psychological functioning. More than half century of empirical research has demonstrated the impact of defensive functioning in psychological well-being, personality organization and treatment process-outcome. Despite the availability of a large number of measures for their evaluation, only a few instruments assess the whole hierarchy of defenses, based on the Defense Mechanisms Rating Scales (DMRS), which arguably offers an observer-rated gold standard of assessment. The present article illustrates the theoretical and methodological background of the DMRS-Q, the Q-sort version of the DMRS for clinical use. Starting from the definition and function of the 30 defense mechanisms included in the hierarchy, we extracted 150 items that captured a full range of defensive manifestations according to the DMRS theory. The DMRS-Q set is described in this paper with reference to the DMRS manual. Directions are also provided for using the DMRS-Q online software for the free and unlimited coding of defense mechanisms. After each coding, the DMRS-Q software provides a report including qualitative and quantitative scores reflecting the individual's defensive functioning. Qualitative scores are displayed as the Defensive Profile Narratives (DPN), while quantitative scores are reported as Overall Defensive Functioning (ODF), defensive categories, defense levels, and individual defense mechanisms. Syntax for the scoring is displayed in the results and a clinical vignette of a psychotherapy session coded with the DMRS-Q is provided. The DMRS-Q is an easy-to-use, free, computerized measure that can help clinicians in monitoring changes in defense mechanisms, addressing therapeutic intervention, fostering symptoms decreasing and therapeutic alliance. Moreover, the DMRS-Q might be a valid tool for teaching the hierarchy of defense mechanisms and increase the observer-rated assessment of this construct in several research fields.

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

Despite many theoretical and clinical writings, the theorized connection between defense mechanisms and adult attachment in depressed patients has received little empirical attention. This is the first study to examine patients' defense mechanisms in relation to their attachment in a clinical sample of depressed patients and also the first to use observer-rated measures for assessing both defense mechanisms and attachment. In this pilot study, we aimed to investigate the relationship between patients' attachment and their use of defense mechanisms in psychotherapy sessions, as well as patterns of change over treatment. We conducted a secondary analysis of data from a randomized controlled trial of 30 patients receiving psychotherapy for major depression. Session transcripts were previously coded for defense mechanisms using the Defense Mechanisms Rating Scales, and depression severity data were collected by the clinician-rated HRSD-17 and the self-report BDI-II. Patients' attachment was assessed in two transcripts, one in an early session and a second in a late session, using the novel observer-rated Patient Attachment Coding System. In contrast with expectations, in the early phase of therapy, preoccupied attachment-related characteristics were significantly positively related to overall defensive functioning and negatively related to Depressive immature defenses. In the late phase of treatment, preoccupied attachment-related characteristics were negatively correlated with Non-depressive immature defenses. Moreover, as expected, early-phase defense use was related to late phase attachment; specifically, early neurotic and immature Depressive and Non-depressive defenses predicted an increase in avoidant, whereas immature Non-depressive defenses predicted a decrease in preoccupied attachment-related characteristics over the course of treatment, after controlling for early attachment effects. The results imply a longitudinal relationship between defenses and change in attachment-related characteristics over the course of treatment in a depressed sample and warrant further research about the relationship between defenses and attachment during psychotherapy.

A Naturalistic Study of Time to Recovery in Adults with Treatment-refractory Disorders.

Objectives: Individuals with treatment-refractory disorders have high comorbidity. There is little information on whether recovery is possible and how long it might require. We focused on the individual's recovery using a broad measure of psychopathology, regardless of the variety of disorders present.Methods: We recruited 226 adults [mean age 31.0, SD = 10.3; 75.2% female] entering residential treatment for treatment-refractory disorders to delineate their course and outcome. Individuals received periodic Longitudinal Interval Follow-along Evaluation interviews for symptoms and functioning variables for up to 14 years. Periodic psychodynamic and relationship vignette interviews were rated with the Psychodynamic Conflict Rating Scales (PCRS) for a subgroup of 54 subjects. Outcome variables included modeled rates of change, final scores, time to recovery, and time to attaining healthy adaptive functioning, using Kaplan-Meier estimates from time-to-event analyses.Results: Recovery of PCRS Pathological Functioning occurred in 12 (22%) of 54 subjects rated: median time-to-recovery = 11.63 years (CI: 9.64- upper number not calculable). Eight (14.81%) subjects also developed healthy adaptive functioning, with the time-to-attainment for the first quartile at 10.95 years (CI: 7.87 - upper bound not calculable). Recovery from psychopathology was significantly associated with a median percentage recovered in the domains of symptoms (64.29%), functioning (87.50%), and psychodynamic functioning (50%). Although attaining healthy adaptive functioning was less common, it was highly associated with already achieving recovery from dynamic psychopathology, [OR = 57.40, CI 5.80 - 567.83, p = .0001].Conclusions: These results provided convergent validation of recovery in psychodynamic psychopathology. Some recovered individuals also attained healthy adaptive functioning, which took somewhat longer.

