Development of a Q-Sort Version of the Defense Mechanism Rating

Scales (DMRS-Q) for Clinical Use

Mariagrazia Di Giuseppe,2 J. Christopher Perry,1 Jonathan Petraglia,1
Jennifer Janzen,1 and Vittorio Lingiardi2
1
McGill University
2
Sapienza University of Rome
This report focuses on the need to provide clinicians with a reliable and valid measure for detecting
patient defense mechanisms “inside psychotherapy.” To avoid the limitations of existing methods,
we designed a Q-sort based on the theoretical definitions and criteria of the Defense Mechanisms
Rating Scales (DMRS-Q), but one that does not require transcripts of clinical interviews or sessions
and may be applied without specific training on defenses. The DMRS-Q is sensitive to changes in
psychotherapy and its scores correlate significantly with various aspects of mental functioning, making
it potentially available for the psychotherapy process and outcome research as well. We report the
results of using the DMRS-Q on a systematic single case study with the aim of detecting changes in
defense mechanisms during a long-term psychodynamic psychotherapy. The DMRS-Q reveals change
both in quantitative scores and in the literary Defensive Profile Narrative. C 2014 Wiley Periodicals,

Inc. J. Clin. Psychol.: In Session 70:452–465, 2014.

Keywords: defense mechanisms; Q-sort; psychotherapy process

Psychological defense mechanisms are typically conceptualized as unconscious mental opera-

tions that function to protect against excessive anxiety and protect the self against unconscious
feelings and unacceptable internal or external conflicts (Cooper, Perry, & Arnow, 1988; Cramer,
2006; Perry, 1990; Vaillant, 1992). A comprehensive clinical understanding of defenses in any
specific case would require a clinician to consider how the person deals with distressing feelings,
thoughts, and motives; that is, to specify how specific defenses are related to specific symptoms
and other psychological functions.
Numerous studies have found that the diagnosis of any personality disorder (PD) is associated
with low defensive functioning (Hilsenroth, Callahan, & Eudell, 2003; Lingiardi, Lonati, Fossati,
Vanzulli, & Maffei, 1999; Perry, 2001; Perry & Hoglend, 1998; Perry, Presniak, & Olson, 2013).
For example, in severe PDs, such as borderline, antisocial, and schizotypal personality, action
and major image-distorting defenses and low Overall Defensive Functioning (ODF) predict
exacerbations of episodes of depression as well as self-destructive symptoms, self-cutting, and
recurrent suicidal ideation and suicidal attempts. Action and disavowal defenses predict sub-
stance abuse and antisocial symptoms (Perry & Cooper, 1989) and, in association with minor
image-distorting defenses, risk taking; in addition, minor image-distorting defenses predict dys-
thymic symptoms (Perry, 1990). By contrast, obsessional and mature defenses play a protective
role against both impulsive behaviors and depressive symptoms (Perry, 1988).
The stability of rigid and unadaptive defense mechanisms may change through psychother-
apy; in fact, in recent naturalistic studies, positive change in defenses was associated with
positive outcomes in both short and long-term psychotherapies (Drapeau, De Roten, Perry, &
Despland, 2003; Perry & Bond, 2012). Moreover, investigating defense mechanisms may inform
certain aspects of the psychotherapy process, including momentary shifts in patient discussion
of conflictual topics or choice of therapist intervention (Despland, Despars, De Roten, Stigler, &

Please address correspondence to: Dr. Mariagrazia Di Giuseppe, 11 Via Campana, Teramo, 64100, Italy.
E-mail: psymary@hotmail.it

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 70(5), 452–465 (2014) 

C 2014 Wiley Periodicals, Inc.

Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22089

 Defense Mechanism Rating Scales Q-Sort 453

Perry, 2001; Lingiardi, Gazzillo, & Waldron, 2010; Perry, Petraglia, Olson, Presniak, & Metzger,
2012).
In addition to the contribution of research on defense mechanisms to psychology and psy-
chotherapy, the study of defenses is also very important in clinical work, where clinicians expe-
rience their patients’ defense mechanisms in action. Clinicians often find managing unadaptive
defenses challenging, as they may interfere with the working alliance and lead to attrition. In the
clinical setting, patients recount their lives, reveal their images of themselves and others, repeat
dysfunctional relationship patterns in their work with the therapist, and eventually elaborate
their conflictual themes. In turn, the therapist who comprehends the defensive manifestations
of patients will have an easier time understanding the material they protect, allowing more
informed choices of when and how to address or interpret defenses.
With the aim of providing clinicians with a reliable and valid measure for detecting defense
mechanisms “inside psychotherapy,” we created a Q-sort based on the Defense Mechanisms
Rating Scales (DMRS-Q). We chose the DMRS parent instrument because we view it as the
closest measure to a criterion standard method for assessing defenses, one that has been applied
both to clinical work and to research studies in clinical populations both during and after
psychotherapy. It is our belief that an initial case formulation that includes defensive functioning,
with both qualitative and quantitative information, should improve the diagnostic process. The
advantage of the DMRS-Q is that it does not require any specific intensive training as the parent
DMRS does.
To use the DMRS-Q, a rater should have clinical experience and a basic knowledge of the
theory of defense mechanisms as conceptualized in the DMRS manual (Perry, 1990). Clinical
experience encompasses learning how to separate observation of clinical material from inferences
about that material. Inference is an important part of rating defense but it must be guided by rules
and not done “wildly.” The DMRS-Q rating requires sufficient data, such as one or more clinical
interviews or therapy sessions. After conducting or observing them, it takes an experienced rater
about 30 minutes to complete a DMRS-Q rating of a subject, following the instructions of the
DMRS-Q software.
When the rating is complete, the software automatically provides quantitative scores of indi-
vidual defenses, defensive levels, and ODF. In addiction, the DMRS-Q software also provides
graphics of the defensive scores. If serial ratings are made, this visually displays the subject’s
defensive functioning at different points in time (e.g., stages of the treatment). The software
also provides an initial or follow-up qualitative description of the patient’s defensive profile, the
so-called Defensive Profile Narrative (DPN), based on the most salient defenses rated. These
show specific defensive manifestations of the patient.
For the present report, we examined the defenses of one person who entered long-term
psychotherapy. We focused on two stages of the treatment, at the beginning and approaching
the end of the treatment. The overall effectiveness of this treatment has been reported elsewhere
(Perry & Bond, 2012). The present report focuses on the convergent validity of the DMRS-Q
and DMRS in this case, using four recorded and transcribed sessions, two early and two late near
treatment’s end. The comparison of the DMRS-Q with its parent instrument will demonstrate
the degree to which the methods give similar or different scores for the defenses and defense
levels. It also demonstrates the potential usefulness of the qualitative DPN.

Method
This report examines two psychotherapy sessions early and late in the course of a 3-year psy-
chotherapy of one individual who participated in a naturalistic observational study of long-term
dynamic psychotherapy. Both sessions were rated for defenses independently and blindly (as to
occasion), using both the DMRS and the DMRS-Q.

Measures
DMRS (Perry, 1990). The DMRS provides definitions of 30 nonpsychotic level defenses,
including descriptions of the function of each and how each defense may be discriminated from
454 Journal of Clinical Psychology: In Session, May 2014

other similar defenses; also included is a qualitative scale of definite and probable examples of the
defense. It is an observer-rated method close to a criterion standard, from which the qualitative
Provisional Defense Axis in Appendix B of the DSM-IV (APA, 1994) was largely modeled (Perry
et al., 1998). Several studies have indicated good convergent and discriminant validation for the
overall hierarchy with other measures of functioning and symptoms (Hilsenroth et al., 2003;
Perry & Cooper, 1989; Perry & Hoglend, 1998); the week-to-week stability of ODF and defense
levels are, respectively, intraclass R = .48 and median intraclass R = .47 (Perry, 2001). Inter-rater
reliability is acceptable to very good (Perry & Bond, 2012; Perry & Henry, 2004).
The quantitative scores provided by the DMRS comprise four different levels of scoring. The
individual defense score is a proportional or percentage score calculated by dividing the number of
times each defense was identified by the total instances of all defenses for the session. The defense
level scores are proportional or percentage scores of each of the seven defense levels. Each level
comprises the sum of the scores of the three to eight constituent defenses with shared functions.
The defenses are arranged hierarchically into seven defense levels based on their general level
of adaptiveness. ODF, a summary score obtained by taking the average of each defense level
score, weighted by its order in the hierarchy, yields a number between 1 (lowest) and 7 (highest).
In addition, defense level scores are combined into superordinate categories: mature (level 7),
neurotic (levels 5–6), immature (levels 1–4), and psychotic (level 0), although psychotic defenses
were not included in this study.

