key: cord-0071743-7m79cwjy authors: Di Giuseppe, Mariagrazia; Perry, John Christopher; Prout, Tracy A.; Conversano, Ciro title: Editorial: Recent Empirical Research and Methodologies in Defense Mechanisms: Defenses as Fundamental Contributors to Adaptation date: 2021-12-03 journal: Front Psychol DOI: 10.3389/fpsyg.2021.802602 sha: 578f3191e1dbfbe10e5e8d3846b23706d67c9bf9 doc_id: 71743 cord_uid: 7m79cwjy nan As Cramer stated "Coping mechanisms involve a conscious, purposeful effort, while defense mechanisms are processes that occur without conscious effort and without conscious awareness (i.e., they are unconscious). Also, coping strategies are carried out with the intent of managing or solving a problem situation, while defense mechanisms occur without conscious intentionality; the latter function to change an internal psychological state but may have no effect on external reality, and so may result in non-veridical perception, that is, in reality distortion" (Cramer, 1998, p. 921) . With continued advances in empirical research on the hierarchical nature of defense adaptation, two aspects of Cramer's definition appear incomplete. First, some defenses confuse internal conflict with external stress and lead the individual to maladaptive responses to the environment (e.g., counter-attacking rather than reflecting before acting). Second, it does not capture the partially conscious and more flexibly adaptive aspects of mature defensive functioning. Defense mechanisms higher in the hierarchy (i.e., high adaptive defenses) do not follow the differential criteria described in Cramer's theory (Beresford, 2012) . More than 30 years research with the Defense Mechanisms Rating Scales (DMRS; Perry, 1990) and its derivative measures (DMRS-Q; Di Giuseppe et al., 2014; Di Giuseppe and Perry, 2021; DMRS-SR-30; Di Giuseppe et al., 2020a) have demonstrated that individuals using mature defenses can: (1) be partially or fully aware of their activation (e.g., altruism, self-assertion, or self-observation); (2) intentionally use an adaptive defensive strategy to deal with internal conflict or stressful situations (e.g., anticipation or suppression); and (3) increase the probability of a gratifying resolution of the internal or external stressors without reality distortion (e.g., selfassertion or sublimation). In light of these findings, we affirm that the hierarchy of defense mechanisms (Vaillant, 1992; American Psychiatric Association, 1994; Perry, 2014 ; Di Giuseppe and Perry) is a comprehensive description of both more adaptive (i.e., mature defenses, overlapping in function with coping strategies) and less adaptive (i.e., immature and neurotic defenses) way of automatically responding. A clear result is that the systematic assessment of defenses which reflects this hierarchy of adaptation adds value to the diagnosis of mental disorders. We believe that it is an essential part (Perry et al., 2020; Conversano, 2021) . Research on personality disorders has found that specific defensive profiles are associated with personality traits and disorders (Maffei et al., 1995; Steiner et al., 2007; Presniak et al., 2010; Perry et al., 2013) and revealed a hierarchical organization of personality disorders based on the maturity of defensive functioning (Di Giuseppe et al., 2019) . This confirms Kernberg's Personality Organization, which includes object representations (split vs. ambivalent objects) and reality testing (Kernberg, 1984) . As highlighted by Kempe et al. by analyzing the defensive functioning of individuals with narcissistic personality it is possible to distinguish the defensive profiles of both grandiose and vulnerable narcissism (Kempe et al.) . Similarly, recent studies investigated defenses in relation to attachment and mentalization show promising results. As demonstrated by Tanzilli et al. (2021) , depressed patients with secure attachment showed higher reflective functioning and overall defensive maturity then those with insecure attachment. In line with these findings, Békés et al. found that the use of neurotic and immature defenses in the early phase of treatment predicted an increase in avoidant attachment over the course of treatment, whereas the use of immature non-depressive defenses (e.g., denial, rationalization) predicted a decrease in preoccupied attachment. Similarly, Hayden et al. reported that mentalization played an important role in the reduction of maladaptive defenses during inpatient therapy. However, their results showed that only maladaptive defenses decreased significantly in psychotherapy, while neurotic and mature did not increase significantly as expected. It is possible that some of these contradictory results stem from methodological issues, such as employing measures with inadequate reliability and validity. Furthermore, other research has demonstrated that specific defense are associated with psychiatric symptoms, interpersonal problems, externalizing behaviors, vulnerable sense of self, poor adjustment, suicidal ideation, and attempts (Dell'Osso et al., 2011; Boldrini et al., 2020) . Psychotherapy is important to help individuals improve their defensive functioning and outcome (Hoffman et al., 2016; Babl et al., 2019; Di Giuseppe et al., 2020b; Hersoug et al.) . The proportion of mature and immature defenses change during psychotherapy and predict treatment response (Perry and Bond, 2012; Perry et al., 2020; Prout et al., 2021; Beresford et al.; de Roten et al.) . Patient improvement in defensive maturity is likely to happen within the relationship with the therapist, who in turn activates and works with defenses in response to stress . Therapists appear to utilize higher levels of mature defenses and lower levels of immature defenses compared to a community sample (Aafjes-van Doorn et al.). However, lower therapists' defensive maturity was associated with higher levels of vicarious trauma and professional doubt during the COVID-19 pandemic (Aafjes-van Doorn et al.) . Further studies should investigate the impact of the interplay between patient and therapist defense mechanisms on outcome. In addition to psychopathology research, interesting findings come from a number of recent studies conducted on general populations under stressful conditions. Maladaptive defensive responses were reported more often by younger people during the first wave of COVID-19 pandemic, while greater reliance on mature defenses was evident among older adults during the pandemic (Prout et al., 2020) . These findings were confirmed by Beresford et al. who found that maturity of defensive functioning was associated with older age and it predicted lower depression levels in a large sample of adult cancer patients. Defense mechanisms are also associated with gender. Women use more neurotic and immature-depressive defenses to deal with internal or external stressors, while in similar conditions men tend to rely more on obsessional and immature-non depressive defenses (see Di Giuseppe and Perry, 2021, for review on the hierarchy of defenses). These findings were confirmed also in individuals diagnosed with gender dysphoria, indicating that the individual's dominant defensive functioning is related to the gender to which one chooses instead of the gender assigned at birth (Giovanardi et al.) . Advances in research on defense mechanisms widely demonstrate the impact of defense mechanisms in the onset, course, and amelioration of mental disorders. Despite the increasingly robust findings that defense mechanisms, and the hierarchy of adaptation, add scientific value to diagnosis, many practitioners have limited awareness of these scientific contributions. This special issue of Frontiers is dedicated to increase awareness of the relevance of these constructs to clinical practice. Although defense mechanisms are included in the Psychodynamic Diagnostic Manual as a key construct in diagnosis and personality structure (Lingiardi and Bornstein, 2017) , we believe that greater understanding of patients' defensive functioning will be helpful to non-dynamically oriented clinicians as well. The science of our profession can be improved and the quality of our interventions can be individually tailored as a result of increased research on the role of defenses in the course of treatment. Research on defenses adds information about symptom severity, differential diagnosis, treatment compliance, recommended interventions, and expected prognosis. The inclusion of defensive functioning in diagnosis and case formulation (Perry et al., 2018 (Perry et al., , 2020 has the potential to enrich the overall clinical understanding of patients' mental functioning and how treatment can be tailored to meet their needs. In sum, close assessment of defenses provide some of the information needed to develop truly effective, personalized treatments (Zilcha-Mano, 2021). 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