Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

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

The Hierarchy of Defense Mechanisms: Assessing Defensive Functioning With the Defense Mechanisms... fpsyg-12-718440 October 11, 2021 Time: 15:58 # 1 METHODS published: 15 October 2021 doi: 10.3389/fpsyg.2021.718440 The Hierarchy of Defense Mechanisms: Assessing Defensive Functioning With the Defense Mechanisms Rating Scales Q-Sort 1 2 Mariagrazia Di Giuseppe and J. Christopher Perry 1 2 Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy, McGill University Department of Psychiatry at the Institute of Community and Family Psychiatry, Jewish General Hospital, Montreal, QC, Canada 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. Edited by: Despite the availability of a large number of measures for their evaluation, only a few Annalisa Tanzilli, instruments assess the whole hierarchy of defenses, based on the Defense Mechanisms Sapienza University of Rome, Italy Rating Scales (DMRS), which arguably offers an observer-rated gold standard Reviewed by: of assessment. The present article illustrates the theoretical and methodological Attà Negri, University of Bergamo, Italy background of the DMRS-Q, the Q-sort version of the DMRS for clinical use. Starting Laura Muzi, from the definition and function of the 30 defense mechanisms included in the University of Perugia, Italy Emanuela Brusadelli, hierarchy, we extracted 150 items that captured a full range of defensive manifestations University of Wollongong, Australia according to the DMRS theory. The DMRS-Q set is described in this paper with *Correspondence: reference to the DMRS manual. Directions are also provided for using the DMRS-Q Mariagrazia Di Giuseppe online software for the free and unlimited coding of defense mechanisms. After each [email protected] coding, the DMRS-Q software provides a report including qualitative and quantitative Specialty section: scores reflecting the individual’s defensive functioning. Qualitative scores are displayed This article was submitted to as the Defensive Profile Narratives (DPN), while quantitative scores are reported Psychopathology, a section of the journal as Overall Defensive Functioning (ODF), defensive categories, defense levels, and Frontiers in Psychology individual defense mechanisms. Syntax for the scoring is displayed in the results and Received: 31 May 2021 a clinical vignette of a psychotherapy session coded with the DMRS-Q is provided. Accepted: 24 September 2021 Published: 15 October 2021 The DMRS-Q is an easy-to-use, free, computerized measure that can help clinicians Citation: in monitoring changes in defense mechanisms, addressing therapeutic intervention, Di Giuseppe M and Perry JC fostering symptoms decreasing and therapeutic alliance. Moreover, the DMRS-Q might (2021) The Hierarchy of Defense Mechanisms: Assessing Defensive be a valid tool for teaching the hierarchy of defense mechanisms and increase the Functioning With the Defense observer-rated assessment of this construct in several research fields. Mechanisms Rating Scales Q-Sort. Front. Psychol. 12:718440. Keywords: defense mechanism, DMRS, Q-sort, assessment, personality, emotion regulation, psychotherapy, doi: 10.3389/fpsyg.2021.718440 process-outcome Frontiers in Psychology | www.frontiersin.org 1 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 2 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q not included in the DMRS manual although they can be INTRODUCTION assessed using another DMRS-derived measure, the Psychotic- The psychodynamic concept of defense mechanisms, defined DMRS (P-DMRS; Berney et al., 2014; Boldrini et al., 2020). as automatic psychological mechanisms that mediate the Defense levels can be further organized into three defensive individual’s reaction to emotional conflicts and to internal or categories of relatively similar degree of maturity, often used external stressors (American Psychiatric Association, 2013; Perry, for describing in summary the individual defensive functioning. 2014), has been extensively studied since its first appearance The three defensive categories, from the least to the most in Freud’s psychoanalytic theory (Freud, 1894). After a century adaptive, respectively, include immature, neurotic and mature of clinical and theoretical work, and a quarter century of defenses. The immature defensive category is the most populated empirical research, an assessment of defense mechanisms was and includes all defenses belonging to action, disavowal and included in an Axis for the assessment of defense mechanisms both image distortion defense levels. This defensive category in the DSM-IV (Cramer, 1987, 2015; Kernberg, 1988; American can be further divided into two subcategories. The first is Psychiatric Association, 1994; Hoffman et al., 2016). The main named depressive defenses, including acting out, help-rejecting contribution to the gold-standard approach to the study of complaining, passive aggression, splitting of self-image, splitting defense mechanisms has been provided by the theory of of other’s image, projective identification, projection, devaluation defensive adaptiveness and the hierarchical organization of of self-image, and devaluation of other’s image. The second defense mechanisms proposed by Vaillant (1971, 1992) and subcategory is the non-depressive defenses, including denial, operationalized by Perry (1990). In his extensive and valuable rationalization, autistic fantasy, omnipotence, idealization of work, Vaillant described excellent clinical vignettes of defenses self-image, and idealization of other’s image. Greater reliance as they operate in real life – both in momentary examples, and on immature defenses informs on the subject’s defensive those that recur over time – and integrated findings from several vulnerability and his or her scarce awareness of both emotional longitudinal studies demonstrating the evolution of defense and cognitive sides of internal conflicts or external stressful mechanisms over the life cycle. With the development of the situations. These defenses inhibit awareness of unacceptable Defense Mechanisms Rating Scales (DMRS), Perry has provided a ideas, feelings, and actions, bypassing them to protect oneself comprehensive, accurate and valid observer-rated methodology from feeling threatened. for assessing individual’s defensive functioning based on the The neurotic defensive category represents the middle-range whole hierarchy of defense mechanisms (Perry and Henry, 2004). of adaptiveness and includes all defenses belonging to neurotic In recent years, the authors of this paper have adapted the and obsessional defense levels. High use of these middle-range DMRS theory to additional assessment methods, by developing defenses describes the individual’s ability to deal with either both the Q-sort version (DMRS-Q; Di Giuseppe et al., 2014) the emotional or the cognitive side of internal or external and the self-report version (DMRS-SR-30; Di Giuseppe et al., stressors, which can be handled one at a time. These defenses 2020a) of the DMRS. Our main aim was to provide new measures help the individual in keeping out of awareness parts of the based on the DMRS theory of defense mechanisms applicable in conflict (e.g., associated feelings, desires and thoughts), which different clinical or research contexts, without the requirement would generate intolerable anxiety if perceived as an integrated of training for their valid and reliable use (Békés et al., 2021; psychological experience. Finally, the mature defensive category Conversano and Di Giuseppe, 2021). In this article, we describe corresponds to the high-adaptive defense level and includes theoretical background, coding procedure, scoring system and the most adaptive defense mechanisms, which overlap with results interpretation of the DMRS-Q, a computerized observer- what are called positive coping strategies in other theoretical rated Q-sort for the assessment of defense mechanisms in frameworks. High use of mature defenses fosters the integrated clinical setting. and partially aware experience of feelings, ideas, desires and thoughts associated to an internal conflict or external stressful The Hierarchy of Defense Mechanisms situation. These defenses help the individual in dealing with All DMRS-based measures refer to the generally accepted his or her psychologically stressful experiences by integrating hierarchy of defense mechanisms (American Psychiatric affects with ideas, therefore optimizing and possibly resolving the Association, 1994, 2013; Hoglend and Perry, 1998; Lingiardi internal or external cause of distress (Vaillant, 1977, 1992). This et al., 1999; Drapeau et al., 2003; Hilsenroth et al., 2003; Perry, tripartite model of DMRS hierarchical organization of defenses 2014; Di Giuseppe et al., 2019, 2021; Tanzilli et al., 2021). is often used for summarizing the defensive maturity of an A graphical summary of the hierarchy of defense mechanisms is individual by looking at the proportional scores obtained in each shown in Figure 1. of the three defensive categories. This hierarchy describes 30 defense mechanisms organized For a deeper understanding of individual’s defensive into seven defense levels, each of which has some general functioning, the seven defense levels can be used as the generally functions that the constituent defenses share in how they protect accepted hierarchical organization of defense mechanisms the individual from anxiety, or a sense of threat from internal or (American Psychiatric Association, 1994). Defense levels external sources, or conflicts. differentiate one from another for their defensive function In addition to the seven defense levels, there is level and level of adaptiveness, which are described in Table 1. 0, describing defensive dysregulation, the so-called Psychotic Their assessment may inform about the most used defensive Defenses Level. Defenses belonging to this defense level are patterns, which reveal what defensive function is more frequently Frontiers in Psychology | www.frontiersin.org 2 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 3 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q FIGURE 1 | The DMRS hierarchical organization of defensive categories, defense levels and individual defenses. Table adapted from Perry and Bond (2012), Table 1. So-called depressive defenses are in bold. activated in response to internal conflicts or external stressors. Training individuals to rate defenses reliably is time For example, two individuals who use 40% of defenses belonging consuming, as are making the ratings themselves, both of which to the neurotic defensive category can have a very different limit the use of such ratings in clinical setting. While the DMRS is defensive profile depending on whether they use a more necessary for some types of research, we developed the DMRS-Q obsessional or neurotic defense level. Similarly, high use of to meet the needs of a quicker, more user-friendly computerized action and major image-distorting defense levels is very different tool for the assessment of defense mechanisms in clinical setting from high use of disavowal and minor image-distorting defense (Di Giuseppe et al., 2020b,c). levels, although they are all included in the immature defensive The present article aims to illustrate the DMRS-Q and category. Furthermore, these differentiations among individuals’ its assessment and scoring methodology. We will provide the defensive functioning are extremely evident when we look at the definition and function of 30 defense mechanisms as reported in deepest level of investigation, the individual’s use of 30 individual the DMRS manual (Perry, 1990) and present the five DMRS-Q defense mechanisms. items corresponding to each defense mechanisms. Moreover, we Frontiers in Psychology | www.frontiersin.org 3 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 4 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 1 | The defensive function of the seven hierarchically ordered defense levels. Level 7: High adaptive High adaptive defenses are the individual’s most adaptive ways of handling stressors and are often considered synonymous of positive defenses coping. Internal or external stressors are fully perceived without distortion and the need to adapt to them is fully appropriated to oneself. The individual attempts to maximize the positive expression and gratification of his or her own motives, acknowledging limitations of the self and recurring to external sources of help when available. Level 6: Obsessional Obsessional defenses protect the individual from the awareness of unacceptable or threatening feelings associated with an idea (e.g., wish, defenses fear, experience, memory, or though) by keeping distance from emotions, while remaining aware of the idea itself. As a result, feelings (emotional component) are largely kept out of awareness and indirectly expressed throughout minimization, generalization, or a series of contradictory statements. Level 5: Neurotic Neurotic defenses reflect the experience that awareness of a wish, thought, or motive is unacceptable or threatening and must be kept out of defenses awareness. The individual can experience feelings associated to an internal conflict or external stressor as long as full awareness of the idea (cognitive component) is blocked and expressed indirectly by way of a series of anomalous clues. Neurotic defenses are the most protean of all defense mechanisms, in that there are a seemingly infinite variety of ways to give partial expression of repressed ideas. Level 4: Minor Minor image-distorting defenses protect the individual from experiences that affect one’s self esteem, such as failure, criticism, or image-distorting disappointment that cause feelings of weakness, powerlessness, or shame. These defenses temporarily prop up self-esteem and strengthen defenses self-image by using image-distortion to dismiss any threatening aspect of the stressor. These distortions are not all encompassing like those of the major image-distorting defenses. Nonetheless, they don’t actually improve adaptation to the stressors. Level 3: Disavowal Disavowal defenses reflect the perception of the individual that some aspects of internal experience external reality are unacceptable. By defenses and autistic refusing to acknowledge these aspects of experience, the individual justifies not appropriating a problem as his or her own. The individual can fantasy further misattribute the problem to another source or reason, further covering up internal reality. This results in a failure both to acknowledge one’s own role in the origins of a problem and to consider potential ways of handling the immediate problem, given the assertion that one has no such role. Level 2: Major Major image-distorting defenses protect the individual from intolerable anxiety when self or object representations of conflicting meaning are image-distorting triggered. The individual keeps positive and negative representations separated and simplify the perception of self and others as either all defenses good, powerful, and invulnerable or all bad, unworthy, powerless, and vulnerable. The individual then treats these distorted images in ways consistent with this perception. These defenses protect the self from the anxiety attending a sense of imminent threat of being punished, physically or psychologically abused, abandoned, or even killed. However, oversimplifying self or others and reacting accordingly produces the negative consequent that others withdraw or react negatively. Level 1: Action Action defenses reflect the perception of the individual that the immediate source of stress or conflict is external and that the experience is defenses intolerable. The individual’s perception overlooks the internal sources of the distress, such as personal unacceptability of or limitations in awareness of one’s own wishes, fears, and inhibitions. Unable to contain attendant distress, these defenses operate to engage, manipulate, or counterattack the apparent external source. These defenses lead the individual to impulsive action on the environment or oneself, thereby releasing tension, gratifying wishes, and/or avoiding fears. However, this is done without anticipating negative consequences. Extensive description of defense levels published in Perry (2014). will provide instructions for coding defenses with the DMRS- the coverage of manifestations of each DMRS defense, rather Q online software and syntax for the scoring. Finally, we than on maximizing internal consistency of the items to will provide directions for data interpretations of the DMRS-Q overall defense score. This methodological approach was based qualitative and quantitative output. on author’s hypothesis that reproducing the widely validated DMRS in an easy-to-use Q-sort version would guarantee strong psychometric properties because of the gold-standard theoretical background. Although we are aware that this is far from the METHODS usual methodological approach applied for the development of new psychometric tools, our preliminary analyses on validity Measure Development and reliability of the DMRS-Q (Di Giuseppe et al., 2014; Békés Based on the DMRS definition and function, and discriminations et al., 2021; Tanzilli et al., 2021) confirmed our hypothesis on from near-neighbor defenses, we developed a pool of 300 items – the importance of a strong theoretical base for a measure with 10 statements for each defense mechanism – that refer to statistically relevant properties. verbal and nonverbal expressions, distorted perceptions, personal mental states, relational dynamics, and way of coping that Definitions and Function of Defense emerge on occasions when the subject experiences internal or Mechanisms and Defense Mechanisms external stress or conflict. A group of researchers trained on the DMRS was asked to indicate the five items for each defense Rating Scales Q-Sort Items mechanism that best captured a full range of manifestations The DMRS-Q provides five items for each of the 30 defense according to the DMRS criteria. Following reviewers’ comments mechanisms included in the hierarchy. A comprehensive and basing on item’s clarity, simplicity, and non-redundancy, overview of definitions, functions and DMRS-Q items is we selected the best five items for each defense mechanisms provided below. Tables 2–8 display DMRS-Q items for each obtaining a final set of 150 items that constitute the DMRS- defense included in each defense level; they are reported Q. We decided to select the DMRS-Q item pool, based on in descending order of defensive maturity. The following descriptions of the individual defenses are reproduced or adapted https://webapp.dmrs- q.com/login from the DMRS manual (Perry, 1990), with permission of the Frontiers in Psychology | www.frontiersin.org 4 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 5 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q author, JP to provide the definitional basis for the DMRS-Q High-Adaptive Defense Level: Anticipation items in Tables 2–8. Definition The individual mitigates emotional conflicts, or internal or High-Adaptive Defense Level: Affiliation external stressors, by not only considering realistic, alternative Definition solutions and anticipating emotional reactions to future The individual deals with emotional conflicts, or internal or problems, but experiencing the future distress by mentally external stressors, by turning to others for help or support. bringing the distressing ideas and affects together. This rehearsal By affiliating with others, the individual can express him or allows the individual to prepare a better adaptive response to the herself, confide problems, and feel less alone or isolated with anticipated conflict or stressor. a conflict or problem. This may also result in receiving advice Function or concrete help from the “auxiliary ego” that improves the Using anticipation allows the individual to mitigate the effects individual’s ability to cope. Confiding leads to an increase in of future stressors or conflicts. It requires being able to tolerate the individual’s coping capacity as the other individual supplies the anxiety attendant to imagining how a future situation may emotional validation and support. Affiliation does not include be distressing. By affective rehearsal (e.g., ‘how will I feel trying to make someone else responsible for dealing with one’s when this occurs?’) and planning future responses, the subject own problems, nor does it imply coercing someone to help, or decreases distressing aspects of the future stressor. Anticipation acting helpless to elicit help. Affiliation is not shown simply by also increases the likelihood of positive external outcomes and belonging to an organization (e.g., church, social club, Alcoholics more positive emotional responses. Anonymous) or by seeing a counselor or therapist. Rather it is demonstrated by the give and take around conflicts and problems High-Adaptive Defense Level: Humor that occurs in the context of belonging to the organization, or by Definition the confiding with others. The individual deals with emotional conflicts, or internal or external stressors, by emphasizing the amusing or ironic aspects Function of the conflict or stressor. Humor tends to relieve the tension Affiliation allies the individual’s emotional attachment needs with around conflict in a way that allows everyone to share in the wish to cope effectively with internal conflict or external it, rather than being at one person’s expense, as in derisive stressors. The ability to cope is enhanced by seeking support or cutting remarks. An element of self-observation or truth from others, while attachment needs are also satisfied. Others is often involved. may enhance the individual’s repertoire of ego skills by help with advice, modeling, planning, judgment, role playing, practicing, Function etc. Usually this is accompanied by a reduction in subjective Humor allows some expression of affects and wishes that are tension achieved through expressing one’s feelings and sharing involved with conflict or stressor. Whenever conflict or external one’s conflicts. stressors block full expression of the affects or satisfaction of wishes, humor allows some symbolic expression of them and of High-Adaptive Defense Level: Altruism the source of the conflict. The frustration emanating from the Definition conflict is transiently relieved in a way that both self and others The individual deals with emotional conflicts, or internal or can smile or laugh at. This is especially evident around issues of external stressors, by dedication to fulfilling the needs of others, the human condition in which certain stressors are inescapable. in part as a way of fulfilling his or her own needs. By using altruism, the individual receives some partial gratification either High-Adaptive Defense Level: Self-Assertion vicariously or as a response from others. The subject is usually Definition aware to some extent that his or her own needs or feelings The individual deals with emotional conflicts, or internal or underlie altruistic actions. There may also be a direct reward external stressors, by expressing one’s feelings and thoughts or overt self-interested reason for the subject’s altruistic actions. directly to achieve goals. Self-assertion is not coercive or indirect To rate altruism present, there must be a clear, demonstrable, and manipulative. The goal or purpose of the self-assertive functional relationship between the individual’s feelings and the behavior is usually made clear to all parties affected by it. altruistic response. Function Function Self-assertion deals with emotional conflict through the direct Altruism gratifies social and attachment needs while dealing expression of one’s feelings or wishes, and thereby relieves the with emotional conflict through helping others. In many cases, anxiety or distress that occurs whenever internal or external the conflict revolves around distress over past examples of countervailing forces prevent expression. Self-assertion does not confronting stressful situations for which one needed help that require that the individual get his or her own way to be successful was somehow unavailable or insufficient. Altruism channels as a defense or adaptive response. Rather, it is also emotionally affects, such as anger, and experiences, such as powerlessness, into useful because it allows the individual to function (1) without the socially helpful responses that also enhance the individual’s sense anxiety or tension that builds whenever feelings and wishes are of mastery over the past. unexpressed and (2) without a sense of shame or guilt for not Frontiers in Psychology | www.frontiersin.org 5 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 6 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q speaking up for oneself in emotionally conflictual situations. The activity which one must do (e.g., not dwelling on tangential emotional consequences are worse when self-assertion is blocked problems in order to deal with one pressing problem). The by internal prohibitions, rather than by external factors alone, individual can call the suppressed material back to conscious such as by a domineering person in authority. attention readily, since it is not forgotten. Function High-Adaptive Defense Level: Self-Observation Suppression keeps both the idea and affect associated with Definition a stressor out of awareness in the service of attending to The individual deals with emotional conflicts, or internal or something else; however, suppressed material may be voluntarily external stressors, by reflecting on his or her own thoughts, brought back into full awareness. Distressing feelings are feelings, motivation, and behavior. The person can “see himself acknowledged but dealing with them is postponed until the as others see him” in interpersonal situations, and as a result is subject feels more able or the timing is more appropriate. better able to understand other people’s reactions to him or her. Neurotic anxiety is minimized, since the material is not repressed, The defense is not synonymous with simply making observations although anticipatory anxiety may still be present until the or talking about oneself. stressor is dealt with. Function This defense allows the person to make the best adaptation to Obsessional Defense Level: Isolation of Affects the demands of external reality based on having an accurate view Definition of one’s own affects, wishes and impulses, and behavior. While The individual deals with emotional conflicts, or internal or self-observation does not change one per se, it is a precursor for external stressors, by being unable to experience simultaneously seeking better adaptations of internal states to external reality. the cognitive and affective components of an experience, because This defense allows the individual to grow and adapt better as the affect is kept from consciousness. In the defense of isolation, he or she deals with stress. the subject loses touch with the feelings associated with a given idea (e.g., a traumatic event) while remaining aware of High-Adaptive Defense Level: Sublimation the cognitive elements of it (e.g., descriptive details). Only the Definition affect is lost or detached while the idea is conscious. It is the The individual deals with emotional conflicts, or internal converse of repression, where the affect is retained but the or external stressors, by channeling rather than inhibiting idea is detached and unrecognized. Sometimes the affect can potentially maladaptive feelings or impulses into socially be detached temporarily from its associated idea. The affect acceptable behavior. This defense is to be rated present only when is felt later without association to the original experience and a strong functional relationship can be demonstrated between idea. Instead, there is an intervening neutral interval between the feelings and response pattern. Classic examples of the use of cognizance of the idea and experience of the associated affects. sublimation are sports and games used to channel angry impulses, Function or artistic creation that expresses conflicted feelings. Individuals who feel threatened by or anxious over the conscious Function experience of feelings can still deal with the related ideas and Sublimation allows the expression of wishes, impulses, or affects events comfortably when their associated affects are separated that the subject voluntarily inhibits because of their potentially and kept out of awareness. Very often the isolated affects are negative social repercussions. The subject channels them instead associated with anxiety, shame, or guilt that would emerge if into socially acceptable expression. The original aims and experienced directly. The tradeoff for avoiding the associated objects of the impulses, wishes, and affects are often modified anxiety, shame, or guilt is that the individual misses out considerably, resulting in a creative activity or product. For on experiencing the feelings in a way that adds evaluative example, a hostile-competitive urge may be channeled into information and which may be useful in making choices. competitive sports or work, or sexual impulses may be expressed through creative dance or art. The result of sublimation is that Obsessional Defense Level: Intellectualization the original impulses, etc. are allowed some expression while the Definition resulting activity or product may also bring some positive social The individual deals with emotional conflicts, or internal or approval or reward. external stressors, by the excessive use of abstract thinking to avoid disturbing feelings. High-Adaptive Defense Level: Suppression Definition Function The individual deals with emotional conflicts, or internal Intellectualization is a defense against affects or impulses in or external stressors, by voluntarily avoiding thinking about which the idea representing the affect or impulse is kept disturbing problems, wishes, feelings, or experiences temporarily. conscious and expressed as a generalization, thereby detaching or This may entail putting things out of one’s mind until the right distancing the subject from the affect or impulse itself. The felt time to deal with them: it is postponing not procrastinating. quality of emotions is lost, as is the urge in any impulse. The Suppression may also entail avoiding thinking about something cognitive elements remain conscious, although in generalized at the time because it would distract from engaging in another or impersonal terms. The subject commonly refers to his or Frontiers in Psychology | www.frontiersin.org 6 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 7 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 2 | High-adaptive defense level: Definition, function and DMRS-Q items of defenses affiliation, altruism, anticipation, humor, self-assertion, self-observation, sublimation, and suppression. Defense DMRS-Q items mechanism Affiliation ITEM 22: Whenever the subject brings a personal problem to someone for help or advice, the subject is not expecting the other to take care of it, but rather to help come up with a solution which the subject will then implement. ITEM 25: The subject describes an important conflict or external stress in which affiliation played a major emotional role in coping as evident by the description of characteristics of the help received, the individuals or organization involved, and the sense that something was taken away from the experience. ITEM 44: When the subject describes seeking help from others, there is a sense of having learned something from the interchange. ITEM 66: When confronted with emotional conflict or stressful situations, the subject describes confiding in someone. Emotionally meaningful sharing led to enhancement of coping skills, or direct assistance beyond what the subject would have done alone. ITEM 93: When dealing with an emotionally difficult situation, the subject reports that talking to others helps the subject think through how best to handle the problem. Altruism