Change in Defense Mechanisms and Depression in a Pilot Study of Antidepressive Medications Plus 20 Sessions of Psychotherapy for Recurrent Major Depression.

Treatment studies of major depression commonly focus on symptoms, leaving aside change in putative psychological risk factors. This pilot study examines the relationship between changes in eight depressive defenses and depressive symptoms. Twelve adults with acute recurrent major depression were given antidepressive medications and randomized to 20 sessions of either cognitive behavioral therapy or dynamic psychotherapy and followed for 1 year. Defenses were assessed using the Defense Mechanism Rating Scales (DMRS) and Defense Style Questionnaire (DSQ) at intake, termination, and 1-year follow-up. Depression improved highly significantly on both the Hamilton Rating Scale for Depression and Beck Depression Inventory, respectively, eight (67%) and nine (75%) patients attained recovery by 1 year. Depressive defenses improved significantly by termination (mean ES = 0.97; 95% confidence interval, 0.30-2.16), but retrogressed somewhat by 1 year. A mean of 12.17% (SD = 10.60) depressive defenses remained; only five subjects (50%) attained normative levels. Although causal relationships were not established, depressive defenses are promising candidates for mediating treatment effects on outcome of major depression.

The Role of Defense Mechanisms in Emerging Personality Disorders in Clinical Adolescents.

Background: Defensive functioning is related to overall mental functioning and personality traits in adults but only few studies investigated the role of defenses in adolescence. The present study analyzed the use of defense mechanisms in clinical adolescents to test how defensive functioning is related to age, gender, and personality traits.Design: 102 self-referred outpatients were interviewed using the Clinical Diagnostic Interview (CDI). Defense mechanisms and personality profile were assessed using the Defense Mechanisms Rating Scale (DMRS) and the Shedler-Westen Assessment Procedure-200 for Adolescence (SWAP-200-A) respectively.Findings: Multivariate analysis of variance showed significant age and gender differences in clinical adolescents; while younger teenagers used more immature defenses, older adolescents scored significantly higher in high-neurotic and mature defenses. Girls showed higher use of minor image distortion and neurotic defenses, whereas boys recurred more frequently to obsessional level defenses. Neither age nor gender differences were found for narcissistic defense level. Significant correlations between personality disorders and specific defenses were found for all personalities with sufficient base rate, with the exception of paranoid, schizotypal, and schizoid personalities.Conclusions: In line with previous studies we confirmed the hypothesis of an ontogenetic line of development of defense mechanisms. In addition, the present study found that age and gender differences in adolescence are related to the use of specific defenses that contribute to the development of the personality and various psychological capacities. Several clinical implications are linked to the systematic investigation of defense mechanisms in youth, although further studies are required to confirm these findings.

Coping Action Patterns as Mechanisms of Change Across Psychotherapies: Three Case Examples of Personality Disorders With Recurrent Major Depression.

Maladaptive coping has been shown to be related to increased symptoms of distress and lower levels of well-being, whereas the use of adaptive coping has been shown to diminish distress and improve functioning. This suggests that change in coping may constitute a significant mechanism of change in psychotherapy. Utilizing a novel observer-rating method for assessing coping, the current report examined changes in overall coping functioning (OCF) in three participants with diverse personality disorders who were undergoing two different types of psychotherapy (cognitive-behavioral therapy and dynamic therapy) for recurrent major depression. Results showed that overall coping functioning improved in two cases and remained stable in a third. Preliminary findings, based on a detailed examination of changes in specific coping patterns, suggest that improvement may differ according to severity of personality pathology. As hypothesized, coping improved in both types of psychotherapy. Thus, overall results suggest that coping may constitute an important general mechanism of change.