DMRS Q-sort development. The DMRS-Q is a Q-sort system based on the DMRS
definitions, functions, and discriminations from near-neighbor defenses. It includes 150 low-
inference statements, five for each defense mechanism. The Q-sort statements refer to personal
mental states, relational dynamics, verbal and nonverbal expressions, behaviors and coping
skills, and distorted perceptions that emerge on occasions when the subject experiences internal
or external stress or conflict. We initially developed about 300 statements covering a wide variety
of defensive phenomena. We asked a group of researchers trained on the DMRS quantitative
system to advise us on the clarity, simplicity, and nonredundancy of the statements, after which
we selected five items per defense, trying to capture a full range of manifestations, including the
uncommon ones.
The final list of 150 most promising statements, representing all 30 defenses described by the
DMRS, constitute the DMRS-Q items. Most statements are written in the form of a conditional
statement (when x occurs, the patient tends to show y). We gave special attention to differentiating
each item from similar manifestation related to near-neighbors defenses (e.g., rationalization vs.
intellectualization). Since psychotic defenses were not included in the original DMRS, they were
not included in the DMRS Q-sort either, although they will be added in the future.
Following Q-methodology, the DMRS-Q rating process uses a forced distribution in which
each of the 150 items is sorted into one of seven ordinal columns, corresponding to the increasing
level of descriptiveness of the statement for the subject evaluated, in terms of intensity or
frequency. Each column is defined within the scoring system, with 1 as “no evidence for the
defense item” and 7 as “the most characteristic defense item.” The DMRS-Q rater assigns
each of the 150 items to one of the 7 columns, considering the descriptiveness of the defensive
manifestation explained by the item for the subject under observation. The seven categories are
as follows: column 1 = not used at all; column 2 = exceptionally used; column 3 = slightly or
rarely used; column 4 = medium or sometimes used; column 5 = intensive or often used; column
6 = very intensive or frequently used; column 7 = rigidly or always used).
All item scores are forced into a decreasing semilinear distribution as following: 1 = 60 items;
2 = 30 items; 3 = 20 items; 4 = 16 items; 5 = 10 items; 6 = 8 items; 7 = 6 items. It has been widely
proven that there are no statistical implications related to the shape of the chosen distribution
or the capacity of each range (Block, 1978; Brown, 1993, 1995; Stephenson, 1986).
After sorting the 150 items into the forced distribution described above, the Q-sort com-
puterized algorithm calculates three levels of quantitative scores and one qualitative defensive
profile. The raw score for each defense, depending on in which column each of the five items for
defense mechanisms is sorted, is automatically converted to a proportional score for individual
defense. The proportion of defensive functioning for each level is similarly determined, as is the
 Defense Mechanism Rating Scales Q-Sort 455

