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Cooper, E.M. Mellman, L.A. Kramarsky, A. Friedman, J.H. (2004). Symptoms, Defenses, and the Therapeutic Alliance: Findings after one year of Psychodynamic Psychotherapy. J. Amer. Psychoanal. Assn., 52(2):452-453.
Psychoanalytic Electronic Publishing: Symptoms, Defenses, and the Therapeutic Alliance: Findings after one year of Psychodynamic Psychotherapy

(2004). Journal of the American Psychoanalytic Association, 52(2):452-453

Symptoms, Defenses, and the Therapeutic Alliance: Findings after one year of Psychodynamic Psychotherapy

Edith M. Cooper, Lisa A. Mellman, Anna Kramarsky and Jill Harkavy FriedmanAuthor Information

Seventy-three students were referred from a university mental health center to a hospital-based treatment and research clinic for twice-weekly psychodynamic psychotherapy. The first year of treatment was assessed with regard to symptom improvement, development of a therapeutic alliance, and shifts in defense style. The authors hypothesized (1) that symptoms of depression and anxiety would decrease; (2) that

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use of mature defenses would increase, while use of immature and neurotic defenses would decrease; and (3) that the therapeutic alliance would strengthen over the course of the year. In addition, the relation-ships among symptoms, defenses, and therapeutic alliance were investigated.

Data were collected at three points during the year. At entry into treatment, Axis I and II diagnoses were assessed, as were levels of depression, anxiety, and defense styles. At two months, the early therapeutic alliance was measured. At one year, levels of depression, anxiety, therapeutic alliance, and defense style were reevaluated.


Results indicated that subjects began treatment with high levels of depression and anxiety, in addition to substantial Axis I and II psychopathology. At entry into treatment, those who carried both Axis I and II diagnoses were more depressed, more anxious, and more likely to use immature defenses than those who carried an Axis I diagnosis only or received no diagnosis. This suggests an interaction between Axis I and II that heightens psychopathology.

When assessed at two months, the level of therapeutic alliance was found to be both strong and unrelated to diagnosis, indicating the capacity of those with even substantial DSM-IV symptomatology to form a therapeutic connection. Contrary to expectation, the therapeutic alliance did not become stronger over the year in treatment, perhaps due to the high level at which it started. However, an unexpected relationship between defenses and therapeutic alliance emerged. Those who scored high in use of mature defenses began therapy more cautiously with regard to the therapeutic alliance, but ended the year more strongly allied with the therapist than those who used predominantly immature or neurotic defenses. As expected, there was a significant reduction in symptoms of distress, depression, and anxiety by the end of the first year of treatment. While there was a trend toward decreased use of immature defenses, defenses did not change over the year, suggesting an enduring aspect to defense style that would require a longer treatment to address.

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Article Citation

Cooper, E.M., Mellman, L.A., Kramarsky, A. and Friedman, J.H. (2004). Symptoms, Defenses, and the Therapeutic Alliance. J. Amer. Psychoanal. Assn., 52(2):452-453

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