ITEM 11: The subject helps others who are experiencing a problem they cannot adequately deal with alone. The problem appears to have a personal meaning to the subject related to similar experiences in the subject’s past (e.g., ‘It made me feel good to help someone in the same position that I once found so difficult.’). ITEM 15: The subject finds it personally rewarding to help others who are suffering. The subject participates in organizations or groups that help other people in direct person-to-person ways. In this context, the subject gives direct help to others, which the subject apparently finds rewarding. ITEM 104: The subject reacts to a difficult or dangerous situation for someone else by interposing him or herself to protect the other person. While not reckless, the subject may put him or herself at personal physical or material risk in doing so. ITEM 132: The subject helps others who are at a loss to cope with a problem or situation, possibly including standing up to authority. It is clear that the subject obtains some personal gratification or mastery from the meaning of helping, beyond any overt reward obtained. Anticipation ITEM 43: Ahead of an important performance or occasion, the subject practices imagining him or herself in the situation to be both better prepared and less anxious. ITEM 46: The subject describes small events in his or her life in which he or she characteristically mentions thinking about their outcomes ahead of time and emotionally preparing in some way for them. ITEM 62: In confronting a new situation or an unknown task, the subject tries ahead of time to be aware of the emotional challenges and plan for whatever resources that will aid and comfort the subject in the new situation. ITEM 65: The subject describes emotionally meaningful vignettes of upcoming stressful situations in which the subject fully prepared him or herself emotionally as to how to handle it. ITEM 78: In dealing with interpersonal conflicts, the subject tries to imagine how others might respond in planning how to deal with them, but without obsessing or over planning. Humor ITEM 18: The subject makes amusing or ironic comments about embarrassing situations to diffuse them. ITEM 37: The subject can make humorous remarks about him or herself or others without saying negative, hurtful, or deprecating things. ITEM 40: In confronting difficult situations which the subject cannot change, the subject uses humor about the situation to mitigate the negative feelings arising. ITEM 51: The subject diffuses a difficult situation with others by making a pertinent joke that centers on some important point that all can acknowledge without being at anyone’s expense, thereby fostering cooperation. ITEM 119: When confronted by a situation fraught with competitive, hostile, or jealous feelings, the subject reveals something about him or herself in a self-deprecatory, ironic, or amusing way to diffuse the tension. Self-assertion ITEM 23: When pursuing something desirable, including a relationship with someone, the subject can use his or her talents and charms to attract the other, without feeling ashamed or guilty if unsuccessful. ITEM 90: When the subject has a physical or emotional or practical problem, the subject takes steps to deal with his or her needs – possibly including initiating getting help – rather than ignore them or hope they will take care of themselves. ITEM 105: When someone is impolite, dismissive, or derogatory toward the subject, the subject can stand up for him or herself appropriately, even if the subject cannot change the other’s attitude or command an apology. ITEM 109: The subject can disagree with others and express opinions without being overly hostile, devaluing, or manipulative of others. ITEM 146: When confronted with emotionally difficult situations, the subject expresses his or her thoughts, wishes, or feelings clearly and directly without inhibition or excess. Self- ITEM 9: When talking with someone about a personally charged topic, the subject displays an accurate view of him or herself and can see how he or she observation appears from the other person’s point of view. ITEM 32: When confronting emotionally important problems, the subject can reflect upon relevant personal experiences and explore emotional reactions. This allows the subject to adjust better to limitations and compromises, possibly leading to more fulfilling outcomes. ITEM 58: In interpersonal conflicts, the subject uses an understanding of his or her reactions to facilitate understanding others’ points of view or subjective experiences. This may make the subject a better negotiator or collaborator. ITEM 77: When considering an emotionally important decision, the subject explores his or her own motives and limitations to arrive at a more fulfilling decision. ITEM 91: When the subject reflects on past experiences, he or she can relive distressing feelings and make connections between events and feelings and develop understanding thereby changing how the subject views the past and possibly similar situations in the present. Sublimation ITEM 14: In describing any personal artistic or creative activities – such as writing, music, art, or acting – the subject appears to transform emotional conflicts or unfulfilled wishes from elsewhere in life, helping to shape the creative activity or product. ITEM 36: The subject describes emotional conflictual situations in which some of the feelings or dissatisfaction are channeled into creative or artistic activities. The resulting creative products – such as a poem or painting – give the subject a sense of mastery or relief from the conflicts. (Continued) Frontiers in Psychology | www.frontiersin.org 7 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 8 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 2 | (Continued) Defense DMRS-Q items mechanism ITEM 63: Whenever engaging in a creative activity, the subject finds the process of creation itself satisfying, apart from any satisfaction with the final product. ITEM 97: Following experiences of emotional distress or conflict, the subject engages in sports or other physical activities which are an invigorating outlet for any lingering frustrations. ITEM 100: Following some strong experiences, the subject engages in his or her ordinary activities but with less effort, greater accomplishment and more pleasure than they normally would require or yield. Suppression ITEM 49: When presented with an external demanding situation over which the subject has no control, the subject can accept the demand, putting negative feelings aside to deal with what must be done. ITEM 117: When the subject experiences a desire that if acted upon would have bad consequences, the subject is able to decide consciously to put the desire aside and not act upon it. ITEM 128: When the subject experiences a salient personal limitation or problem, rather than pretending it is not a problem, the subject acknowledges and accepts it, which allows the subject to avoid exacerbating problems. For example, acknowledging an addiction and accepting that one must avoid using the desired substance. ITEM 131: When attending to something emotionally important, if interrupted by something more urgent, the subject attends to the interruption as needed, but later returns and finishes dealing with what had to be postponed. ITEM 150: When presented with an emotionally charged situation, the subject can postpone dealing with his or her feelings to attend to the things that need to be done immediately. The feelings don’t get in the way or distract the subject, because the subject is able to give them adequate attention later. TABLE 3 | Obsessional defense level: Definition, function and DMRS-Q items of defenses isolation of affects, intellectualization and undoing. Defense DMRS-Q items mechanism Isolation of affects ITEM 28: When telling an emotionally meaningful story, the subject states that he or she does not have specific feelings that one would expect, although the subject recognizes that he or she should feel something. ITEM 31: In talking about a meaningful, emotionally charged experience, the subject talks in a detached way, as if he or she is not in touch with the feelings that should surround it. ITEM 39: The subject clearly describes the details of either positive or distressing or traumatic experiences but fails to show any attendant emotion in tone of voice, facial expression, or bodily expression. ITEM 107: The subject talks as if emotionally detached from whatever he says about himself or his experiences. ITEM 140: The subject describes events with good detail, but without mention of any attendant feelings, like a reporter describing the narrative of someone’s life, but devoid of personal reactions. Intellectualization ITEM 4: When confronting personal issues, the subject tends to ask general questions, as if getting general information or answers from others will elucidate his or her own feelings and concerns. As a result, personal reactions are kept at a distance. ITEM 26: The subject talks about his personal experiences by making general statements that appear accurate but somehow avoid revealing specific personal feelings and reactions. ITEM 53: There is a lifeless quality to most of the subject’s descriptions of his feelings and reactions, because the subject tries to explain them intellectually rather than experience or express them. For example: ‘My present predicament is an inevitable product of my parents’ extreme expectations and other parental experiences when growing up.’ ITEM 57: The subject distances him or herself from his or her own feelings by speaking about him or herself in the second or third person a lot, as if the subject were talking about someone else. ITEM 60: Whenever focusing on personal issues or experiences the subject tends to generalize or even discuss things in a logical or scientific way, thereby keeping his feelings and experiences very distant. Undoing ITEM 48: When another person tries to clarify a statement made by the subject, the subject says thing like ‘well, not really’ or ‘not exactly’ followed by qualifications that do not clearly clarify things. Because the subject is wary of committing him or herself to any statement, the listener may be unsure as to the subject’s definite opinion. ITEM 67: The subject spontaneously describes some of his or her actions which are followed by actions that are of the opposite intent, as if every action must be balanced by an equal but opposite action. The subject is aware of the contradiction which may seem vexing or ironic. ITEM 70: The subject prefaces a strong statement about a topic with a disclaimer, to the effect that what he or she is about to say may not be true. ITEM 81: The subject conveys opinions about something or someone with a series of opposite or contradictory statements, as if uncomfortable with taking a clear stand one way or the other. ITEM 83: After the subject has done something that probably results in a feeling of guilt or shame, the subject makes an act of reparation, as if sorry. However, the subject focuses on the act but avoids dealing with the sense of guilt or shame as one would whenever making a normal apology. her experience in general terms or in the second or third Obsessional Defense Level: Undoing person. One does not have to be bright or intelligent to use Definition intellectualization. It is simply a cognitive strategy for minimizing The individual deals with emotional conflicts, or internal the felt importance of problems in one’s affective life. Like other or external stressors, by behavior designed to symbolically defenses, it can sometimes be seen in those with intellectual make amends for negate previous thoughts, feelings, disabilities and organic brain syndromes. or actions. Frontiers in Psychology | www.frontiersin.org 8 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 9 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q Function that are diametrically opposed to his or her unacceptable thoughts or feelings. In this defense the subject expresses an affect, impulse or commits an action which elicits guilt feelings or anxiety. He or she then Function minimizes the distress by expressing the opposite effect, impulse, In reaction formation an original impulse or affect is deemed or action. The act of reparation then removes the individual from unacceptable by the subject and an unconscious substitution is experiencing the conflict. In conversation the subject’s statements made. Feelings, impulses, and behaviors of opposite emotional are immediately followed by qualifications bearing the opposite tone are substituted for the original ones. The observer does not meaning from the original statement. To the observer this see the alteration, per se, but only the end product. By supplanting coupling of statement with contradictory statement may make the original unacceptable feelings by its opposite, the subject it difficult to see what the subject’s primary feeling or intention avoids feelings of guilt. In addition, the substitution may gratify a really is. Misdeeds may be followed by acts of reparation to the wish to feel morally superior. Reaction formation is reasonably intended object of the misdeed. The subject appears compelled to inferred when a subject reacts to an event with an emotion erase or undo his or her original action. opposite in tone to the usual feelings evoked in people. Neurotic Defense Level: Repression Neurotic Defense Level: Displacement Definition Definition The individual deals with emotional conflicts, or internal or The individual deals with emotional conflicts, or internal or external stressors, by being unable to remember or be cognitively external stressors, by generalizing or redirecting a feeling about aware of disturbing wishes, feelings, thoughts or experiences. or a response to an object onto another, usually less threatening, object. The person using displacement may or may not be aware Function that the affect or impulse expressed toward the displaced object Repression is a defense that protects the subject from being aware was really meant for someone else. of what he is experiencing or has experienced in the past. The subject may experience a particular affect, impulse, or desire, but Function the actual awareness of what it is, that is, the idea associated with Displacement allows the expression of an affect, impulse, or it, remains out of awareness. While the emotional elements are action toward a person or other object with some similarity to clearly present and experienced, the cognitive elements remain the actual object which initially aroused the affect or impulse. outside of consciousness. The affect or impulse is fully expressed and acknowledged but is misdirected to a less conflictual target. Displacement allows more Neurotic Defense Level: Dissociation expression and gratification, albeit toward the wrong targets, than Definition other neurotic level defenses. The individual deal with emotional conflicts, or internal or Minor Image-Distorting Defense Level: Devaluation external stressors, by a temporary alteration in the integrative Definition functions of consciousness or identity. In the defense of The individual deals with emotional conflicts or internal or dissociation, a particular affect or impulse which the subject is not external stressors by attributing exaggeratedly negative qualities aware of operates in the subject’s life out of normal awareness. to oneself or others. Both the idea and associated affect or impulse remain out of awareness but are expressed by an alteration in consciousness. Function While the subject may be dimly aware that something unusual Devaluation refers to the use of derogatory, sarcastic, or takes place at such times, full acknowledgment that his or her own other negative statements about oneself or others to boost affect or impulses are being expressed is not made. Dissociation self-esteem. Devaluation may fend off awareness of wishes may result in a loss of function or in uncharacteristic behavior. or the disappointment when wishes go unfulfilled. The negative comments about others usually cover up a certain Function sense of vulnerability, shame or worthlessness which the Dissociated material is commonly experienced as too threatening, subject experiences vis a vis expressing his own wishes and too conflict-laden, or too anxiety-provoking to be allowed into meeting his own needs. awareness and fully acknowledged by the subject. Examples of common threatening material include recollection of a trauma Minor Image-Distorting Defense Level: Idealization with attendant fear of death and feelings of powerlessness, or a Definition sudden impulse to kill an intimate associate. Dissociation allows The individual deals with emotional conflicts, or internal or expression of the affect or impulse by altering consciousness external stressors, by attributing exaggerated positive qualities which allows the individual to feel less guilty or threatened. to self or others. Neurotic Defense Level: Reaction Formation Function Definition In the defense of idealization, the subject describes real or alleged The individual deals with emotional conflicts, or internal or relationships to others (including institutions, belief systems, external stressors, by substituting behavior, thoughts, or feelings etc.) who are powerful, revered, important, etc. This usually Frontiers in Psychology | www.frontiersin.org 9 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 10 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 4 | Neurotic defense level: Definition, function and DMRS-Q items of defenses repression, dissociation, reaction formation, and displacement. Defense DMRS-Q items mechanism Repression ITEM 13: The subject keeps unpleasant things vague: he or she has trouble remembering or can’t recall specific examples, when at least some should be forthcoming. This may include loss of memory for whole periods of time (e.g., childhood). ITEM 47: At points when a topic is emotionally loaded, the subject forgets what he or she is talking about and seems to get lost while talking. ITEM 50: When discussing a topic that brings up negative, conflicting feelings, the subject prefers to keep things vague, reflected in very vague, general or inexact statements. ITEM 108: The subject cannot remember certain facts which would normally not be forgotten, such as a distressing incident, reflecting some uneasy feelings about the topic. ITEM 136: When certain feelings or wishes would arise, the subject gives some evidence of them – such as crying or appearing anxious but cannot clearly identify in words the specific feeling or the specific ideas that give the wish a clear meaning. Dissociation ITEM 8: The subject behaves or says something in a very uncharacteristic way that expresses an uninhibited impulse operating out of the subject’s usual control, yet the subject is surprised by it (e.g., “I threw a glass of water in my friend’s face, but I don’t know what made me do it’). ITEM 27: The individual describes fugue states, amnesia (not alcoholic blackouts), multiple personality, spontaneous trance states, or temporary loss of sensory or motor function. ITEM 30: In response to an emotionally charged situation, the subject suddenly becomes confused, depersonalized, “spaced out,” or can’t think or talk about the topic. Consciousness becomes clouded to a lesser or greater extent. ITEM 41: In response to a distressing topic or situation, the subject develops a symptom, such as headache, stomach pain, or loss of an ability to do something, which temporarily eclipses awareness of what was distressing. The symptom may have a symbolic relationship to the type of distress. ITEM 73: The subject associates with or is fascinated by people who do very uninhibited, dramatic, or socially outrageous things, which appear to express some of the subject’s own inhibited wishes. Nonetheless, the subject is unaware of any such connection. Reaction ITEM 52: When confronting a personal wish about which the subject may feel guilty, the subject does not acknowledge or express it, but substitutes an formation opposite attitude against the wish, for instance, a desire is supplanted by renunciation or anger at anything to do with the desire. ITEM 55: The subject is very compliant, agreeing to most everything the interviewer points out, when some disagreement and discussion would be expected. ITEM 74: In dealing with people who are angry or abusive, the subject is cooperative and nice and eager to please, failing to express any negative feelings which might be expected. ITEM 96: In relationships, the subject has an attitude of giving much more than he or she receives but is unaware of the imbalance. ITEM 99: In fearful situations, the subject does not show expected fear, but reacts with exaggerated enthusiasm or courage, failing to acknowledge the fear. Displacement ITEM 1: In dealing with an important problem that makes the anxious, the subject prefers to focus on minor or unrelated matters instead, which distracts the subject away from the central problem, for example, cleaning or organizing rather than working on projects that need to be done. ITEM 64: The subject directs strong feelings toward a person or object who has little to do with the subject but who may bear similarities to someone significant to the subject. The subject may be somewhat puzzled by the ‘reason’ for the strength of these feelings. ITEM 69: When confronting emotionally charged topics, the subject tends not to address concerns directly and fully but wanders off to tangentially related topics that are emotionally easier for the subject to discuss or prefers to pay attention to someone else dealing with a similar situation. This can include preferring to read or watch a film portraying people dealing with similar problems. ITEM 122: When discussing an affect-laden event, the subject expresses more feelings directed toward incidental details or issues than about the major point or effect of the event, perhaps appearing “picky.” ITEM 125: The subject gets irritated easily by minor things that bother him or her and tends to lose a focus on the main things that need attention. serves as a source of gratification as well as protection from latter experiences, although they may remain objectively feelings of powerlessness, unimportance, worthlessness, and the obvious to others. Self-esteem is artificially propped like. The defense accomplishes a sort of alchemy of worthiness up at the expense of positively distorting one’s self- by association. The subject believes certain others to be good and evaluation in response to real experiences which bring up powerful in an exaggerated way and while able to acknowledge contrary feelings. factual aspects of any faults or shortcomings in the idealized person, they dismiss their significance, thereby preserving a Disavowal Defense Level: Denial sterling image of the person, or object. Definition The individual deals with emotional conflicts, or internal or Minor Image-Distorting Defense Level: Omnipotence external stressors, by refusing to acknowledge some aspect of Definition external reality or of his or her experience that would be apparent Omnipotence is a defense in which the subject responds to to others. The subject actively denies that a feeling, behavioral emotional conflict or internal and external stressors by acting response, or intention (regarding the past or present) was or superior to others, as if one possessed special powers or abilities. is not present, even though its presence is considered more Function than likely by the observer. The subject is blinded to both the This defense commonly protects the subject from a loss of ideational and emotional content of what is denied. This excludes self-esteem that is a consequence whenever stressors trigger ‘psychotic denial” in which the subject refuses to acknowledge feelings of disappointment, powerlessness, worthlessness, a physical object or event within the subject’s field in the and the like. Omnipotence subjectively minimizes the present time. Frontiers in Psychology | www.frontiersin.org 10 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 11 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 5 | Minor image-distorting defense level: Definition, function and DMRS-Q items of defenses devaluation of Self-image, devaluation of other’s image, idealization of self-image, idealization of other’s image, and omnipotence. Defense DMRS-Q items mechanism Devaluation of ITEM 12: The subject says demeaning things about him – whether somewhat funny or not – such as “I am so-ooooo stupid.” self-image ITEM 29: The subject makes a lot of unwarranted negative, sarcastic, or biting statements about the self, but the individual can acknowledge some of their positive aspects, if these are pointed out. ITEM 34: When experiencing failure, disappointment, shame or loss of self-esteem, the subject dismisses the issue by saying something negative about him or herself, then dismisses the problem by moving to another topic and avoids focusing on the feelings. ITEM 56: The subject is preoccupied with real or exaggerated faults in him or herself, although he or she can acknowledge some realistic positive aspects, if these are pointed out. ITEM 147: When confronted by a personal disappointment the subject makes negative comments about him or herself but then avoids further discussion of the disappointment in any detail. Devaluation of ITEM 54: When a topic brings with it feelings of disappointment, shame or loss of self-esteem, the subject dismisses the issue by finding some fault or other’s image criticism elsewhere or by uttering obscene comments about it. ITEM 82: The subject devalues others’ accomplishments or motives, to minimize their significance, but he or she quickly dismisses such topics rather than dwell on them. ITEM 85: When asked to discuss something about him or herself, the subject diverts the focus to saying negative things about others, as if devaluing others will raise his or her own self-esteem. ITEM 111: The subject has negative things to say about a lot of individuals or objects, although he or she can acknowledge some of their positive aspects, if these are pointed out. ITEM 143: The subject makes sarcastic or biting statements about others to minimize their positive qualities and dismiss any competition or threat they may pose. Idealization of ITEM 38: When confronted with any negative aspects of him or herself, the subject appears to downplay or ignore them by substituting talk about self-image positive self-attributes instead. ITEM 71: The subject makes many references to how important he or she is with an emphasis on self-image, rather than real accomplishments which might make the person important to others. ITEM 87: The subject tells stories in which others are saying positive things about him or herself. ITEM 133: The subject takes pleasure in referring a lot to his or her own positive but superficial attributes, like being beautiful, lovable, smart, well-dressed, worthy, a center of attention. This may be true even if the subject longs for qualities that are only imagined, wished for, or in the past. ITEM 135: When confronted with problems, the subject prefers to dwell on his or her own positive qualities, such as being lovable, smart, beautiful, creative, “the best,” as if those qualities will take care of the problems. Idealization of ITEM 16: The subject makes many references to how important certain people or objects are with an emphasis on their image, rather than real abilities other’s image or accomplishments which might make the person or object important to others. ITEM 17: The subject tells stories in which he or she says glowing positive things about another person or object, without giving much detail to back it up. ITEM 95: When confronted with problems, the subject prefers to dwell on the positive qualities of others on whom he or she relies, such as being lovable, smart, beautiful, creative, “the best,” as if those qualities will take care of the problems. ITEM 138: The subject takes pleasure in referring a lot to positive but superficial attributes of others, like being beautiful, lovable, smart, well-dressed, worthy, a center of attention. This may be true even if the subject longs for qualities that are only imagined, wished for, or in the past. ITEM 139: When confronted with any negative aspects of others important to the subject, the subject appears to downplay or ignore them, by substituting talk about the positive image or attributes instead. Omnipotence ITEM 7: The subject talks about how capable he or she is of influencing events or famous and important people. However, the emphasis is on the sense of personal power or abilities, rather than the detailed stories that support the claims as real. ITEM 10: The subject acts in a very self-assured way and asserts an ‘I can handle anything’ attitude, in the face of problems that he or she in fact cannot fully control. ITEM 68: The subject makes clearly false statements about his own special powers and abilities (these may or may not be delusional). ITEM 126: There is excessive bravado in discussing problems or personal accomplishments that stands out as excessive or unrealistic. ITEM 129: The subject is very grandiose in describing personal plans, accomplishments or abilities, perhaps comparing him or herself to famous people. Function Disavowal Defense Level: Rationalization Neurotic denial serves to prevent the subject who uses it and Definition anyone querying him from recognizing specific feelings, wishes, The individual deals with emotional conflicts, or internal intentions, or actions for which the subject might be responsible. or external stressors, by devising reassuring or self- The denial avoids admitting or becoming aware of a psychic serving but incorrect explanations for his or her own or fact (idea and feeling) which the subject believes would bring others’ behavior. him aversive consequences (such as shame, grief, or other Function painful affect). The evidence for this is clear whenever a subject breaks through his own denial and experiences shame or other Rationalization involves the substitution of a plausible reason emotion at what he learns about himself, often apologizing to the for a given action or impulse on the subject’s part, when a interviewer and so forth. motive that is more self-serving or difficult to acknowledge Frontiers in Psychology | www.frontiersin.org 11 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 12 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q is evident to the outsider. While the underlying covert Function motivation may be selfish, it may also involve caring or Non-delusional projection allows the subject to deal with loving feelings which the subject finds uncomfortable. The emotions and motives which make him feel too vulnerable subject is usually thought to be unaware or minimally (especially to shame or humiliation) to admit having himself. aware of his true underlying motive; instead, he or she Instead he concerns himself with these same emotions and sees only the substituted, more socially acceptable reason for motives in others. The use of projection therefore commits the the action. The subject’s reasons commonly have nothing to subject to a continual concern with those on whom he has do with any personal satisfaction, and thus disguise his or projected his inner feelings as a way to minimize awareness her real impulse or motive, although any related affect may of them himself. still show. Disavowal Defense Level: Autistic (or Schizoid) Disavowal Defense Level: Projection Fantasy Definition Definition The individual deals with emotional conflicts, or internal The individual deals with emotional conflicts, or internal or or external stressors, by falsely attributing his or her own external stressors, by excessive daydreaming as a substitute for unacknowledged feelings, impulses, or thought to others. The human relationships, more direct and effective action, or problem subject disavows his or her own feelings, intentions, or experience solving. Fantasy denotes the use