ODF score. These scores are displayed graphically as well, allowing comparison of two or more
administrations, such as before and after treatment.
In addition to the quantitative scores, the DMRS-Q also provides a qualitative profile of
the patient’s most relevant defensive manifestation, DPN. This comprises those 14 items sorted
in columns 6 and 7, considered as highly descriptive of the subject. The DPN provides a case
description of the subject’s defensive functioning, highlighting the most characteristic ways
the subject handles stress and conflict. The software automatically lists the written items and
indicates the individual defense and defense level associated with each statement. Therapists may
use the DPN to remind themselves of the most common manifestations of defensive functioning
to which they should attend. As with the quantitative scores, it is possible to compare the
patient DPNs at different stages of the treatment, for a narrative description of how defensive
phenomena evolve during psychotherapy as well as which specific defensive manifestations
remain stable over time.
The amount and type of data required for a stable DMRS-Q rating varies with the aim. The
parent DMRS quantitative method usually requires a minimum of 20–25 minutes of interview
material, though about 50 minutes of a transcribed clinical interview or therapy session provides
a more stable estimate (Perry, 2001; Perry & Henry, 2004). The DMRS-Q requires a sufficient
knowledge of the subject evaluated, as provided by either a thorough evaluative session or
sessions or several consecutive therapeutic sessions.

Procedures
For the present report, we selected four therapy sessions of a woman in long-term dynamic
psychotherapy, which were previously rated using the original DMRS quantitative method. We
included two early sessions (sessions 5 and 6) and two sessions after 2.5 years of psychotherapy
(sessions 105 and 107), with the aim of detecting change over this period of time. This subject
was a participant in the earlier, larger study (N = 21) on the DMRS, the results of which have
been previously reported (Perry & Bond, 2012).
Current DMRS-Q raters were blind to all other subject data and session order. Two raters
independently listened to each pair of sessions, made one DMRS-Q rating for each pair (blinded
as to occasion), and then formed a consensus rating that was used for this report. This yielded
four DMRS ratings (one for each session) and two for the DMRS-Q. For statistical analysis,
we took the mean scores of the two separate DMRS ratings at each treatment time point and
compared them with the single DMRS-Q rating on the respective sessions. We then compared
all DMRS and DMRSQ scores at each of the two time points. We also compared the DPNs at
early and late stages for qualitative analysis of changes in defenses.

Case Example
Ms. N was a student in her mid-twenties living at home who sought psychotherapy after a family
crisis. She had grown quite close to a homeless woman her own age who the family had taken
into their home. The woman had been self-destructive (e.g., self-mutilating) and the family was
subsequently advised to ask her to leave. When they complied with this, the patient became very
upset, impulsively tried to kill herself by cutting, and went to the emergency room.
Diagnostically the patient had a DSM-IV recurrent major depressive disorder, in remission, at
intake. However, she also struggled with multiple other disorders, including dysthymic disorder
(onset at age 5), mild obsessive-compulsive disorder (obsessions only), and binge eating (onset
age 13), which progressed to bulimia nervosa with purging at age 19. Alcohol and substance
abuse and dependence began at 15 years of age, but she had been abstinent for many months
after a detoxification. She also had panic disorder since 20 years of age, and posttraumatic stress
disorder with onset at age 16 after a sibling’s suicide. Her PTSD was recently exacerbated when
she was present during a robbery at work one month prior to intake. On Axis II she had significant
borderline and avoidant traits, with milder depressive, dependent, and passive-aggressive traits,
but she remained shy of full criteria for a personality disorder.
456 Journal of Clinical Psychology: In Session, May 2014

History
The youngest of several siblings, Ms. N reported that her mother loved her and was a reasonably
good caretaker and meant well, but was also ineffectual setting rules or expectations, especially
in dealing with her father. Her mother was “a martyr” to others’ needs, but also made the patient
feel guilty whenever she asked for something. While she tried to be the perfect little girl at home,
as a teen she created a “second personality,” never doing what mother wanted when not at home.
Nonetheless she remained emotionally close to her mother throughout her growing up.
At 6 years of age, she realized that her father had a drinking problem. He was pleasant, even
entertaining, but not disciplinary. He was ineffectual in raising the children. Initially money was
plentiful, but he lost his job and continued to spend unwisely. Her parents argued frequently
and loudly, including in public, and the children followed suit. The household lacked consistent
rules, and while there was considerable emotional neglect, there was no abuse or physical neglect.
Ms. N began drinking at 15 years of age and using marijuana and other drugs at 16, saying,
“being drunk numbed the guilt I felt.” She also had a number of relationships that often
started with partying and drinking and sometimes lasted months, but none were described as
emotionally close or satisfying. Ms. N reported that she always had to have a guy in her life,
describing herself as “clingy.” When sober, she was self-conscious, fearing being judged and
rejected, which prevented her from pursuing certain jobs, or even going to a public swimming
pool. She was a “screamer” when upset.
In recent years, she had developed an intense attachment to an older man, mostly around
having fun, although he made her feel valued. She decided her life was being wasted and sought
to sober up and stop drugs. After detoxification she attained sobriety and tried to break up with
her boyfriend who still used drugs. He eventually sobered up, and they continued to see each
other although with an unclear relationship status. At intake, the patient was back in a training
program while working part-time. She considered herself desperate with a great need for therapy.
She had ambition but didn’t know how to put it to use toward her life goals. Guilt plagued her
and she knew that being an “overprotected child” with a dysfunctional father and a sibling with
severe mental illness were seriously affecting her relationships with men.