Psychological masochism: A systematic review of the literature on conflicts, defenses, and motives.

OBJECTIVE: Our aim was to conduct a systematic review of the literature on psychological masochism to identify hypotheses for examination in clinical studies. METHOD: We identified defenses, conflicts, and motives using standardized measures in 23 psychoanalytic papers. RESULTS: Three primary and three secondary subtypes of masochism emerged in the literature. Overall Gratification Inhibition (subtype I.1) was the "healthiest" form, associated with higher developmental level motives and neurotic defenses. The Global Conflict (I.2) was the least healthy form of masochism, consistent with personality disorder. It was associated with early developmental level motives and immature defenses, including depressive defenses, often associated with depression. Dominant Other (I.3) represented masochistic attachment problems, associated with early developmental level motives, object-related, image-distorting defenses, and narcissism. Of the secondary types, Separation-Abandonment (II.1) reflected object-related defenses, and separation-related motives. Rejection of Others (II.2) represented a sadistic-narcissistic form, associated with image-distorting and disavowal defenses, with both early and later developmental level motives. Finally, Sexual Pleasure vs. Guilt (II.3) was associated with autistic fantasy, and both early and later developmental level motives, suggesting a distinct traumatic origin and representing the juncture of sexual and psychological masochism. CONCLUSIONS: Analysts described six distinguishable types of masochism. Future studies should examine their validity.

The Rate of Improvement in Long-Term Dynamic Psychotherapy For Borderline Personality Disorder.

Controlled trials of psychotherapy and follow-up studies of borderline personality disorder (BPD) have shown significant, but usually limited, improvement. We examined the hypothesis that BPD changes more slowly than nonborderline disorders. In a study of long-term dynamic psychotherapy, 16 subjects with BPD and 35 with non-BPD disorders were treated for a median of 3 years with a follow-up of 5 years. From periodic assessments, we calculated the rate of change for each subject over the course of the study on each measure of symptoms and functioning. At intake, borderline psychopathology was associated with higher levels on 76% of 17 measures of comorbid axis I disorders, symptoms, and functioning. BPD psychopathology was associated with faster (not slower) rates of improvement on three measures, but after controlling for the initial level of each measure, there were no significant associations. These findings counsel both optimism and patience in the long-term treatment of patients with BPD.

Masochism: A Mixed-Method Analysis of Its Development, Psychological Function, and Conceptual Evolution.

This article reviewed the concept of masochism by using a mixed-method approach to analyze 23 publications from 1924 to 2012 by authors from different psychoanalytic schools. Qualitative analysis showed that most authors emphasized painful early attachments, early injury of self-representation, identification with an abusing parent, and narcissistic injury as core experiences in the early childhood of patients with masochism. The main psychological function of masochism was described as a way of avoiding uncontrollable suffering by willingly undertaking other, milder, more controllable suffering. Quantitative analyses using standardized measures of conflicts, defenses, and motives revealed that most authors described early, global psychodynamic conflicts, developmentally early motives, and both action-level and neurotic defenses in masochism. Correlation analyses showed that although the main ideas in the concept of masochism remained stable over time, emphasis on certain aspects changed. The findings provide a conceptual overview of masochism and hypotheses for further clinical studies.

The Computerized Implicit Representation Test: Construct and incremental validity.

Discrepancies in mental representations between self-aspects and significant others are associated with depression, personality disorders, emotional reactivity, and interpersonal distress. The Computerized Implicit Representation Test (CIRT) is a novel measure developed to assess discrepancies in mental representations. Inpatient participants (N = 165) enrolled in a longitudinal study completed baseline CIRT ratings of similarity between self-aspects (actual-self, ideal-self, and ought-self) and between actual-self and significant others (mother, father, liked others, and disliked others). Based on the similarity ratings, multidimensional scaling was utilized to generate distances between key self- and other representations in three-dimensional space. Results of univariate linear regression analyses demonstrated that discrepancies (distances) between self-aspects, actual-self to others, and actual-self to mother were significantly associated with impulsive and self-destructive behaviors and/or lifetime anxiety disorders. Multivariate hierarchical linear regression models further indicated that three CIRT variables provided incremental validity above and beyond age, gender, and/or borderline personality disorder.