of daydreaming as either a by means of attributing them to others, usually by whom substitute for dealing with or solving external problems or as a the subject feels threatened and to whom the subject feels way of expressing and satisfying one’s feelings and desires. While some affinity. the subject may be aware of the ‘I’m just pretending’ quality of TABLE 6 | Disavowal defense level: Definition, function and DMRS-Q items of defenses denial, rationalization, projection, and autistic fantasy. Defense DMRS-Q items mechanism Denial ITEM 20: When confronted with topics that might be personally meaningful, the subject denies they are important and refuses to talk about them further. ITEM 33: Contrary to the evidence from the interview, the subject claims to have done something that in all likelihood he or she did not do, and may become irritated if confronted with any discrepancy. ITEM 121: Whenever talking about potentially distressing events or experiences, the subject strongly claims not to have any feelings about the topic, although this seems highly unlikely. ITEM 124: Whenever asked about things the subject did or felt, the subject denies any involvement, does not want to talk about them or avoids explaining his or her reluctance. ITEM 137: The subject is hard to talk with, responding to many questions with answers like “no” or “not really” and does not elaborate, rather than giving some fuller answers which one would normally expect. Rationalization ITEM 19: To avoid taking responsibility for one’s actions or misdeeds, the subject makes excuses or points out others’ contributions to the problem, thereby minimizing his or her own role. ITEM 42: The subject avoids feelings of guilt or shame by justifying his actions or by referring to external reasons that impelled him to act. ITEM 59: When discussing a problem that the subject contributed to, the subject explains his or her own actions far more than necessary, as if explaining away his or her own fault. ITEM 86: Whenever confronted about his or her own feelings or intentions, the subject avoids acknowledging them by giving a plausible explanation that covers up the real subjective reasons. ITEM 120: Whenever discussing something uncomfortable about him or herself, the subject tries to convince someone else of a more positive explanation, as if lying to him or herself about the truth. Projection ITEM 112: When others comment or inquire about the subject’s own feelings, actions, or intentions, the subject is very elusive or frankly denies the material, but the subject subsequently talks about similar feelings, actions, intentions, etc., in others. ITEM 115: When experiencing or confronted with a problem, the subject shames, humiliates, or blames someone else for the problem, ignoring his or her own role. ITEM 123: An attitude of suspiciousness or prejudice toward a group of other individuals, allows the subject not to express an interest in the same motives or feelings but remain blind to them in him or herself. ITEM 134: When others ask the subject questions, the subject is suspicious about others’ real reasons or motives for the question. ITEM 141: The subject perceives others as untrustworthy, unfaithful, or manipulative when there is no objective basis for these concerns. This may even appear paranoid. Autistic fantasy ITEM 2: The subject has repetitive or serial daydreams to which he or she retreats in lieu of real life social relationships. ITEM 24: The subject daydreams a lot, not in a way that leads to creative planning or action, but simply for its own gratification, in lieu of action. ITEM 106: In dealing with some problems, the subject prefers to daydream about solutions, as a substitute for planning direct, realistic, and effective actions. ITEM 110: Whenever being self-assertive would be helpful, the subject may act passively but later withdraw into fantasies of being assertive or aggressive toward others as a compensation. ITEM 148: The subject gets intensely involved in fantasy roles or actions that express wishes and feelings that the subject does not express in real life. For example, living out a role in a social situation or game or which has no connection to real life ways in which the subject expresses him or herself. Frontiers in Psychology | www.frontiersin.org 12 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 13 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q the fantasy, nonetheless, it may be the closest that he or she contradictory views, expectations, or feelings about the object ever comes to expressing or gratifying the need for satisfying arc excluded from emotional awareness, although not necessarily interpersonal relationships. from cognitive awareness. Function Function Fantasy allows the subject to obtain some temporary, vicarious Splitting of object images and self-images is the subject’s defense gratification by daydreaming a solution to a real-world problem against the anxiety of ruining the good images of people by of conflict. The subject feels good while using fantasy and allowing bad aspects of them to intrude upon the good. Splitting momentarily bypasses the conviction of powerlessness. In fact, of self-images has one adaptive function: it minimizes the during fantasy the opposite conviction (i.e., grandiosity) may be anxiety the subject would experience attempting to match his in operation, that one can do anything. Fantasy is maladaptive view of himself with how significant others will in fact see only when it short-circuits rather than rehearses attempts to deal him and treat him. Instead, when seeing himself one way, the with the real world by substituting dream world gratification. subject continues to see himself in the same valence no matter how others see him and treat him; contradictions then aren’t Sometimes, there may be a wholesale substitution of daydream activity in the place of real world attempts to meet needs allowed into experience. This minimizes the disruptive, anxiety- provoking effects of trying to predict unpredictable people. The and solve conflicts. This occurs without any loss of the ability to perceive and test external reality. The subject knows the disadvantage is that the subject’s view of himself then becomes inflexible to the environmental realities, and the switch from difference between reality and fantasy life. good to bad views of himself is also unpredictable. This leaves the subject insensitive to more reasonable, predictable, and Major Image-Distorting Defense Level: Splitting potentially more rewarding relationships outside of his original Definition learning environment. In a better environment, the subject The individual deals with emotional conflicts, or internal or suffers from what was paradoxically so protective originally: external stressors, by viewing himself or herself or others an insensitivity to experiencing contradictory views of the self. as all good or all bad, failing to integrate the positive and Splitting of object images and self-images is the subject’s defense negative qualities of the self and others into cohesive images; against the anxiety of ruining the good images of people by often the same individual will be alternately idealized and allowing bad aspects of them to intrude upon the good. Splitting devalued. Splitting of self-images often occurs alongside splitting of object images limits the anxiety the subject would feel in trying of others’ images, since they both were learned in response to the to discriminate how others will respond when he experiences unpredictability of one’s early significant others. In splitting of or expresses his needs, feelings, etc. To see others as all good self-images, the subject demonstrates that he has contradictory or all bad eliminates the anxiety-provoking task of trying to views, expectations, and feelings about himself which he cannot discern how others will behave toward the self, a task the subject reconcile into one coherent whole. believes to be impossible. Instead, the subject quickly categorizes The self-images are divided into polar opposites: at a given people into good and bad camps based on subtle initial cues time the subject’s awareness is limited to those aspects of the (e.g., ‘he frowned when I spoke, so he hates me”) or based self-having the same emotional feeling tone. He sees himself in largely on internal feeling states (e.g., “I feel so bad that I “black or white” terms. At one point in time the subject believes know you must hate me, so why should I open up to you?”). he himself has good attributes, such as being loving, powerful, The defense is maladaptive, however, because the subject acts worthy, or correct, and having good feelings, or he believes as unpredictably and irrationally toward others as he himself the opposite: that he is bad, hateful, angry, destructive, weak, was treated; he forgoes the rewards he might attain if he were powerless, worthless, or always wrong and has only negative flexible in how he interacts with others. Using this defense, feelings about himself. The subject cannot experience himself as the subject wins some friends and makes some enemies, but a more realistic mixture of both positive and negative attributes. not in a realistic way that considers the aggregate of others’ In splitting of other’s images (object images), the subject actual characteristics. demonstrates that his views, expectations, and feelings about others are contradictory and that he cannot reconcile these Major Image-Distorting Defense Level: Projective differences to form realistic and coherent views of others. Identification Object images are divided into polar opposites, such that the subject can only see one emotional aspect or side of the Definition object at a time. Objects are experienced in black or white In projective identification the subject has an affect or impulse terms. Splitting is revealed in two major ways. The subject which he finds unacceptable and projects onto someone else, may initially describe an object wholly in one way but later as if it was really that other person who originated the affect describe that same object in opposite ways. Second, each object or impulse. However, the subject does not disavow what is is simply lumped with other objects into good and bad, positive projected – unlike in simple projection – but remains fully and negative camps. When the subject uses splitting of object aware of the affects or impulses, and simply misattributes images, he cannot integrate anything that doesn’t match his them as justifiable reactions to the other person! Hence, the immediate experience of and feeling about a given object. All subject eventually admits his affect or impulse, but believes the attributes with the same feeling tone are highlighted, and it to be a reaction to those same feelings and impulses in Frontiers in Psychology | www.frontiersin.org 13 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 14 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 7 | Major image-distorting defense level: Definition, function and DMRS-Q items of defenses splitting of self-image, splitting of other’s image, and projective identification. Defense DMRS-Q items mechanism Splitting of ITEM 3: The subject has periods of saying highly positive things about him or herself, and other periods saying highly negative things about him or self-image herself, without appearing to notice the contradiction and without addressing it, other than to feel confused about him or herself at moments. ITEM 6: The subject speaks of him or herself in a wholly negative way at times, as if there is nothing positive or redeeming about him or herself. ITEM 98: The subject expresses a series of highly unrealistic positive attributes about him or herself whereas at another point the subject sees only negatives in him or herself. The subject dismisses attempts to see things in a balanced more realistic way. ITEM 142: The subject tends to highlight objects with an emotional meaning that matches his or her own emotional tone at the moment. Any feeling that doesn’t match this is ignored or denied. ITEM 145: Whenever saying something negative about him or herself, the subject rejects others’ attempts to explore positive or more balanced views, and paradoxically becomes even more confirmed in his or her own worthlessness. Splitting of ITEM 35: The subject experiences other people and objects in “black or white” terms, failing to form more realistic views that balance positive and other’s image negative aspects of them. ITEM 61: The subject attributes unrealistic positive characteristics to an object, such as being all-powerful, omni-benevolent, a savior. Because of the unrealistic belief that the positive object will take care of one’s problems, the subject ignores the need to take care of some of his or her own needs. ITEM 92: The subject attributes unrealistic negative characteristics to an object, such as being all-powerful, malevolent, threatening. As a result, he or she makes some effort to protect him or herself from its influence, even though this response appears unwarranted or exaggerated. ITEM 94: The subject fails to recognize that someone may be untrustworthy, hurtful, or manipulative and does not draw obvious conclusions based on their behavior. This generally results in using very poor judgment about how others will treat the subject. ITEM 114: The subject expresses hatred toward someone or something and refuses to acknowledge anything that does not confirm the hatred. Projective ITEM 72: Sometimes the subject gets angry or fearful toward someone for no apparent reason, but then accuses the other person of intending to make identification him or her feel that way. ITEM 75: At times the subject’s feelings merge with those of another person and the subject assumes the other’s feelings and needs are exactly the same as the subject’s own. He or she then tends to “put words in the other’s mouth.” ITEM 101: In conversations, the subject sometimes seems confused about distinguishing his or her own feelings from those of the other person. ITEM 103: When the subject gets upset at someone, he or she gets very angry and loses control, but then blames the other person for making him or her lose control. Nonetheless, the subject may feel some guilt for losing control. ITEM 113: The subject feels provoked by someone when no obvious provocation is apparent. As the subject becomes angry, accusatory or verbally abusive, the subject provokes the same negative feelings in the other which the subject mistakenly believed the other person had at the outset. others. The subject confuses the fact that it was he himself who and guilt in others that he or she feels, which may result in originated the projected material. This defense is seen most others backing away. clearly in a lengthy interchange in which the subject initially Action Defense Level: Passive Aggression projects his feelings but later experiences his original feelings as Definition reactions to the other. Paradoxically, the subject often arouses The individual deals with emotional conflicts, or internal or the very feelings in others he at first mistakenly believed to external stressors, by indirectly and unassertively expressing be there. It is then difficult to clarify who did what to whom aggression toward others. There is a facade of overt compliance first. This process is more extensive than simple projection, masking covert resistance toward others. Passive aggression which involves the denial and subsequent external attribution is characterized by venting hostile or resentful feelings in an of an impulse. Projective identification involves attribution of indirect, veiled, and unassertive manner toward others. Passive an image so that the whole object is seen and reacted to in a aggression often occurs in response to demands for independent distorted light. action or performance by the subject or when someone has disappointed the subject’s wish or sense of entitlement Function to be taken care of, regardless of whether the subject has Projective identification is the defense of the traumatized person made this wish known. This term includes ‘turning against who felt irrationally responsible for his or her traumas. The the self.’ defense is called into play when interpersonal cues stimulate memories of traumatic situations or interchanges or their Function residues. The individual experiences the other person as doing The person using passive-aggression has learned to expect something to him or herself that is threatening, which make him punishment, frustration, or dismissal if he or she expresses needs or her feel powerless. The subject reacts to this imagined (or or feelings directly to someone who has power or authority partially real) threat by attacking and believing that his or her over him or her. The subject feels powerless and resentful. own actions are justified, despite provoking the other. Guilt over This expectation is most pronounced in hierarchical power having aggressive wishes toward the other person emerges and is relationships. Resentment is expressed by a passive stance: that handled by identification with the other, reinforced ‘by the belief the subject is entitled to the very things he doesn’t speak up that the alleged threat attack on oneself is deserved. Paradoxically for or that he is entitled to special dispensation. There is also the subject often induces the very feeling of powerlessness some pleasure taken in the discomfort that the passive aggressive Frontiers in Psychology | www.frontiersin.org 14 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 15 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q behavior causes others. Passive expression of anger through emotional reliance on others. The anger rises from the conviction, stubborn, inept, procrastinating, and forgetful behavior is quickly or often the experience that nobody will really satisfy the learned as a way to express: the conviction that the subject has subject’s perceived needs. The subject expresses the anger as the right to remain passive while expecting his needs to be met; an indirect reproach by rejecting help as “not good enough” to appear well-intentioned on the surface (overtly compliant), while continuing to ask for more of it. Instead of driving the thus avoiding retaliation for the direct expression of affects, other person away by the expression of anger, the use of help- needs, or resentment; to express the resentment experienced rejecting complaining binds the person to the subject by the toward those making demands by covert noncompliance that overt request for help. The subject’s expression of helplessness annoys others and obtain some satisfaction or vengeance, even over the problem at hand reflects a sense of powerlessness to if it means hurting oneself. In extremes, the resentment is not get the right help, comfort, and attention, while discharging just expressed indirectly toward the other, but in fact, is turned resentment for the expected disappointment that enough help 180 degrees around toward the self (turning against the self ) to will not be forthcoming. get at the other. Action Defense Level: Acting Out Action Defense Level: Help-Rejecting Complaining Definition Definition The individual deals with emotional conflicts, or internal or Help-rejecting complaining (formerly called hypochondriasis, external stressors, by acting without reflection or apparent which term we do not us as it can be confused with the symptom regard for negative consequences. Acting out involves the disorder) involves the repetitious use of a complaint or series expression of feelings, wishes or impulses in uncontrolled of complaint in which the subject ostensibly asks for help. behavior with apparent disregard for personal or social However, covert feelings of hostility or resentment toward others consequences. It usually occurs in response to interpersonal are expressed simultaneously by the subject’s rejection of the events with significant people in the subject’s life, such as suggestions, advice, or whatever others offer. The complaints may parents, authority figures, friends, or lovers. This definition is consist of either somatic concerns or life problems. Either type of broader than the original concept of acting out transference complaint is followed by a ‘help-rejecting complainer’ response feelings or wishes during psychotherapy. It includes behavior to whatever help is offered. arising both within and outside of the transference relationship. Function It is not synonymous with “bad behavior,” or with any Help-rejecting complaining is a defense against the anger the symptom per se, although acting out often involves socially subject experiences whenever he or she feels the need for disruptive or self-destructive behavior. So-called acting out TABLE 8 | Action defense level: Definition, function and DMRS-Q items of defenses acting out, help-rejecting complaining, and passive aggression. Defense DMRS-Q items mechanism Passive ITEM 45: At times when expressing an opinion or wish might be helpful, the subject fails to express himself adequately, instead finding indirect, even aggression annoying ways to show his or her opposition to the influence of others, for example, being silent. ITEM 88: The subject fails to stand up for his or her interests and seems to let bad things happen to him or herself that could be prevented, maybe even assuming a “martyr” role. ITEM 89: While outwardly cooperative or compliant, the individual procrastinates and refuses to do things on time or as asked, even when it would be easy to do so. ITEM 102: When angry toward someone significant, the subject takes anger out on himself instead of expressing it directly. ITEM 116: The subject has “a chip on his or her shoulder” or a grudge, and seems to find reasons to feel unfairly treated, even when he or she is not. Help-rejecting ITEM 21: The subject complains spontaneously about how others don’t really care, or have made his or her problems worse, even when there is clear complaining evidence that others have tried to help. ITEM 84: The subject recites a litany of issues and problems but does not appear to be engaged in solving them, but rather prefers to complain. ITEM 127: The subject tends to exaggerate his or her complaints about a life problem or somatic symptom, making them seem worse or more significant than they are. ITEM 130: The subject complains about life issues or problems as if each were insoluble, and systematically rejects others’ suggestions about ways of handling them. ITEM 149: When the subject brings up a problem to discuss, others try to address the problem, but in response the subject skips to a different problem, thereby dismissing rather than engaging others in any suggestions offered. Acting out ITEM 5: The subject loses his or her temper easily. ITEM 76: In response to interpersonal disappointment or disagreement the subject tends to act impulsively, without reflection or considering the negative consequences. ITEM 80: The subject is often inhibited from expressing him or herself, but sometimes acts in uncontrolled ways to get or do something he or she wants, ignoring normal constraints. ITEM 118: Whenever the subject feels angry, disappointed or rejected by someone, the subject resorts to uncontrolled behaviors as an escape from distressing feelings, such as binge-eating, drinking, sexual escapades, drug use, reckless driving, or getting into trouble. ITEM 144: The subject tends to express feelings, wishes or impulses directly in behavior, not only words, without prior thought. However, afterward, he or she may feel guilty or expect some punishment. Frontiers in Psychology | www.frontiersin.org 15 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 16 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q behaviors, such as physical fighting, or compulsive drug use, must show some relationship to affects or impulses that the person cannot tolerate to serve as evidence for the defense of acting out. Function Acting out allows the subject to discharge or express feelings and impulses rather than tolerate them and reflect on the painful events that stimulate them. The following elements are present. First, the subject has feelings or urges which he is inhibited from expressing. Experiencing the original impulse quickly results in a rise in tension and anxiety. Second, the individual bypasses awareness and ceases any attempt to delay, reflect upon, or plan a strategy to handle the impulse or feeling. Rather it is directly expressed in behavior without prior thought. This results in the expression of rather raw aggression, sex, attachment, or other impulses without taking the consequences into account. Following acting out, reflection may return, and the subject commonly feels guilty or expects some punishment, unless a further defense comes into play, such as denial or rationalization (“I was so angry, I had to do it. It was his fault for stirring me up.”). Acting out is maladaptive because it does not mitigate the effects of the internal conflict, and it often brings upon the subject serious, negative, external consequences. Coding Procedure The DMRS-Q is a computer-based measure that can be used for clinical, research and teaching purposes by registering on the DMRS-Q platform (see text footnote 1 for registration and login). The software use is free of charge and provides the user FIGURE 2 | The DMRS-Q forced distribution (image extracted from the with several functions, such as starting a new coding, revising DMRS-Q web-app). previous ratings, downloading outputs and scoring sheets. At present the DMRS-Q is available in English and in Italian, although other languages may be added on the platform after Clinical Data and Training appropriate validation. Data required for a stable DMRS-Q rating might vary with the Like most Q-sort tools, the DMRS-Q coding procedure aim of its use. Coders must have sufficient information of the follows the rules of ranking items into a force distribution evaluated subject’s defensive functioning, directly observed or (Block, 1978; Brown, 1993, 1995). The 150 items must be obtained from records. Since recorded and transcribed data are ordered into seven ordinal ranks, corresponding to increasing not essential, the DMRS-Q can be applied in multiple contexts. level of descriptiveness, intensity or frequency. Higher ranks The required time for a DMRS-Q coding decreases depending are less populated and include items that best describe the on rater’s experience, ranging from about 60 min in the very most characteristic defensive patterns activated by an individual. first ratings to less than 15 min for expert coders. A 6-h training Conversely, lower ranks are more populated and include items is highly suggested for reaching high reliability on all DMRS- that either do not apply or are only somewhat descriptive Q quantitative scores, although a recent study demonstrated of the individual’s defensive profile. In ascending order of that untrained raters obtain acceptable to excellent reliability on descriptiveness, DMRS-Q ranks are as follows: rank 1 (60 most DMRS-Q scales (ICC ranging from 0.60 to 0.91) (Békés items) = not used at all; rank 2 (30 items) = very rarely used; rank et al., 2021). In any case, for the correct use of the DMRS-Q 3 (20 items) = slightly or rarely used; rank 4 (16 items) = medium it is essential to read the present manual for understanding the or sometimes used; rank 5 (10 items) = intensive or often used; theoretical and methodological background behind the measure. rank 6 (8 items) = very intensive or frequently used; rank 7 (6 items) = almost always used. When all items are correctly Scoring System ordered into the DMRS-Q forced distribution, as displayed in Figure 2, the rating is complete and ready to be sent for scoring The DMRS-Q scoring procedure is made with a software that output. For detailed directions of the DMRS-Q rating procedure extracts DPN and quantitative scores from the completed a video-tutorial is available at https://www.youtube.com/watch? DMRS-Q rating. Formulas for quantitative scoring are v=PP1ykSrGLkY&t=87s. displayed in Table 9. Frontiers in Psychology | www.frontiersin.org 16 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 17 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 9 | DMRS-Q quantitative scoring system. Items labels # Defense # Defense # Defense # Defense # Defense 1 Displacement 31 Isolat_Affect 61 Splitting_Self 91 Self_Observat 121 Denial 2 Autis_Fantasy 32 Self_Observat 62 Anticipation 92 Splitting_Self 122 Displacement 3 Splitting_Other 33 Denial 63 Sublimation 93 Affiliation 123 Projection 4 Intellectualizat 34 Devaluat_Self 64 Displacement 94 Splitting_Self 124 Denial 5 Acting_Out 35 Splitting_Self 65 Anticipation 95 Idealizat_Other 125 Displacement 6 Splitting_Other 36 Sublimation 66 Affiliation 96 React_Format 126 Omnipotence 7 Omnipotence 37 Humor 67 Undoing 97 Sublimation 127 Help_Rej_Com 8 Dissociation 38 Idealizat_Self 68 Omnipotence 98 Splitting_Other 128 Suppression 9 Self_Observat 39 Isolat_Affect 69 Displacement 99 React_Format 129 Omnipotence 10 Omnipotence 40 Humor 70 Undoing 100 Sublimation 130 Help_Rej_Com 11 Altruism 41 Dissociation 71 Idealizat_Self 101 Proj_Identific 131 Suppression 12 Devaluat_Self 42 Rationalization 72 Proj_Identific 102 Passive_Aggr 132 Altruism 13 Repression 43 Anticipation 73 Dissociation 103 Proj_Identific 133 Idealizat_Self 14 Sublimation 44 Affiliation 74 React_Format 104 Altruism 134 Projection 15 Altruism 45 Passive_Aggr 75 Proj_Identific 105 Self_Assertion 135 Idealizat_Self 16 Idealizat_Other 46 Anticipation 76 Acting_Out 106 Autis_Fantasy 136 Repression 17 Idealizat_Other 47 Repression 77 Self_Observat 107 Isolat_Affect 137 Denial 18 Humor 48 Undoing 78 Anticipation 108 Repression 138 Idealizat_Other 19 Rationalization 49 Suppression 79 Altruism 109 Self_Assertion 139 Idealizat_Other 20 Denial 50 Repression 80 Acting_Out 110 Autis_Fantasy 140 Isolat_Affect 21 Help_Rej_Com 51 Humor 81 Undoing 111 Devalu_Other 141 Projection 22 Affiliation 52 React_Format 82 Devalu_Other 112 Projection 142 Splitting_Other 23 Self_Assertion 53 Intellectualizat 83 Undoing 113 Proj_Identific 143 Devalu_Other 24 Autis_Fantasy 54 Devalu_Other 84 Help_Rej_Com 114 Splitting_Self 144 Acting_Out 25 Affiliation 55 React_Format 85 Devalu_Other 115 Projection 145 Splitting_Other 26 Intellectualizat 56 Devaluat_Self 86 Rationalization 116 Passive_Aggr 146 Self_Assertion 27 Dissociation 57 Intellectualizat 87 Idealizat_Self 117 Suppression 147 Devaluat_Self 28 Isolat_Affect 58 Self_Observat 88 Passive_Aggr 118 Acting_Out 148 Autis_Fantasy 29 Devaluat_Self 59 Rationalization 89 Passive_Aggr 119 Humor 149 Help_Rej_Com 30 Dissociation 60 Intellectualizat 90 Self_Assertion 120 Rationalization 150 Suppression Label Defense mechanism Scoring Individual defense scores D30 Suppression [(Sum of items 49, 117, 128, 131, and 150) 5]*100/234 D29 Sublimation [(Sum of items 14, 36, 63, 97, and 100) 5]*100/234 D28 Self-observation [(Sum of items 9, 32, 58, 77, and 91) 5]*100/234 D27 Self-assertion [(Sum of items 23, 90, 105, 109, and 146) 5]*100/234 D26 Humor [(Sum of items 18, 37, 40, 51, and 119) 5]*100/234 D25 Anticipation [(Sum of items 43, 46, 62, 65, and 78) 5]*100/234 D24 Altruism [(Sum of items 11, 15, 79, 104, and 132) 5]*100/234 D23 Affiliation [(Sum of items 22, 25, 44, 66, and 93) 5]*100/234 D22 Isolation of affects [(Sum of items 28, 31, 39, 107, and 140) 5]*100/234 D21 Intellectualization [(Sum of items 4, 26, 53, 57, and 60) 5]*100/234 D20 Undoing [(Sum of items 48, 67, 70, 81, and 83) 5]*100/234 D19 Repression [(Sum of items 13, 47, 50, 108, and 136) 5]*100/234 D18 Dissociation [(Sum of items 8, 27, 30, 41, and 73) 5]*100/234 D17 React formation [(Sum of items 52, 55, 74, 96, and 99) 5]*100/234 D16 Displacement [(Sum of items 1, 64, 69, 122, and 125) 5]*100/234 D15 Devaluation other’s image [(Sum of items 54, 82, 85, 111, and 143) 5]*100/234 D14 Devaluation self-image [(Sum of items 12, 29, 34, 56, and 147) 5]*100/234 D13 Idealization other’s image [(Sum of items 16, 17, 95, 138, and 139) 5]*100/234 (Continued) Frontiers in Psychology | www.frontiersin.org 17 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 18 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 9 | (Continued) Label Defense mechanism Scoring D12 Idealization self-image [(Sum of items 38, 71, 87, 133, and 135) 5]*100/234 D11 Omnipotence [(Sum of items 7, 10, 68, 126, and 129) 5]*100/234 D10 Denial [(Sum of items 20, 33, 121, 124, and 137) 5]*100/234 D9 Rationalization Sum of items 19, 42, 59, 86, and 120) 5]*100/234 D8 Projection [(Sum of items 112, 115, 123, 134, and 141) 5]*100/234 D7 Autistic fantasy [(Sum of items 2, 24, 106, 110, and 148) 5]*100/234 D6 Projective identification [(Sum of items 72, 75, 101, 103, and 113) 5]*100/234 D5 Splitting of self-image [(Sum of items 3, 6, 98, 142, and 145) 5]*100/234 D4 Splitting of object’s image [(Sum of items 35, 61, 92, 94, and 114) 5]*100/234 D3 Passive aggression [(Sum of items 45, 88, 89, 102, and 116) 5]*100/234 D2 Help-rejecting complaining [(Sum of items 21, 84, 127, 130, and 149) 5]*100/234 D1 Acting out [(Sum of items 5, 76, 80, 118, and 144) 5]*100/234 Label Defense level Scoring Defense level scores L7 High adaptive Sum of D23, D24, D25, D26, D27, D28, D29, and D30 L6 Obsessional Sum of D20, D21, and D22 L5 Neurotic Sum of D16, D17, D18, and D19 L5a Hysterical Sum of D18 and D19 L5b Other neurotic Sum of D16 and D17 L4 Minor image-distorting Sum of D11, D12, D13, D14, and D15 L3 Disavowal Sum of D7, D8, D9, and D10 L2 Major image-distorting Sum of D4, D5, and D6 L1 Action Sum of D1, D2, and D3 Label Defensive category Scoring Defensive category scores C3 Mature Sum of D23, D24, D25, D26, D27, D28, D29, and D30 C2 Neurotic Sum of D16, D17, D18, D19, D20, D21, and D22 C1 Immature Sum of D1, D2, D3, D4, D5, D6, D7, D8, D9, D10, D11, D12, D13, D14, and D15 C1a Depressive Sum of D1, D2, D3, D4, D5, D6, D8, D14, and D15 C1b Other immature Sum of D7, D9, D10, D11, D12, and D13 Label Scoring Overall defensive functioning ODF (L1/100)*1 C (L2/100)*2 C (L3/100)*3 C (L4/100)*4 C (L5/100)*5 C (L6/100)*6 C (L7/100)*7 For further information about the scoring system please contact the corresponding author. Although the scoring software has not yet been uploaded functioning. Qualitative scores are displayed as the Defensive in the DMRS-Q web-app in order to protect it from hackers, Profile Narratives (DPN), a case description of the most we will include it after the publication of the present article. characteristic ways the subject handles internal conflict and This upgrade will allow the DMRS-Q web-app to automatically external stressors. The DPN comprises all items sorted in ranks calculate qualitative and quantitative scores after each evaluation 6 and 7 (N = 14) and coded as highly descriptive of the subject’s and immediately deliver the DMRS-Q report to the user. defensive profile. The DMRS-Q software automatically lists these items and indicates the defense level and individual defense mechanism associated with each item. Figure 3 shows an example RESULTS of a DPN displayed in the DMRS-Q report. In addition to DPN, the DMRS-Q report provides the The Defense Mechanisms Rating Scales following quantitative scores: a summary Overall Defensive Functioning (ODF), ranging from 1 to 7; proportional scores for Q-Sort Report seven defense levels (see Table 1 for review); and proportional Like the original DMRS, the DMRS-Q provides qualitative scores for 30 individual defense mechanisms (see Tables 2–8 for and quantitative scores reflecting the individual’s defensive Frontiers in Psychology | www.frontiersin.org 18 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 19 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q FIGURE 3 | Defensive Profile Narrative (PDN) of a patient assessed with the DMRS. review). Future updates in the web-app software will also add patient’s demographics, diagnosis, length of treatment, nor scores for defensive categories and subcategories. Quantitative therapist’s approach, experience, etc. A summary of qualitative scores are displayed in both numerical and graphical forms in and quantitative evaluation of patient’s defense mechanisms the DMRS-Q report, which can be downloaded from the user analyzed with the DMRS-Q is displayed in Table 10. The 14 items dashboard at any time. coded as the best descriptive of the patient’s defensive functioning in the session were included in the qualitative defensive profile (DPN), while all item scores contributed to the quantitative Clinical Vignette and Defense scores displayed in the graphics. Mechanisms Rating Scales Q-Sort The session started with the patient telling his negative Rating experience with his lawyer and his attempt to solve a financial issue. While reporting on how the therapy had been helping One example of how to use the DMRS-Q in clinical setting is offered by the following vignette. A brief description of him in enhancing his engagement in professional problems, the patient described himself with very devaluing terms. Even when patient-therapist interactions during the session is used for the DMRS-Q rating with no additional information about the therapist tried to support him, saying that he was not aware Frontiers in Psychology | www.frontiersin.org 19 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 20 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 10 | Qualitative and quantitative DMRS-Q evaluation of the described in the clinical vignette. Qualitative scores – Defensive profile narratives When confronted with topics that might be personally meaningful, the subject denies they are important and refuses to talk about them further. The subject complains spontaneously about how others don’t really care, or have made his or her problems worse, even when there is clear evidence that others have tried to help. At times when expressing an opinion or wish might be helpful, the subject fails to express himself adequately, instead finding indirect, even annoying ways to show his or her opposition to the influence of others, for example, being silent. The subject recites a litany of issues and problems but does not appear to be engaged in solving them, but rather prefers to complain. When others comment or inquire about the subject’s own feelings, actions, or intentions, the subject is very elusive or frankly denies the material, but the subject subsequently talks about similar feelings, actions, intentions, etc. in others. Whenever talking about potentially distressing events or experiences, the subject strongly claims not to have any feelings about the topic, although this seems highly unlikely. When telling an emotionally meaningful story, the subject states that he or she does not have specific feelings that one would expect, although the subject recognizes that he or she should feel something. In talking about a meaningful, emotionally charged experience, the subject talks in a detached way, as if he or she is not in touch with the feelings that should surround it. The subject avoids feelings of guilt or shame by justifying his actions or by referring to external reasons that impelled him to act. At times the subject’s feelings merge with those of another person and the subject assumes the other’s feelings and needs are exactly the same as the subject’s own. He or she then tends to ‘put words in the other’s mouth.’ Whenever confronted about his or her own feelings or intentions, the subject avoids acknowledging them by giving a plausible explanation that covers up the real subjective reasons. When angry toward someone significant, the subject takes anger out on himself instead of expressing it directly. The subject expresses hatred toward someone or something and refuses to acknowledge anything that does not confirm the hatred. When experiencing or confronted with a problem, the subject shames, humiliates, or blames someone else for the problem, ignoring his or her own role. Quantitative scores – Graphics ODF Defense levels Individual defenses Defense levels: 1 = Action; 2 = Minor image-distorting; 3 = Disavowal; 4 = Major image-distorting; 5 = Neurotic; 6 = Obsessional; 7 = High adaptive Individual defenses: 1 = Acting out; 2 = Help-rejecting complaining; 3 = Passive aggression; 4 = Splitting of object’s image; 5 = Splitting of self-image; 6 = Projective identification; 7 = Autistic fantasy; 8 = Projection; 9 = Rationalization; 10 = Denial; 11 = Omnipotence; 12 = Idealization of self-image; 13 = Idealization of other’s image; 14 = Devaluation of other’s image; 15 = Devaluation of self-image; 16 = Displacement; 17 = Reaction formation; 18 = Dissociation; 19 = Repression; 20 = Undoing; 21 = Intellectualization; 22 = Isolation of affects; 23 = Affiliation; 24 = Altruism; 25 = Anticipation; 26 = Humor; 27 = Self-assertion; 28 = Self-observation; 29 = Sublimation; 30 = Suppression of that difficulty, the patient made sarcastic comments toward the rejected them and became even more oppositional. Toward the therapist and switched to another topic: the relationship with his end of the session, after many therapist’s attempts of interpreting girlfriend. The patient complained a lot about how frustrating this patient’s maladaptive pattern, the patient could finally reflect upon relationship was and justified his anger as the result of feeling too it and became more collaborative. However, his reflections were much pressure and low empathy at the same time. He made lots influenced by generalization, detachment and ambivalence. The of devaluing comments about his girlfriend, although he could still patient described himself as stuck in silence, his inability to talk see some positive aspects of her. Moreover, he reported on a series about his feelings, to see things in a different way. At this point the of passive aggressive behaviors toward a number of people (e.g., patient was able to let the therapist help him and get involved in delay in return phone calls, calling up his ex-girlfriend, feeling a shared exploration of his fears, needs and desires. He reflected bored in the session, feeling the therapist detached from him). Most on his difficulty in listening to his girlfriend’s trouble but somehow of the session was characterized by the patient complaining about justified it as a need of physical connection. However, when the several aspects of his life, including the therapy, in which he had therapist made further interpretations of the patient’s fantasy of experienced ambivalence, detachment and frustration. When the emotional fusion, the patient seemed to reactivate the projective therapist tried to interpret these feelings as defensive responses pattern, which was promptly interrupted by the therapist. This to the experience of a temporary unavailability of significant allowed the patient to keep reflecting in an ambiguous manner people, the patient denied the interpretation and perceived the instead of complaining and activating all sorts of immature defense therapist as manipulative. Despite therapist’s interpretations of his mechanisms. opposition, silence and emotional distancing as reactions to feeling Table 10 displays PND and graphics of patient’s defensive frustrated by not getting what he wants when he wants, the patient functioning, including ODF, defense levels, and individual Frontiers in Psychology | www.frontiersin.org 20 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 21 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q defenses scores. Defensive maturity fell in the range of severe often used for a summary picture of the individual’s defensive depression or personality disorders (ODF < 4; Presniak et al., functioning. Third, the seven defense level proportional scores 2010; Perry and Bond, 2012; Di Giuseppe et al., 2019), with about reflect the prevalent defenses that have common functions at 70% of immature defenses in use during the session, in particular each level, and how much this contributes to ODF. Fourth, the those belonging to disavowal defense level. Looking at the use of 30 individual defense proportional scores provide a picture of individual defense mechanisms, the legend shows that patient’s the patient’s characteristic defense mechanisms, which reflects predominant defenses were help-rejecting complaining, passive the most specific detailed level of defense assessment. These aggression, projecting identification, projection, rationalization, scores can capture differences between similar diagnostic and denial. This defensive constellation indicates a depressive, categories, such as personality disorders (Maffei et al., 1995; resistant and passive aggressive patient inclined to withdraw Lingiardi and Giovanardi, 2017; Di Giuseppe et al., 2019, inside himself and view his problems as externally caused, 2020d; Kramer, 2019), and reflect moment-to-moment micro- instead of dealing with his internal conflicts and external changes during the psychotherapy process (Hilsenroth and stressful situations. Pitman, 2019; Leibovich et al., 2020; Prout et al., 2021). Fifth, in addition to other DMRS measures (Perry, 1990; Di Giuseppe et al., 2020a), the DMRS-Q provides the patient’s defensive profile, a qualitative description of the most characteristic DISCUSSION defensive patterns that contribute to determine the individual’s The utility of studying defenses with the DMRS approach is DPN (see the “Defensive Profile Narratives” in Table 10). that it reveals the psychological function behind the use of Therapists can benefit from the use of all the above DMRS-Q defense mechanisms, the unconscious motives for protecting scoring levels, in particular the individual defenses. These can oneself from intolerable emotional experiences. It could be the guide therapeutic interventions to address desired changes in need of withdrawing anger, the threat of self-esteem failures, the patient’s defensive profile, thereby fostering therapeutic the shame of guilt experienced in confronting with unacceptable alliance and alleviating symptoms. Sixth, another remarkable thoughts and many others. Any of these functions suggests quality of the DMRS-Q is its excellent support for teaching what internal conflicts the individual is experiencing and how defense mechanisms. The use of simple examples of defensive adaptive is his or her defensive functioning. In the present article responses provided by the DMRS-Q items, similar to the we described the theoretical and methodological background examples in the original DMRS Manual (Perry, 1990), can of the DMRS-Q, illustrated its computerized and free-of-charge help the students’ understanding of definitions and functions online use, provided directions for coding and described the of defense mechanisms. Moreover, the five items describing interpretation of results. each defense mechanism can help in understanding differences While the assessment of defense mechanisms has been a in various occurrences of the same defense, especially the controversial issue debated among scholars for more than ones used uncommonly. Seventh, the main unique strengths a century, in recent years research, including that with the of the DMRS-Q system are the short training required for DMRS (Perry, 1990) convinced the American Psychiatric its reliable use, the lack of necessity for transcriptions for Association to include in the DSM-IV a provisional axis coding defenses, and the free unlimited access to the DMRS-Q for the assessment of the hierarchy of defense mechanisms software from any electronic device connected to the internet. (American Psychiatric Association, 1994). However, the The estimated time for a DMRS-Q coding is approximately excellence of this highly valid and reliable method is 15 min for expert trained raters who habitually code more than unfortunately accompanied by its time-consuming training three sessions per week. This allows clinicians to code patients’ and coding costs, which led to the elimination of the defense axis defense mechanisms after each session or a group of sessions in the DSM-5 because of lack of empirical findings supporting and monitoring changes in defensive functioning during the the theory (Vaillant, 1992). therapeutic process (Wampold and Imel, 2015; Tanzilli et al., With the development of the Q-sort version of the 2017, 2018, 2020). DMRS we provided a computerized and easy-to-use clinician- The DMRS-Q has also some limitations that need report measure for the assessment of the whole hierarchy of consideration. First, the DMRS-Q is based on the Q-sort defense mechanisms observable in the routine practice of both methodology, which requests the use of a a priori determined dynamic and non-dynamic practitioners, as other have found forced distribution that might limit the rater’s decision-making (Starrs and Perry, 2018). in the rank-ordering process. Second, the need for sufficient Apart from the well-established theory behind their information on the patient’s defensive functioning is essential to development, the advantages of using this DMRS-based ensure that the rater’s clinical inference for scoring all items into measure are numerous. First, the ODF score informs on how the forced distribution has an adequate evidentiary basis. Finally, adaptive the individual’s defensive reaction is to internal conflicts the evaluation of defensive functioning is made on the overall and external stressful situations. This score can also be used defensive profile including all defensive phenomena observed. as an outcome measure due to its strong correlation with This methodology does not allow for the detection of specific other indexes of well-being. Second, the tripartite defensive defense mechanisms in use in particular moments, which is category proportional scores tell to what extent the patient uses instead possible by applying the original DMRS to transcripts of mature, middle-range and immature defenses. These scores are clinical interviews or therapy sessions. Frontiers in Psychology | www.frontiersin.org 21 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 22 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q According to preliminary validation studies, the DMRS-Q and aiding clinicians in choosing how to intervene in response to seems a valid and reliable tool for the assessment of defense defenses used in the session (Fonagy et al., 2008; Gabbard, 2014; mechanisms in clinical settings, where the requirements for the Conversano, 2021). The use of valid and reliable measures based use of the original DMRS are often unavailable (Di Giuseppe on the gold-standard theory is essential for ensuring that what et al., 2014; Békés et al., 2021). A recent study (Békés et al., 2021) we observe is properly operationalized. The DMRS-Q is an easy- demonstrated that graduate students who received 6-h training to-use, low-cost, computerized tool with promising psychometric reached excellent inter-rated reliability on the ODF (ICC = 0.90), properties can help clinicians in monitoring changes in defense good to excellent on defensive categories (ICC ranging from mechanisms during the treatment, as suggested by others (Bhatia 0.83 to 0.92), and acceptable to excellent on the seven defense et al., 2017; Barber and Solomonov, 2019). The automatic levels (ICC ranging from 0.74 to 0.92), with the only exception scoring procedure provides a comprehensive report of qualitative of major image-distorting defense level (ICC = 0.42) which is and quantitative information on patient’s defensive functioning usually the less reliable scale due to the low base-rate of these that can be used for clinical, research, and teaching purposes. defense mechanisms. On the other hand, non-trained students The ease of use of the DMRS-Q makes this measure a also showed excellent ICC on the ODF (ICC = 0.88) and potential candidate for fostering the observer-rated assessment of acceptable to excellent on most DMRS-Q scales (ICC ranging defense mechanisms in routine clinical practice and in process- from 0.60 to 0.91), except for the obsessional defense level (Békés outcome research. et al., 2021). Good criterion validity was found in both clinical (Di Giuseppe et al., 2014) and community samples (Di Giuseppe et al., 2020a). Moreover, comparisons with mentalization and DATA AVAILABILITY STATEMENT attachment showed great convergent and discriminant validity The raw data supporting the conclusions of this article will be (Tanzilli et al., 2021). These results demonstrated that the DMRS- made available by the authors, without undue reservation. Q has very promising psychometric properties that must be confirmed by future studies on larger and more stratified samples. AUTHOR CONTRIBUTIONS CONCLUSION The authors contributed in equal part to this work and approved The systematic assessment of defense mechanisms in clinical it for publication. Both authors contributed to the article and settings is very important for monitoring the therapeutic process approved the submitted version. Conversano, C., and Di Giuseppe, M. (2021). Psychological factors as determinants REFERENCES of chronic conditions: clinical and psychodynamic advances. Front. Psychol. American Psychiatric Association (1994). Diagnostic and Statistical Manual of 12:635708. doi: 10.3389/fpsyg.2021.635708 Mental Disorders, 4th Edn. Washington, DC: American Psychiatric Association. Cramer, P. (1987). The development of defense mechanisms. J. Pers. 55, 597–614. American Psychiatric Association (2013). Diagnostic and Statistical Manual of doi: 10.1111/j.1467- 6494.1987.tb00454.x Mental Disorders, 5th Edn. Washington, DC: American Psychiatric Publishing. Cramer, P. (2015). Defense mechanisms: 40 years of empirical research. J. Pers. Barber, J. P., and Solomonov, N. (2019). Toward a personalized approach to Assess. 97, 114–122. doi: 10.1080/00223891.2014.947997 psychotherapy outcome and the study of therapeutic change. World Psychiatry Di Giuseppe, M., Gennaro, A., Lingiardi, V., and Perry, J. C. (2019). The role of 18, 291–292. doi: 10.1002/wps.20666 defense mechanisms in emerging personality disorders in clinical adolescents. Békés, V., Prout, T. A., Di Giuseppe, M., Wildes Ammar, L., Kui, T., Arsena, G., Psychiatry 82, 128–142. doi: 10.1080/00332747.2019.1579595 et al. (2021). Initial validation of the defense mechanisms rating scales Q-sort: Di Giuseppe, M., Perry, J. C., Lucchesi, M., Michelini, M., Vitiello, S., Piantanida, a comparison of trained and untrained raters. Mediterr. J. Clin. Psychol. 9. A., et al. (2020a). Preliminary reliability and validity of the DMRS-SR-30, a novel doi: 10.13129/2282- 1619/mjcp- 3107 self-report based on the defense mechanisms rating scales. Front. Psychiatry Berney, S., de Roten, Y., Beretta, V., Kramer, U., and Despland, J. N. (2014). 11:870. doi: 10.3389/fpsyt.2020.00870 Identifying psychotic defenses in a clinical interview. J. Clin. Psychol. 70, Di Giuseppe, M., Prout, T. A., Fabiani, M., and Kui, T. (2020b). Defensive profile 428–439. of parents of children with externalizing problems receiving regulation-focused Bhatia, M., Petraglia, J., de Roten, Y., and Drapeau, M. (2017). Do therapists psychotherapy for children (RFP-C): a pilot study. Mediterr. J. Clin. Psychol. 8. practicing psychoanalysis, psychodynamic therapy and short-term dynamic doi: 10.6092/2282- 1619/mjcp- 2515 therapy address patient defences differently? Arch. Psychiatry Psychother. 19, Di Giuseppe, M., Miniati, M., Miccoli, M., Ciacchini, R., Orrù, G., Lo Sterzo, R., 7–14. doi: 10.12740/APP/69642 et al. (2020c). Defensive responses to stressful life events associated with cancer Block, J. (1978). The Q–Sort Method in Personality Assessment and Psychiatric diagnosis. Mediterr. J. Clin. Psychol. 8, 1–22. doi: 10.6092/2282- 1619/mjcp- Research. Palo Alto, CA: Consulting Psychologists Press. 2384 Boldrini, T., Lo Buglio, G., Giovanardi, G., Lingiardi, V., and Salcuni, S. (2020). Di Giuseppe, M., Perry, J. C., Conversano, C., Gelo, O. C. G., and Gennaro, Defense mechanisms in adolescents at high risk of developing psychosis: an A. (2020d). Defense mechanisms, gender, and adaptiveness in emerging empirical investigation. Res. Psychother. 23:456. doi: 10.4081/ripppo.2020.456 personality disorders in adolescent outpatients. J. Nerv. Ment. Dis. 208, 933– Brown, S. R. (1993). A primer on Q methodology. Operant Subjectivity 16, 91–138. 941. doi: 10.1097/NMD.0000000000001230 Brown, S. R. (1995). Q methodology as the foundation for a science of subjectivity. Di Giuseppe, M., Nepa, G., Prout, T. A., Albertini, F., Marcelli, S., Orrù, G., et al. Operant Subjectivity 18, 1–16. (2021). Stress, burnout, and resilience among healthcare workers during the Conversano, C. (2021). The psychodynamic approach during COVID-19 COVID-19 emergency: the role of defense mechanisms. Int. J. Environ. Res. emotional crisis. Front. Psychol. 12:670196. doi: 10.3389/fpsyg.2021.670196 Public Health 18:5258. doi: 10.3390/ijerph18105258 Frontiers in Psychology | www.frontiersin.org 22 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 23 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q Di Giuseppe, M., Perry, J. C., Petraglia, J., Janzen, J., and Lingiardi, V. (2014). Perry, J. C., and Henry, M. (2004). Studying defense mechanisms in psychotherapy Development of a Q-sort version of the defense mechanism rating scales using the defense mechanism rating scales. Def. Mech. 136, 165–186. (DMRS-Q) for clinical use. J. Clin. Psychol. 70, 452–465. doi: 10.1002/jclp.22 Presniak, M. D., Olson, T., and MacGregor, M. W. (2010). The role of defense 089 mechanisms in borderline and antisocial personalities. J. Pers. Assess. 92, 137– Drapeau, M., de Roten, Y., Perry, J. C., and Despland, J. N. (2003). A study of 145. doi: 10.1080/00223890903510373 stability and change in defense mechanisms during a brief psychodynamic Prout, T. A., Rice, T., Chung, H., Gorokhovsky, Y., Murphy, S., and Hoffman, L. investigation. J. Nerv. Ment. Dis. 191, 496–502. doi: 10.1097/01.nmd. (2021). Randomized controlled trial of regulation focused psychotherapy for 0000082210.76762.ec children: a manualized psychodynamic treatment for externalizing behaviors. Fonagy, P., Gergely, G., and Target, M. (2008). “Psychoanalytic constructs and Psychother. Res. 1–16. doi: 10.1080/10503307.2021.1980626 attachment theory and research,” in Handbook of Attachment: Theory, Research, Starrs, C. J., and Perry, J. C. (2018). Coping action patterns as mechanisms of and Clinical Applications, eds J. Cassidy and P. R. Shaver (New York, NY: The change across psychotherapies: three case examples of personality disorders Guilford Press), 783–810. with recurrent major depression. J. Pers. Disord. 32, 58–74. doi: 10.1521/pedi. Freud, S. (1894). “The neuro-psychoses of defence,” in The Standard Edition of 2018.32.supp.58 the Complete Psychological Works of Sigmund Freud (1893–1899) Early Psycho- Tanzilli, A., Di Giuseppe, M., Giovanardi, G., Boldrini, T., Caviglia, G., Conversano, Analytic Publications, Vol. 3, ed. Strachey, J. (London: The Hogarth Press). C., et al. (2021). Mentalization, attachment, and defense mechanisms: a Gabbard, G. O. (2014). Psychodynamic Psychiatry in Clinical Practice, 5th Edn. psychodynamic diagnostic manual-2-oriented empirical investigation. Res. Washington, DC: American Psychiatric Association Publishing. Psychother. 24:531. doi: 10.4081/ripppo.2021.531 Hilsenroth, M. J., and Pitman, S. R. (2019). “Working with cyclical relational Tanzilli, A., Gualco, I., Baiocco, R., and Lingiardi, V. (2020). Clinician patterns in contemporary psychodynamic psychotherapy,” in Contemporary reactions when working with adolescent patients: the therapist response Psychodynamic Psychotherapy, eds D. Kealy and J. S. Ogrodniczuk (Cambridge, questionnaire for adolescents. J. Pers. Assess. 102, 616–627. doi: 10.1080/ MA: Academic Press), 19–31. 00223891.2019.1674318 Hilsenroth, M. J., Callahan, K. L., and Eudell, E. M. (2003). Further reliability, Tanzilli, A., Lingiardi, V., and Hilsenroth, M. (2018). Patient SWAP-200 convergent and discriminant validity of overall defensive functioning. J. Nerv. personality dimensions and FFM traits: do they predict therapist responses? Ment. Dis. 191, 730–737. doi: 10.1097/01.nmd.0000095125.92493.e8 Pers. Disord. 9, 250–262. doi: 10.1037/per0000260 Hoffman, L., Rice, T., and Prout, T. A. (2016). Manual of Regulation- Tanzilli, A., Muzi, L., Ronningstam, E., and Lingiardi, V. (2017). Focused Psychotherapy for Children (RFP-C) with Externalizing Behaviors: A Countertransference when working with narcissistic personality disorder: an Psychodynamic Approach. Abingdon-on-Thames: Routledge. empirical investigation. Psychotherapy 54, 184–194. doi: 10.1037/pst0000111 Hoglend, P., and Perry, J. C. (1998). Defensive functioning predicts improvement Vaillant, G. E. (1971). Theoretical hierarchy of adaptive ego mechanisms: a 30-year in treated major depressive episodes. J. Nerv. Ment. Dis. 186, 238–243. follow-up of 30 men selected for psychological health. Arch. Gen. Psychiatry 24, Kernberg, O. F. (1988). Object relations theory in clinical practice. Psychoanal. Q. 107–118. doi: 10.1001/archpsyc.1971.01750080011003 57, 481–504. Vaillant, G. E. (1977). Adaptation to Life. Boston, MA: Little, Brown. Kramer, U. (2019). Personality, personality disorders, and the process of change. Vaillant, G. E. (1992). Ego Mechanisms of Defense: A Guide for Clinicians and Psychother. Res. 29, 324–336. doi: 10.1080/10503307.2017.1377358 Researchers. Washington, DC: American Psychiatric Press. Leibovich, L., Front, O., McCarthy, K. S., and Zilcha-Mano, S. (2020). How do Wampold, B. E., and Imel, Z. E. (2015). The Great Psychotherapy Debate: The supportive techniques bring about therapeutic change: the role of therapeutic Evidence for What Makes Psychotherapy Work, 2nd Edn. New York, NY: alliance as a potential mediator. Psychotherapy 57, 151–159. doi: 10.1037/ Routledge. pst0000253 Lingiardi, V., and Giovanardi, G. (2017). Challenges in assessing personality of Conflict of Interest: The authors declare that the research was conducted in the individuals with gender dysphoria with the SWAP-200. J. Endocrinol. Invest. absence of any commercial or financial relationships that could be construed as a 40, 693–703. doi: 10.1007/s40618- 017- 0629- 7 potential conflict of interest. Lingiardi, V., Lonati, C., Delucchi, F., Fossati, A., Vanzulli, L., and Maffei, C. (1999). Defense mechanisms and personality disorders. J. Nerv. Ment. Dis. 187, Publisher’s Note: All claims expressed in this article are solely those of the authors 224–228. doi: 10.1097/00005053- 199904000- 00005 and do not necessarily represent those of their affiliated organizations, or those of Maffei, C., Fossati, A., Lingiardi, V., Madeddu, F., Borellini, C., and Petrachi, the publisher, the editors and the reviewers. Any product that may be evaluated in M. (1995). Personality maladjustment, defenses, and psychopathological this article, or claim that may be made by its manufacturer, is not guaranteed or symptoms in nonclinical subjects. J. Pers. Disord. 9, 330–345. doi: 10.1521/pedi. endorsed by the publisher. 1995.9.4.330 Perry, J. C. (1990). Defense Mechanism Rating Scales (DMRS), 5th Edn. Cambridge, Copyright © 2021 Di Giuseppe and Perry. This is an open-access article distributed MA: Perry, JC. under the terms of the Creative Commons Attribution License (CC BY). The use, Perry, J. C. (2014). Anomalies and specific functions in the clinical identification of distribution or reproduction in other forums is permitted, provided the original defense mechansims. J. Clin. Psychol. 70, 406–418. doi: 10.1002/jclp.22085 author(s) and the copyright owner(s) are credited and that the original publication Perry, J. C., and Bond, M. (2012). Change in defense mechanisms during long-term in this journal is cited, in accordance with accepted academic practice. No use, dynamic psychotherapy and five-year outcome. Am. J. Psychiatry 169, 916–925. distribution or reproduction is permitted which does not comply with these terms. Frontiers in Psychology | www.frontiersin.org 23 October 2021 | Volume 12 | Article 718440 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Frontiers in Psychology Pubmed Central

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

Frontiers in Psychology , Volume 12 – Oct 15, 2021

Loading next page...