Course of Therapy
Ms. N’s therapy lasted 117 sessions. After a brief period of missing some sessions, she developed a
positive working alliance with her therapist, eventually terminating therapy at 3 years, the allotted
period of treatment for the study. The total period of follow-up lasted 6 years. She was fully
recovered from her suicidal and self-destructive symptoms by 2 years into treatment. Overall,
her functioning improved on Global Assessment of Functioning (GAF), satisfaction, social role
performance, and subjective distress; in addition, she experienced a greater awareness of other
problems including symptoms of depression and anxiety. Paradoxically, she initially scored as
healthy on the self-report Defense Style Questionnaire (DSQ; Bond, Gardner, Christian, & Sigal,
1983), but this score worsened slightly over time as she became a better (more accurate) reporter
of her true level of functioning.

Defense Scores
Ms. N had eight therapy sessions rated by the DMRS over 2.5 years of treatment. Table 1
indicates her mean scores on the DMRS for sessions 5 and 6 compared to the Q-sort rating
at the beginning of the therapy, and her mean scores on the DMRS for sessions 105 and 17
compared to the Q-sort rating at the end. Overall, her immature defenses decreased in both
DMRS and DMRS Q-sort (−10.4% vs. −7.3%), while her high adaptive level defenses increased
(6.5% vs. 8.2%). However, the neurotic defenses increase slightly in the DMRS ratings, whereas
the Q-sort shows a slight decrease (3.9% vs. −1.0%). Overall, she showed an increase of ODF
using the DMRS from early treatment to late treatment of 0.41, consistent with a move from a
personality or depressive disorder to the lower bound of individuals with neurotic personality
issues (4.48 vs. 4.89). The magnitude of the change in ODF, 0.46, was similar on the DMRS-Q
 Defense Mechanism Rating Scales Q-Sort 457

Table 1
DMRS and DMRS Q-Sort Mean Scores of Two Sessions at Early Treatment Versus Late Treat-
ment (N = 4 Sessions)

Early Early Late Late Early vs. late Early vs. late
Defense treatment treatment treatment treatment treatment treatment
Categories DMRS DMRS-Q DMRS DMRS-Q DMRS DMRS-Q

ODF 4.48 4.19 4.89 4.65 0.41 0.46

Mature 9.73 12.42 16.25 20.64 6.52% 8.22%
Neurotic 47.11 41.42 51.01 40.38 3.9% 1.04%
Immature 43.16 46.25 32.74 38.98 −10.42% −7.27%

Figure 1. Comparison between DMRS and DMRS-Q defense level scores at early and late stage of
treatment.

(4.19 vs. 4.65). These changes are in line with those across the total eight sessions rated on the
DMRS.
Comparisons between DMRS and DMRS Q-sort scores are displayed graphically in Figure 1.
In the early sessions, the patient obtained almost the same profile of defense level scores using
both methods. However, in the late sessions, there was clear divergence at the intermediate levels
of maturity, in particular on the other neurotic level, which includes displacement and reaction
formation. Smaller differences between the DMRS and DMRS Q-sort ratings emerged also on
action, borderline, and obsessional defense levels.
Table 2 displays the Pearson’s correlations using all four sessions comparing the results on the
two methods. We obtained highly positive correlations for both the ODF (r = .92) and the three
supercategories of defenses (median r = .72). The defense levels were generally highly related
(median correlation r = .72), but there were two exceptions: The major image distortion level
(borderline defense level) did not occur at a sufficient base rate to allow the computation of
a correlation, and the minor image distorting defenses (narcissistic defense level) produced a
negative correlation.