Assessing Psychodynamic Conflict.

Psychodynamic psychotherapies suggest that symptomatic relief is provided, in part, with the resolution of psychic conflicts. Clinical researchers have used innovative methods to investigate such phenomenon. This article aims to review the literature on quantitative psychodynamic conflict rating scales. An electronic search of the literature was conducted to retrieve quantitative observer-rated scales used to assess conflict noting each measure's theoretical model, information source, and training and clinical experience required. Scales were also examined for levels of reliability and validity. Five quantitative observer-rated conflict scales were identified. Reliability varied from poor to excellent with each measure demonstrating good validity. However a small number of studies and limited links to current conflict theory suggest further clinical research is needed.

Defensive Functioning Among Women With Breast Cancer and Matched Community Controls.

OBJECTIVE: The general theory of defense mechanisms posits that stress is associated with using defenses lower on the hierarchy of defensive adaptation. Some have observed that individuals with cancer use certain defenses, such as repression, denial, and immature defenses. This cross-sectional study examined four hypotheses about defensive functioning in a sample of women who are mothers with a recent history of breast cancer (BC), compared to a matched sample of healthy mothers in the community. METHOD: We rated defenses from interview transcripts about interpersonal vignettes, using the Defense Mechanism Rating Scales quantitative method. Measures of symptoms and functioning were also gathered. RESULTS: The BC group displayed lower (z = 5.39, df = 1,231, p < .0001) overall defensive functioning than controls: 5.32 [95% CI: 5.13 to 5.51] versus 5.63 [95% CI: 5.50 to 5.76], which is equivalent to a medium effect size (0.62). Compared to controls, the BC group displayed more denial, idealization, displacement, isolation of affect, and splitting of others' images; conversely, they used less altruism, anticipation, intellectualization, and undoing. Controls used a mixture of high adaptive (35.5%), neurotic (43.0%), and immature defenses (21.4%). In contrast, the BC group used fewer high adaptive (30.7%) and neurotic (38.8%) and more immature defenses (30.5%). Both groups scored in relatively healthy ranges on other measures. Correlations with other measures supported the hierarchy of defense adaptiveness. CONCLUSIONS: The relationships among stress, defensive functioning, and adaptation were largely as predicted. Future studies should examine defenses in the process of seeking care, diagnosis, and treatment response for breast cancer.

Phenomenology in need of treatment: commentary for the special series "Narcissistic personality disorder--new perspectives on diagnosis and treatment".

Comments on the articles by A. E. Skodol et al. (see record 2013-24395-001), E. Ronningstam (see record 2014-42878-005), D. Diamond et al. (see record 2014-42878-004), and A. L. Pincus et al. (see record 2014-01439-001). Good delineation of the phenomenology of narcissistic personality disorder (NPD) is necessary but insufficient for informing us on what to do clinically. Perry suspects that we will see reams of publications comparing Section III and II diagnoses with various external measures and possibly experimental procedures. We will learn some important things, along with many facts without actionable consequences. However, because NPD does not show many differential relationships to particular functional measures, I believe that treatment studies will likely be the most informative.

Development of a Q-sort version of the Defense Mechanism Rating Scales (DMRS-Q) for clinical use.

This report focuses on the need to provide clinicians with a reliable and valid measure for detecting patient defense mechanisms "inside psychotherapy." To avoid the limitations of existing methods, we designed a Q-sort based on the theoretical definitions and criteria of the Defense Mechanisms Rating Scales (DMRS-Q), but one that does not require transcripts of clinical interviews or sessions and may be applied without specific training on defenses. The DMRS-Q is sensitive to changes in psychotherapy and its scores correlate significantly with various aspects of mental functioning, making it potentially available for the psychotherapy process and outcome research as well. We report the results of using the DMRS-Q on a systematic single case study with the aim of detecting changes in defense mechanisms during a long-term psychodynamic psychotherapy. The DMRS-Q reveals change both in quantitative scores and in the literary Defensive Profile Narrative.