 
/lp/pubmed-central/the-hierarchy-of-defense-mechanisms-assessing-defensive-functioning-YshUQOf1sm

References (86)

Publisher
Pubmed Central
Copyright
Copyright © 2021 Di Giuseppe and Perry.
eISSN
1664-1078
DOI
10.3389/fpsyg.2021.718440
Publisher site
See Article on Publisher Site

Abstract

fpsyg-12-718440 October 11, 2021 Time: 15:58 # 1 METHODS published: 15 October 2021 doi: 10.3389/fpsyg.2021.718440 The Hierarchy of Defense Mechanisms: Assessing Defensive Functioning With the Defense Mechanisms Rating Scales Q-Sort 1 2 Mariagrazia Di Giuseppe and J. Christopher Perry 1 2 Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy, McGill University Department of Psychiatry at the Institute of Community and Family Psychiatry, Jewish General Hospital, Montreal, QC, Canada 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. Edited by: Despite the availability of a large number of measures for their evaluation, only a few Annalisa Tanzilli, instruments assess the whole hierarchy of defenses, based on the Defense Mechanisms Sapienza University of Rome, Italy Rating Scales (DMRS), which arguably offers an observer-rated gold standard Reviewed by: of assessment. The present article illustrates the theoretical and methodological Attà Negri, University of Bergamo, Italy background of the DMRS-Q, the Q-sort version of the DMRS for clinical use. Starting Laura Muzi, from the definition and function of the 30 defense mechanisms included in the University of Perugia, Italy Emanuela Brusadelli, hierarchy, we extracted 150 items that captured a full range of defensive manifestations University of Wollongong, Australia according to the DMRS theory. The DMRS-Q set is described in this paper with *Correspondence: reference to the DMRS manual. Directions are also provided for using the DMRS-Q Mariagrazia Di Giuseppe online software for the free and unlimited coding of defense mechanisms. After each [email protected] coding, the DMRS-Q software provides a report including qualitative and quantitative Specialty section: scores reflecting the individual’s defensive functioning. Qualitative scores are displayed This article was submitted to as the Defensive Profile Narratives (DPN), while quantitative scores are reported Psychopathology, a section of the journal as Overall Defensive Functioning (ODF), defensive categories, defense levels, and Frontiers in Psychology individual defense mechanisms. Syntax for the scoring is displayed in the results and Received: 31 May 2021 a clinical vignette of a psychotherapy session coded with the DMRS-Q is provided. Accepted: 24 September 2021 Published: 15 October 2021 The DMRS-Q is an easy-to-use, free, computerized measure that can help clinicians Citation: in monitoring changes in defense mechanisms, addressing therapeutic intervention, Di Giuseppe M and Perry JC fostering symptoms decreasing and therapeutic alliance. Moreover, the DMRS-Q might (2021) The Hierarchy of Defense Mechanisms: Assessing Defensive be a valid tool for teaching the hierarchy of defense mechanisms and increase the Functioning With the Defense observer-rated assessment of this construct in several research fields. Mechanisms Rating Scales Q-Sort. Front. Psychol. 12:718440. Keywords: defense mechanism, DMRS, Q-sort, assessment, personality, emotion regulation, psychotherapy, doi: 10.3389/fpsyg.2021.718440 process-outcome Frontiers in Psychology | www.frontiersin.org 1 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 2 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q not included in the DMRS manual although they can be INTRODUCTION assessed using another DMRS-derived measure, the Psychotic- The psychodynamic concept of defense mechanisms, defined DMRS (P-DMRS; Berney et al., 2014; Boldrini et al., 2020). as automatic psychological mechanisms that mediate the Defense levels can be further organized into three defensive individual’s reaction to emotional conflicts and to internal or categories of relatively similar degree of maturity, often used external stressors (American Psychiatric Association, 2013; Perry, for describing in summary the individual defensive functioning. 2014), has been extensively studied since its first appearance The three defensive categories, from the least to the most in Freud’s psychoanalytic theory (Freud, 1894). After a century adaptive, respectively, include immature, neurotic and mature of clinical and theoretical work, and a quarter century of defenses. The immature defensive category is the most populated empirical research, an assessment of defense mechanisms was and includes all defenses belonging to action, disavowal and included in an Axis for the assessment of defense mechanisms both image distortion defense levels. This defensive category in the DSM-IV (Cramer, 1987, 2015; Kernberg, 1988; American can be further divided into two subcategories. The first is Psychiatric Association, 1994; Hoffman et al., 2016). The main named depressive defenses, including acting out, help-rejecting contribution to the gold-standard approach to the study of complaining, passive aggression, splitting of self-image, splitting defense mechanisms has been provided by the theory of of other’s image, projective identification, projection, devaluation defensive adaptiveness and the hierarchical organization of of self-image, and devaluation of other’s image. The second defense mechanisms proposed by Vaillant (1971, 1992) and subcategory is the non-depressive defenses, including denial, operationalized by Perry (1990). In his extensive and valuable rationalization, autistic fantasy, omnipotence, idealization of work, Vaillant described excellent clinical vignettes of defenses self-image, and idealization of other’s image. Greater reliance as they operate in real life – both in momentary examples, and on immature defenses informs on the subject’s defensive those that recur over time – and integrated findings from several vulnerability and his or her scarce awareness of both emotional longitudinal studies demonstrating the evolution of defense and cognitive sides of internal conflicts or external stressful mechanisms over the life cycle. With the development of the situations. These defenses inhibit awareness of unacceptable Defense Mechanisms Rating Scales (DMRS), Perry has provided a ideas, feelings, and actions, bypassing them to protect oneself comprehensive, accurate and valid observer-rated methodology from feeling threatened. for assessing individual’s defensive functioning based on the The neurotic defensive category represents the middle-range whole hierarchy of defense mechanisms (Perry and Henry, 2004). of adaptiveness and includes all defenses belonging to neurotic In recent years, the authors of this paper have adapted the and obsessional defense levels. High use of these middle-range DMRS theory to additional assessment methods, by developing defenses describes the individual’s ability to deal with either both the Q-sort version (DMRS-Q; Di Giuseppe et al., 2014) the emotional or the cognitive side of internal or external and the self-report version (DMRS-SR-30; Di Giuseppe et al., stressors, which can be handled one at a time. These defenses 2020a) of the DMRS. Our main aim was to provide new measures help the individual in keeping out of awareness parts of the based on the DMRS theory of defense mechanisms applicable in conflict (e.g., associated feelings, desires and thoughts), which different clinical or research contexts, without the requirement would generate intolerable anxiety if perceived as an integrated of training for their valid and reliable use (Békés et al., 2021; psychological experience. Finally, the mature defensive category Conversano and Di Giuseppe, 2021). In this article, we describe corresponds to the high-adaptive defense level and includes theoretical background, coding procedure, scoring system and the most adaptive defense mechanisms, which overlap with results interpretation of the DMRS-Q, a computerized observer- what are called positive coping strategies in other theoretical rated Q-sort for the assessment of defense mechanisms in frameworks. High use of mature defenses fosters the integrated clinical setting. and partially aware experience of feelings, ideas, desires and thoughts associated to an internal conflict or external stressful The Hierarchy of Defense Mechanisms situation. These defenses help the individual in dealing with All DMRS-based measures refer to the generally accepted his or her psychologically stressful experiences by integrating hierarchy of defense mechanisms (American Psychiatric affects with ideas, therefore optimizing and possibly resolving the Association, 1994, 2013; Hoglend and Perry, 1998; Lingiardi internal or external cause of distress (Vaillant, 1977, 1992). This et al., 1999; Drapeau et al., 2003; Hilsenroth et al., 2003; Perry, tripartite model of DMRS hierarchical organization of defenses 2014; Di Giuseppe et al., 2019, 2021; Tanzilli et al., 2021). is often used for summarizing the defensive maturity of an A graphical summary of the hierarchy of defense mechanisms is individual by looking at the proportional scores obtained in each shown in Figure 1. of the three defensive categories. This hierarchy describes 30 defense mechanisms organized For a deeper understanding of individual’s defensive into seven defense levels, each of which has some general functioning, the seven defense levels can be used as the generally functions that the constituent defenses share in how they protect accepted hierarchical organization of defense mechanisms the individual from anxiety, or a sense of threat from internal or (American Psychiatric Association, 1994). Defense levels external sources, or conflicts. differentiate one from another for their defensive function In addition to the seven defense levels, there is level and level of adaptiveness, which are described in Table 1. 0, describing defensive dysregulation, the so-called Psychotic Their assessment may inform about the most used defensive Defenses Level. Defenses belonging to this defense level are patterns, which reveal what defensive function is more frequently Frontiers in Psychology | www.frontiersin.org 2 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 3 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q FIGURE 1 | The DMRS hierarchical organization of defensive categories, defense levels and individual defenses. Table adapted from Perry and Bond (2012), Table 1. So-called depressive defenses are in bold. activated in response to internal conflicts or external stressors. Training individuals to rate defenses reliably is time For example, two individuals who use 40% of defenses belonging consuming, as are making the ratings themselves, both of which to the neurotic defensive category can have a very different limit the use of such ratings in clinical setting. While the DMRS is defensive profile depending on whether they use a more necessary for some types of research, we developed the DMRS-Q obsessional or neurotic defense level. Similarly, high use of to meet the needs of a quicker, more user-friendly computerized action and major image-distorting defense levels is very different tool for the assessment of defense mechanisms in clinical setting from high use of disavowal and minor image-distorting defense (Di Giuseppe et al., 2020b,c). levels, although they are all included in the immature defensive The present article aims to illustrate the DMRS-Q and category. Furthermore, these differentiations among individuals’ its assessment and scoring methodology. We will provide the defensive functioning are extremely evident when we look at the definition and function of 30 defense mechanisms as reported in deepest level of investigation, the individual’s use of 30 individual the DMRS manual (Perry, 1990) and present the five DMRS-Q defense mechanisms. items corresponding to each defense mechanisms. Moreover, we Frontiers in Psychology | www.frontiersin.org 3 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 4 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 1 | The defensive function of the seven hierarchically ordered defense levels. Level 7: High adaptive High adaptive defenses are the individual’s most adaptive ways of handling stressors and are often considered synonymous of positive defenses coping. Internal or external stressors are fully perceived without distortion and the need to adapt to them is fully appropriated to oneself. The individual attempts to maximize the positive expression and gratification of his or her own motives, acknowledging limitations of the self and recurring to external sources of help when available. Level 6: Obsessional Obsessional defenses protect the individual from the awareness of unacceptable or threatening feelings associated with an idea (e.g., wish, defenses fear, experience, memory, or though) by keeping distance from emotions, while remaining aware of the idea itself. As a result, feelings (emotional component) are largely kept out of awareness and indirectly expressed throughout minimization, generalization, or a series of contradictory statements. Level 5: Neurotic Neurotic defenses reflect the experience that awareness of a wish, thought, or motive is unacceptable or threatening and must be kept out of defenses awareness. The individual can experience feelings associated to an internal conflict or external stressor as long as full awareness of the idea (cognitive component) is blocked and expressed indirectly by way of a series of anomalous clues. Neurotic defenses are the most protean of all defense mechanisms, in that there are a seemingly infinite variety of ways to give partial expression of repressed ideas. Level 4: Minor Minor image-distorting defenses protect the individual from experiences that affect one’s self esteem, such as failure, criticism, or image-distorting disappointment that cause feelings of weakness, powerlessness, or shame. These defenses temporarily prop up self-esteem and strengthen defenses self-image by using image-distortion to dismiss any threatening aspect of the stressor. These distortions are not all encompassing like those of the major image-distorting defenses. Nonetheless, they don’t actually improve adaptation to the stressors. Level 3: Disavowal Disavowal defenses reflect the perception of the individual that some aspects of internal experience external reality are unacceptable. By defenses and autistic refusing to acknowledge these aspects of experience, the individual justifies not appropriating a problem as his or her own. The individual can fantasy further misattribute the problem to another source or reason, further covering up internal reality. This results in a failure both to acknowledge one’s own role in the origins of a problem and to consider potential ways of handling the immediate problem, given the assertion that one has no such role. Level 2: Major Major image-distorting defenses protect the individual from intolerable anxiety when self or object representations of conflicting meaning are image-distorting triggered. The individual keeps positive and negative representations separated and simplify the perception of self and others as either all defenses good, powerful, and invulnerable or all bad, unworthy, powerless, and vulnerable. The individual then treats these distorted images in ways consistent with this perception. These defenses protect the self from the anxiety attending a sense of imminent threat of being punished, physically or psychologically abused, abandoned, or even killed. However, oversimplifying self or others and reacting accordingly produces the negative consequent that others withdraw or react negatively. Level 1: Action Action defenses reflect the perception of the individual that the immediate source of stress or conflict is external and that the experience is defenses intolerable. The individual’s perception overlooks the internal sources of the distress, such as personal unacceptability of or limitations in awareness of one’s own wishes, fears, and inhibitions. Unable to contain attendant distress, these defenses operate to engage, manipulate, or counterattack the apparent external source. These defenses lead the individual to impulsive action on the environment or oneself, thereby releasing tension, gratifying wishes, and/or avoiding fears. However, this is done without anticipating negative consequences. Extensive description of defense levels published in Perry (2014). will provide instructions for coding defenses with the DMRS- the coverage of manifestations of each DMRS defense, rather Q online software and syntax for the scoring. Finally, we than on maximizing internal consistency of the items to will provide directions for data interpretations of the DMRS-Q overall defense score. This methodological approach was based qualitative and quantitative output. on author’s hypothesis that reproducing the widely validated DMRS in an easy-to-use Q-sort version would guarantee strong psychometric properties because of the gold-standard theoretical background. Although we are aware that this is far from the METHODS usual methodological approach applied for the development of new psychometric tools, our preliminary analyses on validity Measure Development and reliability of the DMRS-Q (Di Giuseppe et al., 2014; Békés Based on the DMRS definition and function, and discriminations et al., 2021; Tanzilli et al., 2021) confirmed our hypothesis on from near-neighbor defenses, we developed a pool of 300 items – the importance of a strong theoretical base for a measure with 10 statements for each defense mechanism – that refer to statistically relevant properties. verbal and nonverbal expressions, distorted perceptions, personal mental states, relational dynamics, and way of coping that Definitions and Function of Defense emerge on occasions when the subject experiences internal or Mechanisms and Defense Mechanisms external stress or conflict. A group of researchers trained on the DMRS was asked to indicate the five items for each defense Rating Scales Q-Sort Items mechanism that best captured a full range of manifestations The DMRS-Q provides five items for each of the 30 defense according to the DMRS criteria. Following reviewers’ comments mechanisms included in the hierarchy. A comprehensive and basing on item’s clarity, simplicity, and non-redundancy, overview of definitions, functions and DMRS-Q items is we selected the best five items for each defense mechanisms provided below. Tables 2–8 display DMRS-Q items for each obtaining a final set of 150 items that constitute the DMRS- defense included in each defense level; they are reported Q. We decided to select the DMRS-Q item pool, based on in descending order of defensive maturity. The following descriptions of the individual defenses are reproduced or adapted https://webapp.dmrs- q.com/login from the DMRS manual (Perry, 1990), with permission of the Frontiers in Psychology | www.frontiersin.org 4 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 5 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q author, JP to provide the definitional basis for the DMRS-Q High-Adaptive Defense Level: Anticipation items in Tables 2–8. Definition The individual mitigates emotional conflicts, or internal or High-Adaptive Defense Level: Affiliation external stressors, by not only considering realistic, alternative Definition solutions and anticipating emotional reactions to future The individual deals with emotional conflicts, or internal or problems, but experiencing the future distress by mentally external stressors, by turning to others for help or support. bringing the distressing ideas and affects together. This rehearsal By affiliating with others, the individual can express him or allows the individual to prepare a better adaptive response to the herself, confide problems, and feel less alone or isolated with anticipated conflict or stressor. a conflict or problem. This may also result in receiving advice Function or concrete help from the “auxiliary ego” that improves the Using anticipation allows the individual to mitigate the effects individual’s ability to cope. Confiding leads to an increase in of future stressors or conflicts. It requires being able to tolerate the individual’s coping capacity as the other individual supplies the anxiety attendant to imagining how a future situation may emotional validation and support. Affiliation does not include be distressing. By affective rehearsal (e.g., ‘how will I feel trying to make someone else responsible for dealing with one’s when this occurs?’) and planning future responses, the subject own problems, nor does it imply coercing someone to help, or decreases distressing aspects of the future stressor. Anticipation acting helpless to elicit help. Affiliation is not shown simply by also increases the likelihood of positive external outcomes and belonging to an organization (e.g., church, social club, Alcoholics more positive emotional responses. Anonymous) or by seeing a counselor or therapist. Rather it is demonstrated by the give and take around conflicts and problems High-Adaptive Defense Level: Humor that occurs in the context of belonging to the organization, or by Definition the confiding with others. The individual deals with emotional conflicts, or internal or external stressors, by emphasizing the amusing or ironic aspects Function of the conflict or stressor. Humor tends to relieve the tension Affiliation allies the individual’s emotional attachment needs with around conflict in a way that allows everyone to share in the wish to cope effectively with internal conflict or external it, rather than being at one person’s expense, as in derisive stressors. The ability to cope is enhanced by seeking support or cutting remarks. An element of self-observation or truth from others, while attachment needs are also satisfied. Others is often involved. may enhance the individual’s repertoire of ego skills by help with advice, modeling, planning, judgment, role playing, practicing, Function etc. Usually this is accompanied by a reduction in subjective Humor allows some expression of affects and wishes that are tension achieved through expressing one’s feelings and sharing involved with conflict or stressor. Whenever conflict or external one’s conflicts. stressors block full expression of the affects or satisfaction of wishes, humor allows some symbolic expression of them and of High-Adaptive Defense Level: Altruism the source of the conflict. The frustration emanating from the Definition conflict is transiently relieved in a way that both self and others The individual deals with emotional conflicts, or internal or can smile or laugh at. This is especially evident around issues of external stressors, by dedication to fulfilling the needs of others, the human condition in which certain stressors are inescapable. in part as a way of fulfilling his or her own needs. By using altruism, the individual receives some partial gratification either High-Adaptive Defense Level: Self-Assertion vicariously or as a response from others. The subject is usually Definition aware to some extent that his or her own needs or feelings The individual deals with emotional conflicts, or internal or underlie altruistic actions. There may also be a direct reward external stressors, by expressing one’s feelings and thoughts or overt self-interested reason for the subject’s altruistic actions. directly to achieve goals. Self-assertion is not coercive or indirect To rate altruism present, there must be a clear, demonstrable, and manipulative. The goal or purpose of the self-assertive functional relationship between the individual’s feelings and the behavior is usually made clear to all parties affected by it. altruistic response. Function Function Self-assertion deals with emotional conflict through the direct Altruism gratifies social and attachment needs while dealing expression of one’s feelings or wishes, and thereby relieves the with emotional conflict through helping others. In many cases, anxiety or distress that occurs whenever internal or external the conflict revolves around distress over past examples of countervailing forces prevent expression. Self-assertion does not confronting stressful situations for which one needed help that require that the individual get his or her own way to be successful was somehow unavailable or insufficient. Altruism channels as a defense or adaptive response. Rather, it is also emotionally affects, such as anger, and experiences, such as powerlessness, into useful because it allows the individual to function (1) without the socially helpful responses that also enhance the individual’s sense anxiety or tension that builds whenever feelings and wishes are of mastery over the past. unexpressed and (2) without a sense of shame or guilt for not Frontiers in Psychology | www.frontiersin.org 5 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 6 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q speaking up for oneself in emotionally conflictual situations. The activity which one must do (e.g., not dwelling on tangential emotional consequences are worse when self-assertion is blocked problems in order to deal with one pressing problem). The by internal prohibitions, rather than by external factors alone, individual can call the suppressed material back to conscious such as by a domineering person in authority. attention readily, since it is not forgotten. Function High-Adaptive Defense Level: Self-Observation Suppression keeps both the idea and affect associated with Definition a stressor out of awareness in the service of attending to The individual deals with emotional conflicts, or internal or something else; however, suppressed material may be voluntarily external stressors, by reflecting on his or her own thoughts, brought back into full awareness. Distressing feelings are feelings, motivation, and behavior. The person can “see himself acknowledged but dealing with them is postponed until the as others see him” in interpersonal situations, and as a result is subject feels more able or the timing is more appropriate. better able to understand other people’s reactions to him or her. Neurotic anxiety is minimized, since the material is not repressed, The defense is not synonymous with simply making observations although anticipatory anxiety may still be present until the or talking about oneself. stressor is dealt with. Function This defense allows the person to make the best adaptation to Obsessional Defense Level: Isolation of Affects the demands of external reality based on having an accurate view Definition of one’s own affects, wishes and impulses, and behavior. While The individual deals with emotional conflicts, or internal or self-observation does not change one per se, it is a precursor for external stressors, by being unable to experience simultaneously seeking better adaptations of internal states to external reality. the cognitive and affective components of an experience, because This defense allows the individual to grow and adapt better as the affect is kept from consciousness. In the defense of isolation, he or she deals with stress. the subject loses touch with the feelings associated with a given idea (e.g., a traumatic event) while remaining aware of High-Adaptive Defense Level: Sublimation the cognitive elements of it (e.g., descriptive details). Only the Definition affect is lost or detached while the idea is conscious. It is the The individual deals with emotional conflicts, or internal converse of repression, where the affect is retained but the or external stressors, by channeling rather than inhibiting idea is detached and unrecognized. Sometimes the affect can potentially maladaptive feelings or impulses into socially be detached temporarily from its associated idea. The affect acceptable behavior. This defense is to be rated present only when is felt later without association to the original experience and a strong functional relationship can be demonstrated between idea. Instead, there is an intervening neutral interval between the feelings and response pattern. Classic examples of the use of cognizance of the idea and experience of the associated affects. sublimation are sports and games used to channel angry impulses, Function or artistic creation that expresses conflicted feelings. Individuals who feel threatened by or anxious over the conscious Function experience of feelings can still deal with the related ideas and Sublimation allows the expression of wishes, impulses, or affects events comfortably when their associated affects are separated that the subject voluntarily inhibits because of their potentially and kept out of awareness. Very often the isolated affects are negative social repercussions. The subject channels them instead associated with anxiety, shame, or guilt that would emerge if into socially acceptable expression. The original aims and experienced directly. The tradeoff for avoiding the associated objects of the impulses, wishes, and affects are often modified anxiety, shame, or guilt is that the individual misses out considerably, resulting in a creative activity or product. For on experiencing the feelings in a way that adds evaluative example, a hostile-competitive urge may be channeled into information and which may be useful in making choices. competitive sports or work, or sexual impulses may be expressed through creative dance or art. The result of sublimation is that Obsessional Defense Level: Intellectualization the original impulses, etc. are allowed some expression while the Definition resulting activity or product may also bring some positive social The individual deals with emotional conflicts, or internal or approval or reward. external stressors, by the excessive use of abstract thinking to avoid disturbing feelings. High-Adaptive Defense Level: Suppression Definition Function The individual deals with emotional conflicts, or internal Intellectualization is a defense against affects or impulses in or external stressors, by voluntarily avoiding thinking about which the idea representing the affect or impulse is kept disturbing problems, wishes, feelings, or experiences temporarily. conscious and expressed as a generalization, thereby detaching or This may entail putting things out of one’s mind until the right distancing the subject from the affect or impulse itself. The felt time to deal with them: it is postponing not procrastinating. quality of emotions is lost, as is the urge in any impulse. The Suppression may also entail avoiding thinking about something cognitive elements remain conscious, although in generalized at the time because it would distract from engaging in another or impersonal terms. The subject commonly refers to his or Frontiers in Psychology | www.frontiersin.org 6 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 7 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 2 | High-adaptive defense level: Definition, function and DMRS-Q items of defenses affiliation, altruism, anticipation, humor, self-assertion, self-observation, sublimation, and suppression. Defense DMRS-Q items mechanism Affiliation ITEM 22: Whenever the subject brings a personal problem to someone for help or advice, the subject is not expecting the other to take care of it, but rather to help come up with a solution which the subject will then implement. ITEM 25: The subject describes an important conflict or external stress in which affiliation played a major emotional role in coping as evident by the description of characteristics of the help received, the individuals or organization involved, and the sense that something was taken away from the experience. ITEM 44: When the subject describes seeking help from others, there is a sense of having learned something from the interchange. ITEM 66: When confronted with emotional conflict or stressful situations, the subject describes confiding in someone. Emotionally meaningful sharing led to enhancement of coping skills, or direct assistance beyond what the subject would have done alone. ITEM 93: When dealing with an emotionally difficult situation, the subject reports that talking to