Defensive Profiles
Table 3 displays the DPNs of the patient at the beginning and late in treatment, comparing
her most characteristic defense mechanisms. For each rating occasion, the scoring program
extracts a list of the 14 items rated in the DMRS Q-sort as “very descriptive of the subject”
(sorted as either column 6 or 7). These are presented in the order of the three supercategories of
458 Journal of Clinical Psychology: In Session, May 2014

Table 2
Pearson’s Correlation Between DMRS Versus DMRS Q-Sort on the Defensive Levels (N = 4
Sessions)

Supercategories Defense levels

ODF Mature Neurot Immat Mature Obsess Hyster Dis/RF Narciss Denial Border Action

ODFQ .92
MatureQ .72
NeurotQ .68
ImmatQ .83
MatureQ .72
ObsessQ .92
HysterQ .71
Dis/RFQ .73
NarcissQ −.35
DenialQ .58
BorderQ –
ActionQ .73

immature, neurotic, and mature defenses, and within those, the subsumed seven defense levels.
We observed changes in (a) the number of items in each category, (b) the frequency of specific
adaptive defensive levels, and (c) the manifestations of specific defense mechanisms (i.e., the
items themselves). Table 3 displays the 14 items describing the patient’s Defensive Profile before
and after the treatment.
At early treatment, her defensive profile was characterized by several features: spontaneous
complaining about problems and life issues, while systematically rejecting others’ suggestions
about solving them (item 130); insistently reciting a litany of issues and problems, while not
appearing to be engaged in solving them (item 84); and complaining about how others don’t
really care, or have actually made her problems worse (item 21). She appeared very judgmental
about others, in particular her parents, although she could acknowledge some of their positive
aspects (item 111). In particular, when she felt ashamed or low in self-esteem, she tended to
dismiss issues by finding some fault or criticism elsewhere or by uttering obscene comments
about them (item 54).
However she was not just devaluing others. She made many unwarranted negative, sarcastic,
or biting statements about herself (item 29), and appeared very preoccupied with her faults,
although she could acknowledge some of her realistic positive aspects when these were pointed
out (item 56).
The minor image-distorting defenses were also associated with neurotic defenses that helped
her keep distance from painful feelings by (a) substituting anger with an opposite attitude (item
52); (b) failing to express any negative feelings toward angry or abusive people, although it
might be expected (item 74); (c) expressing more feelings directed toward incidental details
or issues than about the major point or effect of the event (item 122); (d) wandering off to
topics only tangentially related to the problem but that are emotionally easier to discuss (item
69); (e) keeping things vague, reflected in very vague, general, or inexact statements (item 50);
and (f) conveying opinions about charged relations or situations with a series of opposite or
contradictory statements, as if uncomfortable with taking a clear stand one way or the other
(item 81 and item 48). Mature defenses were not descriptive of her DPN at intake.
Later in her therapy she became able to cope with important conflicts or stressful situations
by exploring her own motives and limitations to arrive at a more fulfilling decision (item 77)
and accepting her personal problems and avoiding exacerbating them, in particular acknowl-
edging her addictions and accepting that she must avoid using either drugs, alcohol, or food as
compensation for her sadness (item 128). Neurotic and immature defenses also showed up in
Table 3
Defensive Profile Narrative at Early and Late Treatment

Early treatment defensive profile narratives Late treatment defensive profile narratives

High adaptive defenses. Whenever the subject handles internal or external stressors or conflicts most adaptively, the subject defends in the following ways.
Item 77: When considering an emotionally important Level 7 Self-observation
decision, the subject explores his or her own motives
and limitations to arrive at a more fulfilling decision.
Item 128: When the subject experiences a salient Level 7 Suppression
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.
Neurotic defenses. When the subject handles internal or external stressors or conflicts with some difficulty, which the subject is partially or wholly unaware of, the subject defends
in the following ways.
Level 6 Undoing Item 48: When another person tries to clarify a Item 26: The subject talks about his personal Level 6 Intellectualize
statement made by the subject, the subject says thing experiences by making general statements that appear
like “well, not really” or “not exactly,” followed by accurate but somehow avoid revealing specific
qualifications that do not clearly clarify things. personal feelings and reactions.
Because the subject is wary of committing
Defense Mechanism Rating Scales Q-Sort

him/herself to any statement, the listener may be

unsure as to the subject’s definite opinion.
Level 6 Undoing 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 41: In response to a distressing topic or situation, Level 5 Dissociation
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.
459
Table 3
Continued
Early treatment defensive profile narratives
Level 5 Repression
Level 5 Displacement
Level 5 Displacement
Level 5 Reaction
formation
Level 5 Reaction
formation
Immature defenses. When the subject is able handle internal and external stressors or conflicts with great difficulty, tending to externalize avoid or attack, the subject defends in
the following ways.
Level 4 Devaluation of Item 29: The subject makes a lot of unwarranted negative,
self-image
460
Late treatment defensive profile narratives
Item 50: When discussing a topic that brings up negative, Item 50: When discussing a topic that brings up Level 5 Repression
conflicting feelings, the subject prefers to keep things negative, conflicting feelings, the subject prefers to
vague, reflected in very vague, general or inexact keep things vague, reflected in very vague, general
statements. or inexact statements.
Item 69: When confronting emotionally charged topics, the Item 69: When confronting emotionally charged Level 5 Displacement
subject tends not to address concerns directly and fully, topics, the subject tends not to address concerns
but wanders off to tangentially related topics that are directly and fully, but wanders off to tangentially
emotionally easier for the subject to discuss, or prefers to related topics that are emotionally easier for the
pay attention to someone else dealing with a similar subject to discuss, or prefers to pay attention to
situation. This can include preferring to read or watch a someone else dealing with a similar situation. This
film portraying people dealing with similar problems. 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 52: When confronting a personal wish about which the
subject may feel guilty, the subject does not acknowledge
or express it, but substitutes an opposite attitude against
the wish, for instance, a desire is supplanted by
renunciation or anger at anything to do with the desire.
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 that might be
Journal of Clinical Psychology: In Session, May 2014
expected.
Item 29: The subject makes a lot of unwarranted Level 4 Devaluation of
sarcastic, or biting statements about the self, but the negative, sarcastic, or biting statements about the self-image
individual can acknowledge some of their positive self, but the individual can acknowledge some of
aspects, if these are pointed out. their positive aspects, if these are pointed out.
Table 3
Continued
Early treatment defensive profile narratives
Level 4 Devaluation of Item 56: The subject is preoccupied with real or
self-image exaggerated faults in him or herself, although he or she
can acknowledge some realistic positive aspects, if these
are pointed out.
Level 4 Devaluation of Item 54: When a topic brings with it feelings of
other’s image disappointment, shame or loss of self-esteem, the subject
dismisses the issue by finding some fault or criticism
elsewhere or by uttering obscene comments about it.
Level 4 Devaluation of Item 111: The subject has negative things to say about a lot
other’s image of individuals or objects, although he or she can
acknowledge some of their positive aspects, if these are
pointed out.
Level 1 Help- rejecting Item 21: The subject complains spontaneously about how
Complaining others don’t really care, or have actually made his or her
problems worse, even when there is clear evidence that
others have tried to help.
Level 1 Help- rejecting Item 84: The subject recites a litany of issues and problems
Complaining but does not appear to be engaged in solving them, but
rather prefers to complain.
Level 1 Help- rejecting Item 130: The subject complains about life issues or
Complaining problems as if each is insoluble, and systematically
rejects others’ suggestions about ways of handling them.
Late treatment defensive profile narratives
Item 56: The subject is preoccupied with real or exaggerated Level 4 Devaluation of
faults in him or herself, although he or she can self-image
acknowledge some realistic positive aspects, if these are
pointed out.
Item 16: The subject makes many references to how Level 4 Idealization of
important certain people or objects are with an emphasis other’s image
on their image, rather than real abilities or
accomplishments that might make the person or object
important to others.
Item 17:The subject tells stories in which he or she says Level 2 Splitting of
glowing positive things about another person or object, other’s image
without giving much detail to back it up.
Item 35: The subject experiences other people and objects in Level 2 Splitting of
“black or white” terms, failing to form more realistic other’s image
views that balance positive and negative aspects of them
Item 92: The subject attributes unrealistic positive Level 2 Splitting of
characteristics to an object, such as being all-powerful, other’s image
omnibenevolent, a savior. Because of the unrealistic belief
that the positive object will take care of one’s problems,
Defense Mechanism Rating Scales Q-Sort
the subject ignores the need to take care of some of his or
her own needs.
Item 88: The subject fails to stand up for his or her interests Level 1
and seems to let bad things happen to him or herself that Passive-aggression
could be prevented, maybe even assuming a “martyr” role.
Item 118: Whenever the subject feels angry, disappointed or Level 1 Acting out
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.
461
462 Journal of Clinical Psychology: In Session, May 2014