others helps the subject think through how best to handle the problem. Altruism ITEM 11: The subject helps others who are experiencing a problem they cannot adequately deal with alone. The problem appears to have a personal meaning to the subject related to similar experiences in the subject’s past (e.g., ‘It made me feel good to help someone in the same position that I once found so difficult.’). ITEM 15: The subject finds it personally rewarding to help others who are suffering. The subject participates in organizations or groups that help other people in direct person-to-person ways. In this context, the subject gives direct help to others, which the subject apparently finds rewarding. ITEM 104: The subject reacts to a difficult or dangerous situation for someone else by interposing him or herself to protect the other person. While not reckless, the subject may put him or herself at personal physical or material risk in doing so. ITEM 132: The subject helps others who are at a loss to cope with a problem or situation, possibly including standing up to authority. It is clear that the subject obtains some personal gratification or mastery from the meaning of helping, beyond any overt reward obtained. Anticipation ITEM 43: Ahead of an important performance or occasion, the subject practices imagining him or herself in the situation to be both better prepared and less anxious. ITEM 46: The subject describes small events in his or her life in which he or she characteristically mentions thinking about their outcomes ahead of time and emotionally preparing in some way for them. ITEM 62: In confronting a new situation or an unknown task, the subject tries ahead of time to be aware of the emotional challenges and plan for whatever resources that will aid and comfort the subject in the new situation. ITEM 65: The subject describes emotionally meaningful vignettes of upcoming stressful situations in which the subject fully prepared him or herself emotionally as to how to handle it. ITEM 78: In dealing with interpersonal conflicts, the subject tries to imagine how others might respond in planning how to deal with them, but without obsessing or over planning. Humor ITEM 18: The subject makes amusing or ironic comments about embarrassing situations to diffuse them. ITEM 37: The subject can make humorous remarks about him or herself or others without saying negative, hurtful, or deprecating things. ITEM 40: In confronting difficult situations which the subject cannot change, the subject uses humor about the situation to mitigate the negative feelings arising. ITEM 51: The subject diffuses a difficult situation with others by making a pertinent joke that centers on some important point that all can acknowledge without being at anyone’s expense, thereby fostering cooperation. ITEM 119: When confronted by a situation fraught with competitive, hostile, or jealous feelings, the subject reveals something about him or herself in a self-deprecatory, ironic, or amusing way to diffuse the tension. Self-assertion ITEM 23: When pursuing something desirable, including a relationship with someone, the subject can use his or her talents and charms to attract the other, without feeling ashamed or guilty if unsuccessful. ITEM 90: When the subject has a physical or emotional or practical problem, the subject takes steps to deal with his or her needs – possibly including initiating getting help – rather than ignore them or hope they will take care of themselves. ITEM 105: When someone is impolite, dismissive, or derogatory toward the subject, the subject can stand up for him or herself appropriately, even if the subject cannot change the other’s attitude or command an apology. ITEM 109: The subject can disagree with others and express opinions without being overly hostile, devaluing, or manipulative of others. ITEM 146: When confronted with emotionally difficult situations, the subject expresses his or her thoughts, wishes, or feelings clearly and directly without inhibition or excess. Self- ITEM 9: When talking with someone about a personally charged topic, the subject displays an accurate view of him or herself and can see how he or she observation appears from the other person’s point of view. ITEM 32: When confronting emotionally important problems, the subject can reflect upon relevant personal experiences and explore emotional reactions. This allows the subject to adjust better to limitations and compromises, possibly leading to more fulfilling outcomes. ITEM 58: In interpersonal conflicts, the subject uses an understanding of his or her reactions to facilitate understanding others’ points of view or subjective experiences. This may make the subject a better negotiator or collaborator. ITEM 77: When considering an emotionally important decision, the subject explores his or her own motives and limitations to arrive at a more fulfilling decision. ITEM 91: When the subject reflects on past experiences, he or she can relive distressing feelings and make connections between events and feelings and develop understanding thereby changing how the subject views the past and possibly similar situations in the present. Sublimation ITEM 14: In describing any personal artistic or creative activities – such as writing, music, art, or acting – the subject appears to transform emotional conflicts or unfulfilled wishes from elsewhere in life, helping to shape the creative activity or product. ITEM 36: The subject describes emotional conflictual situations in which some of the feelings or dissatisfaction are channeled into creative or artistic activities. The resulting creative products – such as a poem or painting – give the subject a sense of mastery or relief from the conflicts. (Continued) Frontiers in Psychology | www.frontiersin.org 7 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 8 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 2 | (Continued) Defense DMRS-Q items mechanism ITEM 63: Whenever engaging in a creative activity, the subject finds the process of creation itself satisfying, apart from any satisfaction with the final product. ITEM 97: Following experiences of emotional distress or conflict, the subject engages in sports or other physical activities which are an invigorating outlet for any lingering frustrations. ITEM 100: Following some strong experiences, the subject engages in his or her ordinary activities but with less effort, greater accomplishment and more pleasure than they normally would require or yield. Suppression ITEM 49: When presented with an external demanding situation over which the subject has no control, the subject can accept the demand, putting negative feelings aside to deal with what must be done. ITEM 117: When the subject experiences a desire that if acted upon would have bad consequences, the subject is able to decide consciously to put the desire aside and not act upon it. ITEM 128: When the subject experiences a salient personal limitation or problem, rather than pretending it is not a problem, the subject acknowledges and accepts it, which allows the subject to avoid exacerbating problems. For example, acknowledging an addiction and accepting that one must avoid using the desired substance. ITEM 131: When attending to something emotionally important, if interrupted by something more urgent, the subject attends to the interruption as needed, but later returns and finishes dealing with what had to be postponed. ITEM 150: When presented with an emotionally charged situation, the subject can postpone dealing with his or her feelings to attend to the things that need to be done immediately. The feelings don’t get in the way or distract the subject, because the subject is able to give them adequate attention later. TABLE 3 | Obsessional defense level: Definition, function and DMRS-Q items of defenses isolation of affects, intellectualization and undoing. Defense DMRS-Q items mechanism Isolation of affects ITEM 28: When telling an emotionally meaningful story, the subject states that he or she does not have specific feelings that one would expect, although the subject recognizes that he or she should feel something. ITEM 31: In talking about a meaningful, emotionally charged experience, the subject talks in a detached way, as if he or she is not in touch with the feelings that should surround it. ITEM 39: The subject clearly describes the details of either positive or distressing or traumatic experiences but fails to show any attendant emotion in tone of voice, facial expression, or bodily expression. ITEM 107: The subject talks as if emotionally detached from whatever he says about himself or his experiences. ITEM 140: The subject describes events with good detail, but without mention of any attendant feelings, like a reporter describing the narrative of someone’s life, but devoid of personal reactions. Intellectualization ITEM 4: When confronting personal issues, the subject tends to ask general questions, as if getting general information or answers from others will elucidate his or her own feelings and concerns. As a result, personal reactions are kept at a distance. ITEM 26: The subject talks about his personal experiences by making general statements that appear accurate but somehow avoid revealing specific personal feelings and reactions. ITEM 53: There is a lifeless quality to most of the subject’s descriptions of his feelings and reactions, because the subject tries to explain them intellectually rather than experience or express them. For example: ‘My present predicament is an inevitable product of my parents’ extreme expectations and other parental experiences when growing up.’ ITEM 57: The subject distances him or herself from his or her own feelings by speaking about him or herself in the second or third person a lot, as if the subject were talking about someone else. ITEM 60: Whenever focusing on personal issues or experiences the subject tends to generalize or even discuss things in a logical or scientific way, thereby keeping his feelings and experiences very distant. Undoing ITEM 48: When another person tries to clarify a statement made by the subject, the subject says thing like ‘well, not really’ or ‘not exactly’ followed by qualifications that do not clearly clarify things. Because the subject is wary of committing him or herself to any statement, the listener may be unsure as to the subject’s definite opinion. ITEM 67: The subject spontaneously describes some of his or her actions which are followed by actions that are of the opposite intent, as if every action must be balanced by an equal but opposite action. The subject is aware of the contradiction which may seem vexing or ironic. ITEM 70: The subject prefaces a strong statement about a topic with a disclaimer, to the effect that what he or she is about to say may not be true. ITEM 81: The subject conveys opinions about something or someone with a series of opposite or contradictory statements, as if uncomfortable with taking a clear stand one way or the other. ITEM 83: After the subject has done something that probably results in a feeling of guilt or shame, the subject makes an act of reparation, as if sorry. However, the subject focuses on the act but avoids dealing with the sense of guilt or shame as one would whenever making a normal apology. her experience in general terms or in the second or third Obsessional Defense Level: Undoing person. One does not have to be bright or intelligent to use Definition intellectualization. It is simply a cognitive strategy for minimizing The individual deals with emotional conflicts, or internal the felt importance of problems in one’s affective life. Like other or external stressors, by behavior designed to symbolically defenses, it can sometimes be seen in those with intellectual make amends for negate previous thoughts, feelings, disabilities and organic brain syndromes. or actions. Frontiers in Psychology | www.frontiersin.org 8 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 9 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q Function that are diametrically opposed to his or her unacceptable thoughts or feelings. In this defense the subject expresses an affect, impulse or commits an action which elicits guilt feelings or anxiety. He or she then Function minimizes the distress by expressing the opposite effect, impulse, In reaction formation an original impulse or affect is deemed or action. The act of reparation then removes the individual from unacceptable by the subject and an unconscious substitution is experiencing the conflict. In conversation the subject’s statements made. Feelings, impulses, and behaviors of opposite emotional are immediately followed by qualifications bearing the opposite tone are substituted for the original ones. The observer does not meaning from the original statement. To the observer this see the alteration, per se, but only the end product. By supplanting coupling of statement with contradictory statement may make the original unacceptable feelings by its opposite, the subject it difficult to see what the subject’s primary feeling or intention avoids feelings of guilt. In addition, the substitution may gratify a really is. Misdeeds may be followed by acts of reparation to the wish to feel morally superior. Reaction formation is reasonably intended object of the misdeed. The subject appears compelled to inferred when a subject reacts to an event with an emotion erase or undo his or her original action. opposite in tone to the usual feelings evoked in people. Neurotic Defense Level: Repression Neurotic Defense Level: Displacement Definition Definition The individual deals with emotional conflicts, or internal or The individual deals with emotional conflicts, or internal or external stressors, by being unable to remember or be cognitively external stressors, by generalizing or redirecting a feeling about aware of disturbing wishes, feelings, thoughts or experiences. or a response to an object onto another, usually less threatening, object. The person using displacement may or may not be aware Function that the affect or impulse expressed toward the displaced object Repression is a defense that protects the subject from being aware was really meant for someone else. of what he is experiencing or has experienced in the past. The subject may experience a particular affect, impulse, or desire, but Function the actual awareness of what it is, that is, the idea associated with Displacement allows the expression of an affect, impulse, or it, remains out of awareness. While the emotional elements are action toward a person or other object with some similarity to clearly present and experienced, the cognitive elements remain the actual object which initially aroused the affect or impulse. outside of consciousness. The affect or impulse is fully expressed and acknowledged but is misdirected to a less conflictual target. Displacement allows more Neurotic Defense Level: Dissociation expression and gratification, albeit toward the wrong targets, than Definition other neurotic level defenses. The individual deal with emotional conflicts, or internal or Minor Image-Distorting Defense Level: Devaluation external stressors, by a temporary alteration in the integrative Definition functions of consciousness or identity. In the defense of The individual deals with emotional conflicts or internal or dissociation, a particular affect or impulse which the subject is not external stressors by attributing exaggeratedly negative qualities aware of operates in the subject’s life out of normal awareness. to oneself or others. Both the idea and associated affect or impulse remain out of awareness but are expressed by an alteration in consciousness. Function While the subject may be dimly aware that something unusual Devaluation refers to the use of derogatory, sarcastic, or takes place at such times, full acknowledgment that his or her own other negative statements about oneself or others to boost affect or impulses are being expressed is not made. Dissociation self-esteem. Devaluation may fend off awareness of wishes may result in a loss of function or in uncharacteristic behavior. or the disappointment when wishes go unfulfilled. The negative comments about others usually cover up a certain Function sense of vulnerability, shame or worthlessness which the Dissociated material is commonly experienced as too threatening, subject experiences vis a vis expressing his own wishes and too conflict-laden, or too anxiety-provoking to be allowed into meeting his own needs. awareness and fully acknowledged by the subject. Examples of common threatening material include recollection of a trauma Minor Image-Distorting Defense Level: Idealization with attendant fear of death and feelings of powerlessness, or a Definition sudden impulse to kill an intimate associate. Dissociation allows The individual deals with emotional conflicts, or internal or expression of the affect or impulse by altering consciousness external stressors, by attributing exaggerated positive qualities which allows the individual to feel less guilty or threatened. to self or others. Neurotic Defense Level: Reaction Formation Function Definition In the defense of idealization, the subject describes real or alleged The individual deals with emotional conflicts, or internal or relationships to others (including institutions, belief systems, external stressors, by substituting behavior, thoughts, or feelings etc.) who are powerful, revered, important, etc. This usually Frontiers in Psychology | www.frontiersin.org 9 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 10 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 4 | Neurotic defense level: Definition, function and DMRS-Q items of defenses repression, dissociation, reaction formation, and displacement. Defense DMRS-Q items mechanism Repression ITEM 13: The subject keeps unpleasant things vague: he or she has trouble remembering or can’t recall specific examples, when at least some should be forthcoming. This may include loss of memory for whole periods of time (e.g., childhood). ITEM 47: At points when a topic is emotionally loaded, the subject forgets what he or she is talking about and seems to get lost while talking. ITEM 50: When discussing a topic that brings up negative, conflicting feelings, the subject prefers to keep things vague, reflected in very vague, general or inexact statements. ITEM 108: The subject cannot remember certain facts which would normally not be forgotten, such as a distressing incident, reflecting some uneasy feelings about the topic. ITEM 136: When certain feelings or wishes would arise, the subject gives some evidence of them – such as crying or appearing anxious but cannot clearly identify in words the specific feeling or the specific ideas that give the wish a clear meaning. Dissociation ITEM 8: The subject behaves or says something in a very uncharacteristic way that expresses an uninhibited impulse operating out of the subject’s usual control, yet the subject is surprised by it (e.g., “I threw a glass of water in my friend’s face, but I don’t know what made me do it’). ITEM 27: The individual describes fugue states, amnesia (not alcoholic blackouts), multiple personality, spontaneous trance states, or temporary loss of sensory or motor function. ITEM 30: In response to an emotionally charged situation, the subject suddenly becomes confused, depersonalized, “spaced out,” or can’t think or talk about the topic. Consciousness becomes clouded to a lesser or greater extent. ITEM 41: In response to a distressing topic or situation, the subject develops a symptom, such as headache, stomach pain, or loss of an ability to do something, which temporarily eclipses awareness of what was distressing. The symptom may have a symbolic relationship to the type of distress. ITEM 73: The subject associates with or is fascinated by people who do very uninhibited, dramatic, or socially outrageous things, which appear to express some of the subject’s own inhibited wishes. Nonetheless, the subject is unaware of any such connection. Reaction ITEM 52: When confronting a personal wish about which the subject may feel guilty, the subject does not acknowledge or express it, but substitutes an formation opposite attitude against the wish, for instance, a desire is supplanted by renunciation or anger at anything to do with the desire. ITEM 55: The subject is very compliant, agreeing to most everything the interviewer points out, when some disagreement and discussion would be expected. ITEM 74: In dealing with people who are angry or abusive, the subject is cooperative and nice and eager to please, failing to express any negative feelings which might be expected. ITEM 96: In relationships, the subject has an attitude of giving much more than he or she receives but is unaware of the imbalance. ITEM 99: In fearful situations, the subject does not show expected fear, but reacts with exaggerated enthusiasm or courage, failing to acknowledge the fear. Displacement ITEM 1: In dealing with an important problem that makes the anxious, the subject prefers to focus on minor or unrelated matters instead, which distracts the subject away from the central problem, for example, cleaning or organizing rather than working on projects that need to be done. ITEM 64: The subject directs strong feelings toward a person or object who has little to do with the subject but who may bear similarities to someone significant to the subject. The subject may be somewhat puzzled by the ‘reason’ for the strength of these feelings. ITEM 69: When confronting emotionally charged topics, the subject tends not to address concerns directly and fully but wanders off to tangentially related topics that are emotionally easier for the subject to discuss or prefers to pay attention to someone else dealing with a similar situation. This can include preferring to read or watch a film portraying people dealing with similar problems. ITEM 122: When discussing an affect-laden event, the subject expresses more feelings directed toward incidental details or issues than about the major point or effect of the event, perhaps appearing “picky.” ITEM 125: The subject gets irritated easily by minor things that bother him or her and tends to lose a focus on the main things that need attention. serves as a source of gratification as well as protection from latter experiences, although they may remain objectively feelings of powerlessness, unimportance, worthlessness, and the obvious to others. Self-esteem is artificially propped like. The defense accomplishes a sort of alchemy of worthiness up at the expense of positively distorting one’s self- by association. The subject believes certain others to be good and evaluation in response to real experiences which bring up powerful in an exaggerated way and while able to acknowledge contrary feelings. factual aspects of any faults or shortcomings in the idealized person, they dismiss their significance, thereby preserving a Disavowal Defense Level: Denial sterling image of the person, or object. Definition The individual deals with emotional conflicts, or internal or Minor Image-Distorting Defense Level: Omnipotence external stressors, by refusing to acknowledge some aspect of Definition external reality or of his or her experience that would be apparent Omnipotence is a defense in which the subject responds to to others. The subject actively denies that a feeling, behavioral emotional conflict or internal and external stressors by acting response, or intention (regarding the past or present) was or superior to others, as if one possessed special powers or abilities. is not present, even though its presence is considered more Function than likely by the observer. The subject is blinded to both the This defense commonly protects the subject from a loss of ideational and emotional content of what is denied. This excludes self-esteem that is a consequence whenever stressors trigger ‘psychotic denial” in which the subject refuses to acknowledge feelings of disappointment, powerlessness, worthlessness, a physical object or event within the subject’s field in the and the like. Omnipotence subjectively minimizes the present time. Frontiers in Psychology | www.frontiersin.org 10 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 11 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 5 | Minor image-distorting defense level: Definition, function and DMRS-Q items of defenses devaluation of Self-image, devaluation of other’s image, idealization of self-image, idealization of other’s image, and omnipotence. Defense DMRS-Q items mechanism Devaluation of ITEM 12: The subject says demeaning things about him – whether somewhat funny or not – such as “I am so-ooooo stupid.” self-image ITEM 29: The subject makes a lot of unwarranted negative, sarcastic, or biting statements about the self, but the individual can acknowledge some of their positive aspects, if these are pointed out. ITEM 34: When experiencing failure, disappointment, shame or loss of self-esteem, the subject dismisses the issue by saying something negative about him or herself, then dismisses the problem by moving to another topic and avoids focusing on the feelings. ITEM 56: The subject is preoccupied with real or exaggerated faults in him or herself, although he or she can acknowledge some realistic positive aspects, if these are pointed out. ITEM 147: When confronted by a personal disappointment the subject makes negative comments about him or herself but then avoids further discussion of the disappointment in any detail. Devaluation of ITEM 54: When a topic brings with it feelings of disappointment, shame or loss of self-esteem, the subject dismisses the issue by finding some fault or other’s image criticism elsewhere or by uttering obscene comments about it. ITEM 82: The subject devalues others’ accomplishments or motives, to minimize their significance, but he or she quickly dismisses such topics rather than dwell on them. ITEM 85: When asked to discuss something about him or herself, the subject diverts the focus to saying negative things about others, as if devaluing others will raise his or her own self-esteem. ITEM 111: The subject has negative things to say about a lot of individuals or objects, although he or she can acknowledge some of their positive aspects, if these are pointed out. ITEM 143: The subject makes sarcastic or biting statements about others to minimize their positive qualities and dismiss any competition or threat they may pose. Idealization of ITEM 38: When confronted with any negative aspects of him or herself, the subject appears to downplay or ignore them by substituting talk about self-image positive self-attributes instead. ITEM 71: The subject makes many references to how important he or she is with an emphasis on self-image, rather than real accomplishments which might make the person important to others. ITEM 87: The subject tells stories in which others are saying positive things about him or herself. ITEM 133: The subject takes pleasure in referring a lot to his or her own positive but superficial attributes, like being beautiful, lovable, smart, well-dressed, worthy, a center of attention. This may be true even if the subject longs for qualities that are only imagined, wished for, or in the past. ITEM 135: When confronted with problems, the subject prefers to dwell on his or her own positive qualities, such as being lovable, smart, beautiful, creative, “the best,” as if those qualities will take care of the problems. Idealization of ITEM 16: The subject makes many references to how important certain people or objects are with an emphasis on their image, rather than real abilities other’s image or accomplishments which might make the person or object important to others. ITEM 17: The subject tells stories in which he or she says glowing positive things about another person or object, without giving much detail to back it up. ITEM 95: When confronted with problems, the subject prefers to dwell on the positive qualities of others on whom he or she relies, such as being lovable, smart, beautiful, creative, “the best,” as if those qualities will take care of the problems. ITEM 138: The subject takes pleasure in referring a lot to positive but superficial attributes of others, like being beautiful, lovable, smart, well-dressed, worthy, a center of attention. This may be true even if the subject longs for qualities that are only imagined, wished for, or in the past. ITEM 139: When confronted with any negative aspects of others important to the subject, the subject appears to downplay or ignore them, by substituting talk about the positive image or attributes instead. Omnipotence ITEM 7: The subject talks about how capable he or she is of influencing events or famous and important people. However, the emphasis is on the sense of personal power or abilities, rather than the detailed stories that support the claims as real. ITEM 10: The subject acts in a very self-assured way and asserts an ‘I can handle anything’ attitude, in the face of problems that he or she in fact cannot fully control. ITEM 68: The subject makes clearly false statements about his own special powers and abilities (these may or may not be delusional). ITEM 126: There is excessive bravado in discussing problems or personal accomplishments that stands out as excessive or unrealistic. ITEM 129: The subject is very grandiose in describing personal plans, accomplishments or abilities, perhaps comparing him or herself to famous people. Function Disavowal Defense Level: Rationalization Neurotic denial serves to prevent the subject who uses it and Definition anyone querying him from recognizing specific feelings, wishes, The individual deals with emotional conflicts, or internal intentions, or actions for which the subject might be responsible. or external stressors, by devising reassuring or self- The denial avoids admitting or becoming aware of a psychic serving but incorrect explanations for his or her own or fact (idea and feeling) which the subject believes would bring others’ behavior. him aversive consequences (such as shame, grief, or other Function painful affect). The evidence for this is clear whenever a subject breaks through his own denial and experiences shame or other Rationalization involves the substitution of a plausible reason emotion at what he learns about himself, often apologizing to the for a given action or impulse on the subject’s part, when a interviewer and so forth. motive that is more self-serving or difficult to acknowledge Frontiers in Psychology | www.frontiersin.org 11 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 12 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q is evident to the outsider. While the underlying covert Function motivation may be selfish, it may also involve caring or Non-delusional projection allows the subject to deal with loving feelings which the subject finds uncomfortable. The emotions and motives which make him feel too vulnerable subject is usually thought to be unaware or minimally (especially to shame or humiliation) to admit having himself. aware of his true underlying motive; instead, he or she Instead he concerns himself with these same emotions and sees only the substituted, more socially acceptable reason for motives in others. The use of projection therefore commits the the action. The subject’s reasons commonly have nothing to subject to a continual concern with those on whom he has do with any personal satisfaction, and thus disguise his or projected his inner feelings as a way to minimize awareness her real impulse or motive, although any related affect may of them himself. still show. Disavowal Defense Level: Autistic (or Schizoid) Disavowal Defense Level: Projection Fantasy Definition Definition The individual deals with emotional conflicts, or internal The individual deals with emotional conflicts, or internal or or external stressors, by falsely attributing his or her own external stressors, by excessive daydreaming as a substitute for unacknowledged feelings, impulses, or thought to others. The human relationships, more direct and effective action, or problem subject disavows his or her own feelings, intentions, or experience solving. Fantasy denotes the use of daydreaming as either a by means of attributing them to others, usually by whom substitute for dealing with or solving external problems or as a the subject feels threatened and to whom the subject feels way of expressing and satisfying one’s feelings and desires. While some affinity. the subject may be aware of the ‘I’m just pretending’ quality of TABLE 6 | Disavowal defense level: Definition, function and DMRS-Q items of defenses denial, rationalization, projection, and autistic fantasy. Defense DMRS-Q items mechanism Denial ITEM 20: When confronted with topics that might be personally meaningful, the subject denies they are important and refuses to talk about them further. ITEM 33: Contrary to the evidence from the interview, the subject claims to have done something that in all likelihood he or she did not do, and may become irritated if confronted with any discrepancy. ITEM 121: Whenever talking about potentially distressing events or experiences, the subject strongly claims not to have any feelings about the topic, although this seems highly unlikely. ITEM 124: Whenever asked about things the subject did or felt, the subject denies any involvement, does not want to talk about them or avoids explaining his or her reluctance. ITEM 137: The subject is hard to talk with, responding to many questions with answers like “no” or “not really” and does not elaborate, rather than giving some fuller answers which one would normally expect. Rationalization ITEM 19: To avoid taking responsibility for one’s actions or misdeeds, the subject makes excuses or points out others’ contributions to the problem, thereby minimizing his or her own role. ITEM 42: The subject avoids feelings of guilt or shame by justifying his actions or by referring to external reasons that impelled him to act. ITEM 59: When discussing a problem that the subject contributed to, the subject explains his or her own actions far more than necessary, as if explaining away his or her own fault. ITEM 86: Whenever confronted about his or her own feelings or intentions, the subject avoids acknowledging them by giving a plausible explanation that covers up the real subjective reasons. ITEM 120: Whenever discussing something uncomfortable about him or herself, the subject tries to convince someone else of a more positive explanation, as if lying to him or herself about the truth. Projection ITEM 112: When others comment or inquire about the subject’s own feelings, actions, or intentions, the subject is very elusive or frankly denies the material, but the subject subsequently talks about similar feelings, actions, intentions, etc., in others. ITEM 115: When experiencing or confronted with a problem, the subject shames, humiliates, or blames someone else for the problem, ignoring his or her own role. ITEM 123: An attitude of suspiciousness or prejudice toward a group of other individuals, allows the subject not to express an interest in the same motives or feelings but remain blind to them in him or herself. ITEM 134: When others ask the subject questions, the subject is suspicious about others’ real reasons or motives for the question. ITEM 141: The subject perceives others as untrustworthy, unfaithful, or manipulative when there is no objective basis for these concerns. This may even appear paranoid. Autistic fantasy ITEM 2: The subject has repetitive or serial daydreams to which he or she retreats in lieu of real life social relationships. ITEM 24: The subject daydreams a lot, not in a way that leads to creative planning or action, but simply for its own gratification, in lieu of action. ITEM 106: In dealing with some problems, the subject prefers to daydream about solutions, as a substitute for planning direct, realistic, and effective actions. ITEM 110: Whenever being self-assertive would be helpful, the subject may act passively but later withdraw into fantasies of being assertive or aggressive toward others as a compensation. ITEM 148: The subject gets intensely involved in fantasy roles or actions that express wishes and feelings that the subject does not express in real life. For example, living out a role in a social situation or game or which has no connection to real life ways in which the subject expresses him or herself. Frontiers in Psychology | www.frontiersin.org 12 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 13 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q the fantasy, nonetheless, it may be the closest that he or she contradictory views, expectations, or feelings about the object ever comes to expressing or gratifying the need for satisfying arc excluded from emotional awareness, although not necessarily interpersonal relationships. from cognitive awareness. Function Function Fantasy allows the subject to obtain some temporary, vicarious Splitting of object images and self-images is the subject’s defense gratification by daydreaming a solution to a real-world problem against the anxiety of ruining the good images of people by of conflict. The subject feels good while using fantasy and allowing bad aspects of them to intrude upon the good. Splitting momentarily bypasses the conviction of powerlessness. In fact, of self-images has one adaptive function: it minimizes the during fantasy the opposite conviction (i.e., grandiosity) may be anxiety the subject would experience attempting to match his in operation, that one can do anything. Fantasy is maladaptive view of himself with how significant others will in fact see only when it short-circuits rather than rehearses attempts to deal him and treat him. Instead, when seeing himself one way, the with the real world by substituting dream world gratification. subject continues to see himself in the same valence no matter how others see him and treat him; contradictions then aren’t Sometimes, there may be a wholesale substitution of daydream activity in the place of real world attempts to meet needs allowed into experience. This minimizes the disruptive, anxiety- provoking effects of trying to predict unpredictable people. The and solve conflicts. This occurs without any loss of the ability to perceive and test external reality. The subject knows the disadvantage is that the subject’s view of himself then becomes inflexible to the environmental realities, and the switch from difference between reality and fantasy life. good to bad views of himself is also unpredictable. This leaves the subject insensitive to more reasonable, predictable, and Major Image-Distorting Defense Level: Splitting potentially more rewarding relationships outside of his original Definition learning environment. In a better environment, the subject The individual deals with emotional conflicts, or internal or suffers from what was paradoxically so protective originally: external stressors, by viewing himself or herself or others an insensitivity to experiencing contradictory views of the self. as all good or all bad, failing to integrate the positive and Splitting of object images and self-images is the subject’s defense negative qualities of the self and others into cohesive images; against the anxiety of ruining the good images of people by often the same individual will be alternately idealized and allowing bad aspects of them to intrude upon the good. Splitting devalued. Splitting of self-images often occurs alongside splitting of object images limits the anxiety the subject would feel in trying of others’ images, since they both were learned in response to the to discriminate how others will respond when he experiences unpredictability of one’s early significant others. In splitting of or expresses his needs, feelings, etc. To see others as all good self-images, the subject demonstrates that he has contradictory or all bad eliminates the anxiety-provoking task of trying to views, expectations, and feelings about himself which he cannot discern how others will behave toward the self, a task the subject reconcile into one coherent whole. believes to be impossible. Instead, the subject quickly categorizes The self-images are divided into polar opposites: at a given people into good and bad camps based on subtle initial cues time the subject’s awareness is limited to those aspects of the (e.g., ‘he frowned when I spoke, so he hates me”) or based self-having the same emotional feeling tone. He sees himself in largely on internal feeling states (e.g., “I feel so bad that I “black or white” terms. At one point in time the subject believes know you must hate me, so why should I open up to you?”). he himself has good attributes, such as being loving, powerful, The defense is maladaptive, however, because the subject acts worthy, or correct, and having good feelings, or he believes as unpredictably and irrationally toward others as he himself the opposite: that he is bad, hateful, angry, destructive, weak, was treated; he forgoes the rewards he might attain if he were powerless, worthless, or always wrong and has only negative flexible in how he interacts with others. Using this defense, feelings about himself. The subject cannot experience himself as the subject wins some friends and makes some enemies, but a more realistic mixture of both positive and negative attributes. not in a realistic way that considers the aggregate of others’ In splitting of other’s images (object images), the subject actual characteristics. demonstrates that his views, expectations, and feelings about others are contradictory and that he cannot reconcile these Major Image-Distorting Defense Level: Projective differences to form realistic and coherent views of others. Identification Object images are divided into polar opposites, such that the subject can only see one emotional aspect or side of the Definition object at a time. Objects are experienced in black or white In projective identification the subject has an affect or impulse terms. Splitting is revealed in two major ways. The subject which he finds unacceptable and projects onto someone else, may initially describe an object wholly in one way but later as if it was really that other person who originated the affect describe that same object in opposite ways. Second, each object or impulse. However, the subject does not disavow what is is simply lumped with other objects into good and bad, positive projected – unlike in simple projection – but remains fully and negative camps. When the subject uses splitting of object aware of the affects or impulses, and simply misattributes images, he cannot integrate anything that doesn’t match his them as justifiable reactions to the other person! Hence, the immediate experience of and feeling about a given object. All subject eventually admits his affect or impulse, but believes the attributes with the same feeling tone are highlighted, and it to be a reaction to those same feelings and impulses in Frontiers in Psychology | www.frontiersin.org 13 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 14 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 7 | Major image-distorting defense level: Definition, function and DMRS-Q items of defenses splitting of self-image, splitting of other’s image, and projective identification. Defense DMRS-Q items mechanism Splitting of ITEM 3: The subject has periods of saying highly positive things about him or herself, and other periods saying highly negative things about him or self-image herself, without appearing to notice the contradiction and without addressing it, other than to feel confused about him or herself at moments. ITEM 6: The subject speaks of him or herself in a wholly negative way at times, as if there is nothing positive or redeeming about him or herself. ITEM 98: The subject expresses a series of highly unrealistic positive attributes about him or herself whereas at another point the subject sees only negatives in him or herself. The subject dismisses attempts to see things in a balanced more realistic way. ITEM 142: The subject tends to highlight objects with an emotional meaning that matches his or her own emotional tone at the moment. Any feeling that doesn’t match this is ignored or denied. ITEM 145: Whenever saying something negative about him or herself, the subject rejects others’ attempts to explore positive or more balanced views, and paradoxically becomes even more confirmed in his or her own worthlessness. Splitting of ITEM 35: The subject experiences other people and objects in “black or white” terms, failing to form more realistic views that balance positive and other’s image negative aspects of them. ITEM 61: The subject attributes unrealistic positive characteristics to an object, such as being all-powerful, omni-benevolent, a savior. Because of the unrealistic belief that the positive object will take care of one’s problems, the subject ignores the need to take care of some of his or her own needs. ITEM 92: The subject attributes unrealistic negative characteristics to an object, such as being all-powerful, malevolent, threatening. As a result, he or she makes some effort to protect him or herself from its influence, even though this response appears unwarranted or exaggerated. ITEM 94: The subject fails to recognize that someone may be untrustworthy, hurtful, or manipulative and does not draw obvious conclusions based on their behavior. This generally results in using very poor judgment about how others will treat the subject. ITEM 114: The subject expresses hatred toward someone or something and refuses to acknowledge anything that does not confirm the hatred. Projective ITEM 72: Sometimes the subject gets angry or fearful toward someone for no apparent reason, but then accuses the other person of intending to make identification him or her feel that way. ITEM 75: At times the subject’s feelings merge with those of another person and the subject assumes the other’s feelings and needs are exactly the same as the subject’s own. He or she then tends to “put words in the other’s mouth.” ITEM 101: In conversations, the subject sometimes seems confused about distinguishing his or her own feelings from those of the other person. ITEM 103: When the subject gets upset at someone, he or she gets very angry and loses control, but then blames the other person for making him or her lose control. Nonetheless, the subject may feel some guilt for losing control. ITEM 113: The subject feels provoked by someone when no obvious provocation is apparent. As the subject becomes angry, accusatory or verbally abusive, the subject provokes the same negative feelings in the other which the subject mistakenly believed the other person had at the outset. others. The subject confuses the fact that it was he himself who and guilt in others that he or she feels, which may result in originated the projected material. This defense is seen most others backing away. clearly in a lengthy interchange in which the subject initially Action Defense Level: Passive Aggression projects his feelings but later experiences his original feelings as Definition reactions to the other. Paradoxically, the subject often arouses The individual deals with emotional conflicts, or internal or the very feelings in others he at first mistakenly believed to external stressors, by indirectly and unassertively expressing be there. It is then difficult to clarify who did what to whom aggression toward others. There is a facade of overt compliance first. This process is more extensive than simple projection, masking covert resistance toward others. Passive aggression which involves the denial and subsequent external attribution is characterized by venting hostile or resentful feelings in an of an impulse. Projective identification involves attribution of indirect, veiled, and unassertive manner toward others. Passive an image so that the whole object is seen and reacted to in a aggression often occurs in response to demands for independent distorted light. action or performance by the subject or when someone has disappointed the subject’s wish or sense of entitlement Function to be taken care of, regardless of whether the subject has Projective identification is the defense of the traumatized person made this wish known. This term includes ‘turning against who felt irrationally responsible for his or her traumas. The the self.’ defense is called into play when interpersonal cues stimulate memories of traumatic situations or interchanges or their Function residues. The individual experiences the other person as doing The person using passive-aggression has learned to expect something to him or herself that is threatening, which make him punishment, frustration, or dismissal if he or she expresses needs or her feel powerless. The subject reacts to this imagined (or or feelings directly to someone who has power or authority partially real) threat by attacking and believing that his or her over him or her. The subject feels powerless and resentful. own actions are justified, despite provoking the other. Guilt over This expectation is most pronounced in hierarchical power having aggressive wishes toward the other person emerges and is relationships. Resentment is expressed by a passive stance: that handled by identification with the other, reinforced ‘by the belief the subject is entitled to the very things he doesn’t speak up that the alleged threat attack on oneself is deserved. Paradoxically for or that he is entitled to special dispensation. There is also the subject often induces the very feeling of powerlessness some pleasure taken in the discomfort that the passive aggressive Frontiers in Psychology | www.frontiersin.org 14 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 15 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q behavior causes others. Passive expression of anger through emotional reliance on others. The anger rises from the conviction, stubborn, inept, procrastinating, and forgetful behavior is quickly or often the experience that nobody will really satisfy the learned as a way to express: the conviction that the subject has subject’s perceived needs. The subject expresses the anger as the right to remain passive while expecting his needs to be met; an indirect reproach by rejecting help as “not good enough” to appear well-intentioned on the surface (overtly compliant), while continuing to ask for more of it. Instead of driving the thus avoiding retaliation for the direct expression of affects, other person away by the expression of anger, the use of help- needs, or resentment; to express the resentment experienced rejecting complaining binds the person to the subject by the toward those making demands by covert noncompliance that overt request for help. The subject’s expression of helplessness annoys others and obtain some satisfaction or vengeance, even over the problem at hand reflects a sense of powerlessness to if it means hurting oneself. In extremes, the resentment is not get the right help, comfort, and attention, while discharging just expressed indirectly toward the other, but in fact, is turned resentment for the expected disappointment that enough help 180 degrees around toward the self (turning against the self ) to will not be forthcoming. get at the other. Action Defense Level: Acting Out Action Defense Level: Help-Rejecting Complaining Definition Definition The individual deals with emotional conflicts, or internal or Help-rejecting complaining (formerly called hypochondriasis, external stressors, by acting without reflection or apparent which term we do not us as it can be confused with the symptom regard for negative consequences. Acting out involves the disorder) involves the repetitious use of a complaint or series expression of feelings, wishes or impulses in uncontrolled of complaint in which the subject ostensibly asks for help. behavior with apparent disregard for personal or social However, covert feelings of hostility or resentment toward others consequences. It usually occurs in response to interpersonal are expressed simultaneously by the subject’s rejection of the events with significant people in the subject’s life, such as suggestions, advice, or whatever others offer. The complaints may parents, authority figures, friends, or lovers. This definition is consist of either somatic concerns or life problems. Either type of broader than the original concept of acting out transference complaint is followed by a ‘help-rejecting complainer’ response feelings or wishes during psychotherapy. It includes behavior to whatever help is offered. arising both within and outside of the transference relationship. Function It is not synonymous with “bad behavior,” or with any Help-rejecting complaining is a defense against the anger the symptom per se, although acting out often involves socially subject experiences whenever he or she feels the need for disruptive or self-destructive behavior. So-called acting out TABLE 8 | Action defense level: Definition, function and DMRS-Q items of defenses acting out, help-rejecting complaining, and passive aggression. Defense DMRS-Q items mechanism Passive ITEM 45: At times when expressing an opinion or wish might be helpful, the subject fails to express himself adequately, instead finding indirect, even aggression annoying ways to show his or her opposition to the influence of others, for example, being silent. ITEM 88: The subject fails to stand up for his or her interests and seems to let bad things happen to him or herself that could be prevented, maybe even assuming a “martyr” role. ITEM 89: While outwardly cooperative or compliant, the individual procrastinates and refuses to do things on time or as asked, even when it would be easy to do so. ITEM 102: When angry toward someone significant, the subject takes anger out on himself instead of expressing it directly. ITEM 116: The subject has “a chip on his or her shoulder” or a grudge, and seems to find reasons to feel unfairly treated, even when he or she is not. Help-rejecting ITEM 21: The subject complains spontaneously about how others don’t really care, or have made his or her problems worse, even when there is clear complaining evidence that others have tried to help. ITEM 84: The subject recites a litany of issues and problems but does not appear to be engaged in solving them, but rather prefers to complain. ITEM 127: The subject tends to exaggerate his or her complaints about a life problem or somatic symptom, making them seem worse or more significant than they are. ITEM 130: The subject complains about life issues or problems as if each were insoluble, and systematically rejects others’ suggestions about ways of handling them. ITEM 149: When the subject brings up a problem to discuss, others try to address the problem, but in response the subject skips to a different problem, thereby dismissing rather than engaging others in any suggestions offered. Acting out ITEM 5: The subject loses his or her temper easily. ITEM 76: In response to interpersonal disappointment or disagreement the subject tends to act impulsively, without reflection or considering the negative consequences. ITEM 80: The subject is often inhibited from expressing him or herself, but sometimes acts in uncontrolled ways to get or do something he or she wants, ignoring normal constraints. ITEM 118: Whenever the subject feels angry, disappointed or rejected by someone, the subject resorts to uncontrolled behaviors as an escape from distressing feelings, such as binge-eating, drinking, sexual escapades, drug use, reckless driving, or getting into trouble. ITEM 144: The subject tends to express feelings, wishes or impulses directly in behavior, not only words, without prior thought. However, afterward, he or she may feel guilty or expect some punishment. Frontiers in Psychology | www.frontiersin.org 15 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 16 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q behaviors, such as physical fighting, or compulsive drug use, must show some relationship to affects or impulses that the person cannot tolerate to serve as evidence for the defense of acting out. Function Acting out allows the subject to discharge or express feelings and impulses rather than tolerate them and reflect on the painful events that stimulate them. The following elements are present. First, the subject has feelings or urges which he is inhibited from expressing. Experiencing the original impulse quickly results in a rise in tension and anxiety. Second, the individual bypasses awareness and ceases any attempt to delay, reflect upon, or plan a strategy to handle the impulse or feeling. Rather it is directly expressed in behavior without prior thought. This results in the expression of rather raw aggression, sex, attachment, or other impulses without taking the consequences into account. Following acting out, reflection may return, and the subject commonly feels guilty or expects some punishment, unless a further defense comes into play, such as denial or rationalization (“I was so angry, I had to do it. It was his fault for stirring me up.”). Acting out is maladaptive because it does not mitigate the effects of the internal conflict, and it often brings upon the subject serious, negative, external consequences. Coding Procedure The DMRS-Q is a computer-based measure that can be used for clinical, research and teaching purposes by registering on the DMRS-Q platform (see text footnote 1 for registration and login). The software use is free of charge and provides the user FIGURE 2 | The DMRS-Q forced distribution (image extracted from the with several functions, such as starting a new coding, revising DMRS-Q web-app). previous ratings, downloading outputs and scoring sheets. At present the DMRS-Q is available in English and in Italian, although other languages may be added on the platform after Clinical Data and Training appropriate validation. Data required for a stable DMRS-Q rating might vary with the Like most Q-sort tools, the DMRS-Q coding procedure aim of its use. Coders must have sufficient information of the follows the rules of ranking items into a force distribution evaluated subject’s defensive functioning, directly observed or (Block, 1978; Brown, 1993, 1995). The 150 items must be obtained from records. Since recorded and transcribed data are ordered into seven ordinal ranks, corresponding to increasing not essential, the DMRS-Q can be applied in multiple contexts. level of descriptiveness, intensity or frequency. Higher ranks The required time for a DMRS-Q coding decreases depending are less populated and include items that best describe the on rater’s experience, ranging from about 60 min in the very most characteristic defensive patterns activated by an individual. first ratings to less than 15 min for expert coders. A 6-h training Conversely, lower ranks are more populated and include items is highly suggested for reaching high reliability on all DMRS- that either do not apply or are only somewhat descriptive Q quantitative scores, although a recent study demonstrated of the individual’s defensive profile. In ascending order of that untrained raters obtain acceptable to excellent reliability on descriptiveness, DMRS-Q ranks are as follows: rank 1 (60 most DMRS-Q scales (ICC ranging from 0.60 to 0.91) (Békés items) = not used at all; rank 2 (30 items) = very rarely used; rank et al., 2021). In any case, for the correct use of the DMRS-Q 3 (20 items) = slightly or rarely used; rank 4 (16 items) = medium it is essential to read the present manual for understanding the or sometimes used; rank 5 (10 items) = intensive or often used; theoretical and methodological background behind the measure. rank 6 (8 items) = very intensive or frequently used; rank 7 (6 items) = almost always used. When all items are correctly Scoring System ordered into the DMRS-Q forced distribution, as displayed in Figure 2, the rating is complete and ready to be sent for scoring The DMRS-Q scoring procedure is made with a software that output. For detailed directions of the DMRS-Q rating procedure extracts DPN and quantitative scores from the completed a video-tutorial is available at https://www.youtube.com/watch? DMRS-Q rating. Formulas for quantitative scoring are v=PP1ykSrGLkY&t=87s. displayed in Table 9. Frontiers in Psychology | www.frontiersin.org 16 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 17 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 9 | DMRS-Q quantitative scoring system. Items labels # Defense # Defense # Defense # Defense # Defense 1 Displacement 31 Isolat_Affect 61 Splitting_Self 91 Self_Observat 121 Denial 2 Autis_Fantasy 32 Self_Observat 62 Anticipation 92 Splitting_Self 122 Displacement 3 Splitting_Other 33 Denial 63 Sublimation 93 Affiliation 123 Projection 4 Intellectualizat 34 Devaluat_Self 64 Displacement 94 Splitting_Self 124 Denial 5 Acting_Out 35 Splitting_Self 65 Anticipation 95 Idealizat_Other 125 Displacement 6 Splitting_Other 36 Sublimation 66 Affiliation 96 React_Format 126 Omnipotence 7 Omnipotence 37 Humor 67 Undoing 97 Sublimation 127 Help_Rej_Com 8 Dissociation 38 Idealizat_Self 68 Omnipotence 98 Splitting_Other 128 Suppression 9 Self_Observat 39 Isolat_Affect 69 Displacement 99 React_Format 129 Omnipotence 10 Omnipotence 40 Humor 70 Undoing 100 Sublimation 130 Help_Rej_Com 11 Altruism 41 Dissociation 71 Idealizat_Self 101 Proj_Identific 131 Suppression 12 Devaluat_Self 42 Rationalization 72 Proj_Identific 102 Passive_Aggr 132 Altruism 13 Repression 43 Anticipation 73 Dissociation 103 Proj_Identific 133 Idealizat_Self 14 Sublimation 44 Affiliation 74 React_Format 104 Altruism 134 Projection 15 Altruism 45 Passive_Aggr 75 Proj_Identific 105 Self_Assertion 135 Idealizat_Self 16 Idealizat_Other 46 Anticipation 76 Acting_Out 106 Autis_Fantasy 136 Repression 17 Idealizat_Other 47 Repression 77 Self_Observat 107 Isolat_Affect 137 Denial 18 Humor 48 Undoing 78 Anticipation 108 Repression 138 Idealizat_Other 19 Rationalization 49 Suppression 79 Altruism 109 Self_Assertion 139 Idealizat_Other 20 Denial 50 Repression 80 Acting_Out 110 Autis_Fantasy 140 Isolat_Affect 21 Help_Rej_Com 51 Humor 81 Undoing 111 Devalu_Other 141 Projection 22 Affiliation 52 React_Format 82 Devalu_Other 112 Projection 142 Splitting_Other 23 Self_Assertion 53 Intellectualizat 83 Undoing 113 Proj_Identific 143 Devalu_Other 24 Autis_Fantasy 54 Devalu_Other 84 Help_Rej_Com 114 Splitting_Self 144 Acting_Out 25 Affiliation 55 React_Format 85 Devalu_Other 115 Projection 145 Splitting_Other 26 Intellectualizat 56 Devaluat_Self 86 Rationalization 116 Passive_Aggr 146 Self_Assertion 27 Dissociation 57 Intellectualizat 87 Idealizat_Self 117 Suppression 147 Devaluat_Self 28 Isolat_Affect 58 Self_Observat 88 Passive_Aggr 118 Acting_Out 148 Autis_Fantasy 29 Devaluat_Self 59 Rationalization 89 Passive_Aggr 119 Humor 149 Help_Rej_Com 30 Dissociation 60 Intellectualizat 90 Self_Assertion 120 Rationalization 150 Suppression Label Defense mechanism Scoring Individual defense scores D30 Suppression [(Sum of items 49, 117, 128, 131, and 150) 5]*100/234 D29 Sublimation [(Sum of items 14, 36, 63, 97, and 100) 5]*100/234 D28 Self-observation [(Sum of items 9, 32, 58, 77, and 91) 5]*100/234 D27 Self-assertion [(Sum of items 23, 90, 105, 109, and 146) 5]*100/234 D26 Humor [(Sum of items 18, 37, 40, 51, and 119) 5]*100/234 D25 Anticipation [(Sum of items 43, 46, 62, 65, and 78) 5]*100/234 D24 Altruism [(Sum of items 11, 15, 79, 104, and 132) 5]*100/234 D23 Affiliation [(Sum of items 22, 25, 44, 66, and 93) 5]*100/234 D22 Isolation of affects [(Sum of items 28, 31, 39, 107, and 140) 5]*100/234 D21 Intellectualization [(Sum of items 4, 26, 53, 57, and 60) 5]*100/234 D20 Undoing [(Sum of items 48, 67, 70, 81, and 83) 5]*100/234 D19 Repression [(Sum of items 13, 47, 50, 108, and 136) 5]*100/234 D18 Dissociation [(Sum of items 8, 27, 30, 41, and 73) 5]*100/234 D17 React formation [(Sum of items 52, 55, 74, 96, and 99) 5]*100/234 D16 Displacement [(Sum of items 1, 64, 69, 122, and 125) 5]*100/234 D15 Devaluation other’s image [(Sum of items 54, 82, 85, 111, and 143) 5]*100/234 D14 Devaluation self-image [(Sum of items 12, 29, 34, 56, and 147) 5]*100/234 D13 Idealization other’s image [(Sum of items 16, 17, 95, 138, and 139) 5]*100/234 (Continued) Frontiers in Psychology | www.frontiersin.org 17 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 18 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 9 | (Continued) Label Defense mechanism Scoring D12 Idealization self-image [(Sum of items 38, 71, 87, 133, and 135) 5]*100/234 D11 Omnipotence [(Sum of items 7, 10, 68, 126, and 129) 5]*100/234 D10 Denial [(Sum of items 20, 33, 121, 124, and 137) 5]*100/234 D9 Rationalization Sum of items 19, 42, 59, 86, and 120) 5]*100/234 D8 Projection [(Sum of items 112, 115, 123, 134, and 141) 5]*100/234 D7 Autistic fantasy [(Sum of items 2, 24, 106, 110, and 148) 5]*100/234 D6 Projective identification [(Sum of items 72, 75, 101, 103, and 113) 5]*100/234 D5 Splitting of self-image [(Sum of items 3, 6, 98, 142, and 145) 5]*100/234 D4 Splitting of object’s image [(Sum of items 35, 61, 92, 94, and 114) 5]*100/234 D3 Passive aggression [(Sum of items 45, 88, 89, 102, and 116) 5]*100/234 D2 Help-rejecting complaining [(Sum of items 21, 84, 127, 130, and 149) 5]*100/234 D1 Acting out [(Sum of items 5, 76, 80, 118, and 144) 5]*100/234 Label Defense level Scoring Defense level scores L7 High adaptive Sum of D23, D24, D25, D26, D27, D28, D29, and D30 L6 Obsessional Sum of D20, D21, and D22 L5 Neurotic Sum of D16, D17, D18, and D19 L5a Hysterical Sum of D18 and D19 L5b Other neurotic Sum of D16 and D17 L4 Minor image-distorting Sum of D11, D12, D13, D14, and D15 L3 Disavowal Sum of D7, D8, D9, and D10 L2 Major image-distorting Sum of D4, D5, and D6 L1 Action Sum of D1, D2, and D3 Label Defensive category Scoring Defensive category scores C3 Mature Sum of D23, D24, D25, D26, D27, D28, D29, and D30 C2 Neurotic Sum of D16, D17, D18, D19, D20, D21, and D22 C1 Immature Sum of D1, D2, D3, D4, D5, D6, D7, D8, D9, D10, D11, D12, D13, D14, and D15 C1a Depressive Sum of D1, D2, D3, D4, D5, D6, D8, D14, and D15 C1b Other immature Sum of D7, D9, D10, D11, D12, and D13 Label Scoring Overall defensive functioning ODF (L1/100)*1 C (L2/100)*2 C (L3/100)*3 C (L4/100)*4 C (L5/100)*5 C (L6/100)*6 C (L7/100)*7 For further information about the scoring system please contact the corresponding author. Although the scoring software has not yet been uploaded functioning. Qualitative scores are displayed as the Defensive in the DMRS-Q web-app in order to protect it from hackers, Profile Narratives (DPN), a case description of the most we will include it after the publication of the present article. characteristic ways the subject handles internal conflict and This upgrade will allow the DMRS-Q web-app to automatically external stressors. The DPN comprises all items sorted in ranks calculate qualitative and quantitative scores after each evaluation 6 and 7 (N = 14) and coded as highly descriptive of the subject’s and immediately deliver the DMRS-Q report to the user. defensive profile. The DMRS-Q software automatically lists these items and indicates the defense level and individual defense mechanism associated with each item. Figure 3 shows an example RESULTS of a DPN displayed in the DMRS-Q report. In addition to DPN, the DMRS-Q report provides the The Defense Mechanisms Rating Scales following quantitative scores: a summary Overall Defensive Functioning (ODF), ranging from 1 to 7; proportional scores for Q-Sort Report seven defense levels (see Table 1 for review); and proportional Like the original DMRS, the DMRS-Q provides qualitative scores for 30 individual defense mechanisms (see Tables 2–8 for and quantitative scores reflecting the individual’s defensive Frontiers in Psychology | www.frontiersin.org 18 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 19 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q FIGURE 3 | Defensive Profile Narrative (PDN) of a patient assessed with the DMRS. review). Future updates in the web-app software will also add patient’s demographics, diagnosis, length of treatment, nor scores for defensive categories and subcategories. Quantitative therapist’s approach, experience, etc. A summary of qualitative scores are displayed in both numerical and graphical forms in and quantitative evaluation of patient’s defense mechanisms the DMRS-Q report, which can be downloaded from the user analyzed with the DMRS-Q is displayed in Table 10. The 14 items dashboard at any time. coded as the best descriptive of the patient’s defensive functioning in the session were included in the qualitative defensive profile (DPN), while all item scores contributed to the quantitative Clinical Vignette and Defense scores displayed in the graphics. Mechanisms Rating Scales Q-Sort The session started with the patient telling his negative Rating experience with his lawyer and his attempt to solve a financial issue. While reporting on how the therapy had been helping One example of how to use the DMRS-Q in clinical setting is offered by the following vignette. A brief description of him in enhancing his engagement in professional problems, the patient described himself with very devaluing terms. Even when patient-therapist interactions during the session is used for the DMRS-Q rating with no additional information about the therapist tried to support him, saying that he was not aware Frontiers in Psychology | www.frontiersin.org 19 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 20 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q TABLE 10 | Qualitative and quantitative DMRS-Q evaluation of the described in the clinical vignette. Qualitative scores – Defensive profile narratives When confronted with topics that might be personally meaningful, the subject denies they are important and refuses to talk about them further. The subject complains spontaneously about how others don’t really care, or have made his or her problems worse, even when there is clear evidence that others have tried to help. At times when expressing an opinion or wish might be helpful, the subject fails to express himself adequately, instead finding indirect, even annoying ways to show his or her opposition to the influence of others, for example, being silent. The subject recites a litany of issues and problems but does not appear to be engaged in solving them, but rather prefers to complain. When others comment or inquire about the subject’s own feelings, actions, or intentions, the subject is very elusive or frankly denies the material, but the subject subsequently talks about similar feelings, actions, intentions, etc. in others. Whenever talking about potentially distressing events or experiences, the subject strongly claims not to have any feelings about the topic, although this seems highly unlikely. When telling an emotionally meaningful story, the subject states that he or she does not have specific feelings that one would expect, although the subject recognizes that he or she should feel something. In talking about a meaningful, emotionally charged experience, the subject talks in a detached way, as if he or she is not in touch with the feelings that should surround it. The subject avoids feelings of guilt or shame by justifying his actions or by referring to external reasons that impelled him to act. At times the subject’s feelings merge with those of another person and the subject assumes the other’s feelings and needs are exactly the same as the subject’s own. He or she then tends to ‘put words in the other’s mouth.’ Whenever confronted about his or her own feelings or intentions, the subject avoids acknowledging them by giving a plausible explanation that covers up the real subjective reasons. When angry toward someone significant, the subject takes anger out on himself instead of expressing it directly. The subject expresses hatred toward someone or something and refuses to acknowledge anything that does not confirm the hatred. When experiencing or confronted with a problem, the subject shames, humiliates, or blames someone else for the problem, ignoring his or her own role. Quantitative scores – Graphics ODF Defense levels Individual defenses Defense levels: 1 = Action; 2 = Minor image-distorting; 3 = Disavowal; 4 = Major image-distorting; 5 = Neurotic; 6 = Obsessional; 7 = High adaptive Individual defenses: 1 = Acting out; 2 = Help-rejecting complaining; 3 = Passive aggression; 4 = Splitting of object’s image; 5 = Splitting of self-image; 6 = Projective identification; 7 = Autistic fantasy; 8 = Projection; 9 = Rationalization; 10 = Denial; 11 = Omnipotence; 12 = Idealization of self-image; 13 = Idealization of other’s image; 14 = Devaluation of other’s image; 15 = Devaluation of self-image; 16 = Displacement; 17 = Reaction formation; 18 = Dissociation; 19 = Repression; 20 = Undoing; 21 = Intellectualization; 22 = Isolation of affects; 23 = Affiliation; 24 = Altruism; 25 = Anticipation; 26 = Humor; 27 = Self-assertion; 28 = Self-observation; 29 = Sublimation; 30 = Suppression of that difficulty, the patient made sarcastic comments toward the rejected them and became even more oppositional. Toward the therapist and switched to another topic: the relationship with his end of the session, after many therapist’s attempts of interpreting girlfriend. The patient complained a lot about how frustrating this patient’s maladaptive pattern, the patient could finally reflect upon relationship was and justified his anger as the result of feeling too it and became more collaborative. However, his reflections were much pressure and low empathy at the same time. He made lots influenced by generalization, detachment and ambivalence. The of devaluing comments about his girlfriend, although he could still patient described himself as stuck in silence, his inability to talk see some positive aspects of her. Moreover, he reported on a series about his feelings, to see things in a different way. At this point the of passive aggressive behaviors toward a number of people (e.g., patient was able to let the therapist help him and get involved in delay in return phone calls, calling up his ex-girlfriend, feeling a shared exploration of his fears, needs and desires. He reflected bored in the session, feeling the therapist detached from him). Most on his difficulty in listening to his girlfriend’s trouble but somehow of the session was characterized by the patient complaining about justified it as a need of physical connection. However, when the several aspects of his life, including the therapy, in which he had therapist made further interpretations of the patient’s fantasy of experienced ambivalence, detachment and frustration. When the emotional fusion, the patient seemed to reactivate the projective therapist tried to interpret these feelings as defensive responses pattern, which was promptly interrupted by the therapist. This to the experience of a temporary unavailability of significant allowed the patient to keep reflecting in an ambiguous manner people, the patient denied the interpretation and perceived the instead of complaining and activating all sorts of immature defense therapist as manipulative. Despite therapist’s interpretations of his mechanisms. opposition, silence and emotional distancing as reactions to feeling Table 10 displays PND and graphics of patient’s defensive frustrated by not getting what he wants when he wants, the patient functioning, including ODF, defense levels, and individual Frontiers in Psychology | www.frontiersin.org 20 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 21 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q defenses scores. Defensive maturity fell in the range of severe often used for a summary picture of the individual’s defensive depression or personality disorders (ODF < 4; Presniak et al., functioning. Third, the seven defense level proportional scores 2010; Perry and Bond, 2012; Di Giuseppe et al., 2019), with about reflect the prevalent defenses that have common functions at 70% of immature defenses in use during the session, in particular each level, and how much this contributes to ODF. Fourth, the those belonging to disavowal defense level. Looking at the use of 30 individual defense proportional scores provide a picture of individual defense mechanisms, the legend shows that patient’s the patient’s characteristic defense mechanisms, which reflects predominant defenses were help-rejecting complaining, passive the most specific detailed level of defense assessment. These aggression, projecting identification, projection, rationalization, scores can capture differences between similar diagnostic and denial. This defensive constellation indicates a depressive, categories, such as personality disorders (Maffei et al., 1995; resistant and passive aggressive patient inclined to withdraw Lingiardi and Giovanardi, 2017; Di Giuseppe et al., 2019, inside himself and view his problems as externally caused, 2020d; Kramer, 2019), and reflect moment-to-moment micro- instead of dealing with his internal conflicts and external changes during the psychotherapy process (Hilsenroth and stressful situations. Pitman, 2019; Leibovich et al., 2020; Prout et al., 2021). Fifth, in addition to other DMRS measures (Perry, 1990; Di Giuseppe et al., 2020a), the DMRS-Q provides the patient’s defensive profile, a qualitative description of the most characteristic DISCUSSION defensive patterns that contribute to determine the individual’s The utility of studying defenses with the DMRS approach is DPN (see the “Defensive Profile Narratives” in Table 10). that it reveals the psychological function behind the use of Therapists can benefit from the use of all the above DMRS-Q defense mechanisms, the unconscious motives for protecting scoring levels, in particular the individual defenses. These can oneself from intolerable emotional experiences. It could be the guide therapeutic interventions to address desired changes in need of withdrawing anger, the threat of self-esteem failures, the patient’s defensive profile, thereby fostering therapeutic the shame of guilt experienced in confronting with unacceptable alliance and alleviating symptoms. Sixth, another remarkable thoughts and many others. Any of these functions suggests quality of the DMRS-Q is its excellent support for teaching what internal conflicts the individual is experiencing and how defense mechanisms. The use of simple examples of defensive adaptive is his or her defensive functioning. In the present article responses provided by the DMRS-Q items, similar to the we described the theoretical and methodological background examples in the original DMRS Manual (Perry, 1990), can of the DMRS-Q, illustrated its computerized and free-of-charge help the students’ understanding of definitions and functions online use, provided directions for coding and described the of defense mechanisms. Moreover, the five items describing interpretation of results. each defense mechanism can help in understanding differences While the assessment of defense mechanisms has been a in various occurrences of the same defense, especially the controversial issue debated among scholars for more than ones used uncommonly. Seventh, the main unique strengths a century, in recent years research, including that with the of the DMRS-Q system are the short training required for DMRS (Perry, 1990) convinced the American Psychiatric its reliable use, the lack of necessity for transcriptions for Association to include in the DSM-IV a provisional axis coding defenses, and the free unlimited access to the DMRS-Q for the assessment of the hierarchy of defense mechanisms software from any electronic device connected to the internet. (American Psychiatric Association, 1994). However, the The estimated time for a DMRS-Q coding is approximately excellence of this highly valid and reliable method is 15 min for expert trained raters who habitually code more than unfortunately accompanied by its time-consuming training three sessions per week. This allows clinicians to code patients’ and coding costs, which led to the elimination of the defense axis defense mechanisms after each session or a group of sessions in the DSM-5 because of lack of empirical findings supporting and monitoring changes in defensive functioning during the the theory (Vaillant, 1992). therapeutic process (Wampold and Imel, 2015; Tanzilli et al., With the development of the Q-sort version of the 2017, 2018, 2020). DMRS we provided a computerized and easy-to-use clinician- The DMRS-Q has also some limitations that need report measure for the assessment of the whole hierarchy of consideration. First, the DMRS-Q is based on the Q-sort defense mechanisms observable in the routine practice of both methodology, which requests the use of a a priori determined dynamic and non-dynamic practitioners, as other have found forced distribution that might limit the rater’s decision-making (Starrs and Perry, 2018). in the rank-ordering process. Second, the need for sufficient Apart from the well-established theory behind their information on the patient’s defensive functioning is essential to development, the advantages of using this DMRS-based ensure that the rater’s clinical inference for scoring all items into measure are numerous. First, the ODF score informs on how the forced distribution has an adequate evidentiary basis. Finally, adaptive the individual’s defensive reaction is to internal conflicts the evaluation of defensive functioning is made on the overall and external stressful situations. This score can also be used defensive profile including all defensive phenomena observed. as an outcome measure due to its strong correlation with This methodology does not allow for the detection of specific other indexes of well-being. Second, the tripartite defensive defense mechanisms in use in particular moments, which is category proportional scores tell to what extent the patient uses instead possible by applying the original DMRS to transcripts of mature, middle-range and immature defenses. These scores are clinical interviews or therapy sessions. Frontiers in Psychology | www.frontiersin.org 21 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 22 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q According to preliminary validation studies, the DMRS-Q and aiding clinicians in choosing how to intervene in response to seems a valid and reliable tool for the assessment of defense defenses used in the session (Fonagy et al., 2008; Gabbard, 2014; mechanisms in clinical settings, where the requirements for the Conversano, 2021). The use of valid and reliable measures based use of the original DMRS are often unavailable (Di Giuseppe on the gold-standard theory is essential for ensuring that what et al., 2014; Békés et al., 2021). A recent study (Békés et al., 2021) we observe is properly operationalized. The DMRS-Q is an easy- demonstrated that graduate students who received 6-h training to-use, low-cost, computerized tool with promising psychometric reached excellent inter-rated reliability on the ODF (ICC = 0.90), properties can help clinicians in monitoring changes in defense good to excellent on defensive categories (ICC ranging from mechanisms during the treatment, as suggested by others (Bhatia 0.83 to 0.92), and acceptable to excellent on the seven defense et al., 2017; Barber and Solomonov, 2019). The automatic levels (ICC ranging from 0.74 to 0.92), with the only exception scoring procedure provides a comprehensive report of qualitative of major image-distorting defense level (ICC = 0.42) which is and quantitative information on patient’s defensive functioning usually the less reliable scale due to the low base-rate of these that can be used for clinical, research, and teaching purposes. defense mechanisms. On the other hand, non-trained students The ease of use of the DMRS-Q makes this measure a also showed excellent ICC on the ODF (ICC = 0.88) and potential candidate for fostering the observer-rated assessment of acceptable to excellent on most DMRS-Q scales (ICC ranging defense mechanisms in routine clinical practice and in process- from 0.60 to 0.91), except for the obsessional defense level (Békés outcome research. et al., 2021). Good criterion validity was found in both clinical (Di Giuseppe et al., 2014) and community samples (Di Giuseppe et al., 2020a). Moreover, comparisons with mentalization and DATA AVAILABILITY STATEMENT attachment showed great convergent and discriminant validity The raw data supporting the conclusions of this article will be (Tanzilli et al., 2021). These results demonstrated that the DMRS- made available by the authors, without undue reservation. Q has very promising psychometric properties that must be confirmed by future studies on larger and more stratified samples. AUTHOR CONTRIBUTIONS CONCLUSION The authors contributed in equal part to this work and approved The systematic assessment of defense mechanisms in clinical it for publication. Both authors contributed to the article and settings is very important for monitoring the therapeutic process approved the submitted version. Conversano, C., and Di Giuseppe, M. (2021). Psychological factors as determinants REFERENCES of chronic conditions: clinical and psychodynamic advances. Front. Psychol. American Psychiatric Association (1994). Diagnostic and Statistical Manual of 12:635708. doi: 10.3389/fpsyg.2021.635708 Mental Disorders, 4th Edn. Washington, DC: American Psychiatric Association. Cramer, P. (1987). The development of defense mechanisms. J. Pers. 55, 597–614. American Psychiatric Association (2013). Diagnostic and Statistical Manual of doi: 10.1111/j.1467- 6494.1987.tb00454.x Mental Disorders, 5th Edn. Washington, DC: American Psychiatric Publishing. Cramer, P. (2015). Defense mechanisms: 40 years of empirical research. J. Pers. Barber, J. P., and Solomonov, N. (2019). Toward a personalized approach to Assess. 97, 114–122. doi: 10.1080/00223891.2014.947997 psychotherapy outcome and the study of therapeutic change. World Psychiatry Di Giuseppe, M., Gennaro, A., Lingiardi, V., and Perry, J. C. (2019). The role of 18, 291–292. doi: 10.1002/wps.20666 defense mechanisms in emerging personality disorders in clinical adolescents. Békés, V., Prout, T. A., Di Giuseppe, M., Wildes Ammar, L., Kui, T., Arsena, G., Psychiatry 82, 128–142. doi: 10.1080/00332747.2019.1579595 et al. (2021). Initial validation of the defense mechanisms rating scales Q-sort: Di Giuseppe, M., Perry, J. C., Lucchesi, M., Michelini, M., Vitiello, S., Piantanida, a comparison of trained and untrained raters. Mediterr. J. Clin. Psychol. 9. A., et al. (2020a). Preliminary reliability and validity of the DMRS-SR-30, a novel doi: 10.13129/2282- 1619/mjcp- 3107 self-report based on the defense mechanisms rating scales. Front. Psychiatry Berney, S., de Roten, Y., Beretta, V., Kramer, U., and Despland, J. N. (2014). 11:870. doi: 10.3389/fpsyt.2020.00870 Identifying psychotic defenses in a clinical interview. J. Clin. Psychol. 70, Di Giuseppe, M., Prout, T. A., Fabiani, M., and Kui, T. (2020b). Defensive profile 428–439. of parents of children with externalizing problems receiving regulation-focused Bhatia, M., Petraglia, J., de Roten, Y., and Drapeau, M. (2017). Do therapists psychotherapy for children (RFP-C): a pilot study. Mediterr. J. Clin. Psychol. 8. practicing psychoanalysis, psychodynamic therapy and short-term dynamic doi: 10.6092/2282- 1619/mjcp- 2515 therapy address patient defences differently? Arch. Psychiatry Psychother. 19, Di Giuseppe, M., Miniati, M., Miccoli, M., Ciacchini, R., Orrù, G., Lo Sterzo, R., 7–14. doi: 10.12740/APP/69642 et al. (2020c). Defensive responses to stressful life events associated with cancer Block, J. (1978). The Q–Sort Method in Personality Assessment and Psychiatric diagnosis. Mediterr. J. Clin. Psychol. 8, 1–22. doi: 10.6092/2282- 1619/mjcp- Research. Palo Alto, CA: Consulting Psychologists Press. 2384 Boldrini, T., Lo Buglio, G., Giovanardi, G., Lingiardi, V., and Salcuni, S. (2020). Di Giuseppe, M., Perry, J. C., Conversano, C., Gelo, O. C. G., and Gennaro, Defense mechanisms in adolescents at high risk of developing psychosis: an A. (2020d). Defense mechanisms, gender, and adaptiveness in emerging empirical investigation. Res. Psychother. 23:456. doi: 10.4081/ripppo.2020.456 personality disorders in adolescent outpatients. J. Nerv. Ment. Dis. 208, 933– Brown, S. R. (1993). A primer on Q methodology. Operant Subjectivity 16, 91–138. 941. doi: 10.1097/NMD.0000000000001230 Brown, S. R. (1995). Q methodology as the foundation for a science of subjectivity. Di Giuseppe, M., Nepa, G., Prout, T. A., Albertini, F., Marcelli, S., Orrù, G., et al. Operant Subjectivity 18, 1–16. (2021). Stress, burnout, and resilience among healthcare workers during the Conversano, C. (2021). The psychodynamic approach during COVID-19 COVID-19 emergency: the role of defense mechanisms. Int. J. Environ. Res. emotional crisis. Front. Psychol. 12:670196. doi: 10.3389/fpsyg.2021.670196 Public Health 18:5258. doi: 10.3390/ijerph18105258 Frontiers in Psychology | www.frontiersin.org 22 October 2021 | Volume 12 | Article 718440 fpsyg-12-718440 October 11, 2021 Time: 15:58 # 23 Di Giuseppe and Perry Assessing Defenses With the DMRS-Q Di Giuseppe, M., Perry, J. C., Petraglia, J., Janzen, J., and Lingiardi, V. (2014). Perry, J. C., and Henry, M. (2004). Studying defense mechanisms in psychotherapy Development of a Q-sort version of the defense mechanism rating scales using the defense mechanism rating scales. Def. Mech. 136, 165–186. (DMRS-Q) for clinical use. J. Clin. Psychol. 70, 452–465. doi: 10.1002/jclp.22 Presniak, M. D., Olson, T., and MacGregor, M. W. (2010). The role of defense 089 mechanisms in borderline and antisocial personalities. J. Pers. Assess. 92, 137– Drapeau, M., de Roten, Y., Perry, J. C., and Despland, J. N. (2003). A study of 145. doi: 10.1080/00223890903510373 stability and change in defense mechanisms during a brief psychodynamic Prout, T. A., Rice, T., Chung, H., Gorokhovsky, Y., Murphy, S., and Hoffman, L. investigation. J. Nerv. Ment. Dis. 191, 496–502. doi: 10.1097/01.nmd. (2021). Randomized controlled trial of regulation focused psychotherapy for 0000082210.76762.ec children: a manualized psychodynamic treatment for externalizing behaviors. Fonagy, P., Gergely, G., and Target, M. (2008). “Psychoanalytic constructs and Psychother. Res. 1–16. doi: 10.1080/10503307.2021.1980626 attachment theory and research,” in Handbook of Attachment: Theory, Research, Starrs, C. J., and Perry, J. C. (2018). Coping action patterns as mechanisms of and Clinical Applications, eds J. Cassidy and P. R. Shaver (New York, NY: The change across psychotherapies: three case examples of personality disorders Guilford Press), 783–810. with recurrent major depression. J. Pers. Disord. 32, 58–74. doi: 10.1521/pedi. Freud, S. (1894). “The neuro-psychoses of defence,” in The Standard Edition of 2018.32.supp.58 the Complete Psychological Works of Sigmund Freud (1893–1899) Early Psycho- Tanzilli, A., Di Giuseppe, M., Giovanardi, G., Boldrini, T., Caviglia, G., Conversano, Analytic Publications, Vol. 3, ed. Strachey, J. (London: The Hogarth Press). C., et al. (2021). Mentalization, attachment, and defense mechanisms: a Gabbard, G. O. (2014). Psychodynamic Psychiatry in Clinical Practice, 5th Edn. psychodynamic diagnostic manual-2-oriented empirical investigation. Res. Washington, DC: American Psychiatric Association Publishing. Psychother. 24:531. doi: 10.4081/ripppo.2021.531 Hilsenroth, M. J., and Pitman, S. R. (2019). “Working with cyclical relational Tanzilli, A., Gualco, I., Baiocco, R., and Lingiardi, V. (2020). Clinician patterns in contemporary psychodynamic psychotherapy,” in Contemporary reactions when working with adolescent patients: the therapist response Psychodynamic Psychotherapy, eds D. Kealy and J. S. Ogrodniczuk (Cambridge, questionnaire for adolescents. J. Pers. Assess. 102, 616–627. doi: 10.1080/ MA: Academic Press), 19–31. 00223891.2019.1674318 Hilsenroth, M. J., Callahan, K. L., and Eudell, E. M. (2003). Further reliability, Tanzilli, A., Lingiardi, V., and Hilsenroth, M. (2018). Patient SWAP-200 convergent and discriminant validity of overall defensive functioning. J. Nerv. personality dimensions and FFM traits: do they predict therapist responses? Ment. Dis. 191, 730–737. doi: 10.1097/01.nmd.0000095125.92493.e8 Pers. Disord. 9, 250–262. doi: 10.1037/per0000260 Hoffman, L., Rice, T., and Prout, T. A. (2016). Manual of Regulation- Tanzilli, A., Muzi, L., Ronningstam, E., and Lingiardi, V. (2017). Focused Psychotherapy for Children (RFP-C) with Externalizing Behaviors: A Countertransference when working with narcissistic personality disorder: an Psychodynamic Approach. Abingdon-on-Thames: Routledge. empirical investigation. Psychotherapy 54, 184–194. doi: 10.1037/pst0000111 Hoglend, P., and Perry, J. C. (1998). Defensive functioning predicts improvement Vaillant, G. E. (1971). Theoretical hierarchy of adaptive ego mechanisms: a 30-year in treated major depressive episodes. J. Nerv. Ment. Dis. 186, 238–243. follow-up of 30 men selected for psychological health. Arch. Gen. Psychiatry 24, Kernberg, O. F. (1988). Object relations theory in clinical practice. Psychoanal. Q. 107–118. doi: 10.1001/archpsyc.1971.01750080011003 57, 481–504. Vaillant, G. E. (1977). Adaptation to Life. Boston, MA: Little, Brown. Kramer, U. (2019). Personality, personality disorders, and the process of change. Vaillant, G. E. (1992). Ego Mechanisms of Defense: A Guide for Clinicians and Psychother. Res. 29, 324–336. doi: 10.1080/10503307.2017.1377358 Researchers. Washington, DC: American Psychiatric Press. Leibovich, L., Front, O., McCarthy, K. S., and Zilcha-Mano, S. (2020). How do Wampold, B. E., and Imel, Z. E. (2015). The Great Psychotherapy Debate: The supportive techniques bring about therapeutic change: the role of therapeutic Evidence for What Makes Psychotherapy Work, 2nd Edn. New York, NY: alliance as a potential mediator. Psychotherapy 57, 151–159. doi: 10.1037/ Routledge. pst0000253 Lingiardi, V., and Giovanardi, G. (2017). Challenges in assessing personality of Conflict of Interest: The authors declare that the research was conducted in the individuals with gender dysphoria with the SWAP-200. J. Endocrinol. Invest. absence of any commercial or financial relationships that could be construed as a 40, 693–703. doi: 10.1007/s40618- 017- 0629- 7 potential conflict of interest. Lingiardi, V., Lonati, C., Delucchi, F., Fossati, A., Vanzulli, L., and Maffei, C. (1999). Defense mechanisms and personality disorders. J. Nerv. Ment. Dis. 187, Publisher’s Note: All claims expressed in this article are solely those of the authors 224–228. doi: 10.1097/00005053- 199904000- 00005 and do not necessarily represent those of their affiliated organizations, or those of Maffei, C., Fossati, A., Lingiardi, V., Madeddu, F., Borellini, C., and Petrachi, the publisher, the editors and the reviewers. Any product that may be evaluated in M. (1995). Personality maladjustment, defenses, and psychopathological this article, or claim that may be made by its manufacturer, is not guaranteed or symptoms in nonclinical subjects. J. Pers. Disord. 9, 330–345. doi: 10.1521/pedi. endorsed by the publisher. 1995.9.4.330 Perry, J. C. (1990). Defense Mechanism Rating Scales (DMRS), 5th Edn. Cambridge, Copyright © 2021 Di Giuseppe and Perry. This is an open-access article distributed MA: Perry, JC. under the terms of the Creative Commons Attribution License (CC BY). The use, Perry, J. C. (2014). Anomalies and specific functions in the clinical identification of distribution or reproduction in other forums is permitted, provided the original defense mechansims. J. Clin. Psychol. 70, 406–418. doi: 10.1002/jclp.22085 author(s) and the copyright owner(s) are credited and that the original publication Perry, J. C., and Bond, M. (2012). Change in defense mechanisms during long-term in this journal is cited, in accordance with accepted academic practice. No use, dynamic psychotherapy and five-year outcome. Am. J. Psychiatry 169, 916–925. distribution or reproduction is permitted which does not comply with these terms. Frontiers in Psychology | www.frontiersin.org 23 October 2021 | Volume 12 | Article 718440

Journal

Frontiers in PsychologyPubmed Central

Published: Oct 15, 2021

There are no references for this article.