various ways at the end of the therapy, allowing Ms. N to default to the best defense in different
instances, instead of the rigid patterns that she used at intake.
Together with wandering off to topics tangentially related to the problems that are emotionally
easier to discuss (item 69) and keeping things vague, reflected in very vague, general, or inexact
statements (item 50), after 2.5 years of psychotherapy, she appeared also to be accurate in talking
about personal experiences, while somehow avoiding revealing specific feelings and personal
reactions (item 26). This distancing from distress is noticed in a few somatic symptoms as well,
such as headache and stomach pain, which had symbolic relationship to the associated conflicts
(item 41).
Minor and major image-distortion still played a salient role in her defensive functioning at the
end of the treatment. Just as at intake, she made many unwarranted negative, sarcastic, or biting
statements about herself (item 29), and appeared very preoccupied with her faults, although she
could acknowledge some of her realistic positive aspects, when these were pointed out (item 56).
However, late in treatment she integrated positive image-distortion as well, such as references
to how important certain people are, with an emphasis on their image rather than real abilities
or accomplishments (item 16); she also appeared to have unrealistic, positive judgments about
others, such as being a savior (item 92). She experienced significant people mostly in “black or
white” terms, failing to form more realistic views that balance positive and negative aspects of
them (item 35).
Some action defenses like passive aggression and acting out were still present at the end
of treatment, but less prominent than at intake. She still failed to stand up for her interests
and seemed to let bad things happen to herself that could be prevented, assuming a “martyr”
role (item 88) and resorting to uncontrolled behaviors, such as binge eating, drinking, sexual
escapades, or drug use, as an escape from distressing feelings (item 118).

Discussion
Changes in the use of defense mechanisms during long-term psychotherapy have significant clin-
ical implications. Outcome research has shown that defenses correlate significantly with other
aspects of mental functioning (Perry & Bond, 2012; Perry & Henry, 2004; Perry & Hoglend,
1998). Process research suggests that addressing or interpreting defenses in psychotherapy pre-
dicts change in defenses both within and across sessions (Perry et al., 2012; Winston, Samstag,
& Muran, 1994). While defensive functioning can be assessed using different measurement per-
spectives, the observer-rated methods are best poised to detect these mental processes clinically
(Perry & Ianni, 1998).
While we believe that the DMRS is the closest to a criterion standard method for assessing
defense mechanisms with growing evidence of its reliability and validity (Perry, 2001; Perry &
Cooper, 1989; Perry & Hoglend, 1998), it also has limitations imposed by rating requirements–
including availability of recordings and transcripts of interviews or therapy sessions to be as-
sessed, along with specific training and calibration of raters. These are clearly problematic for
everyday clinical purposes. The availability of the DMRS-Q-sort extends the availability of
investigating defenses beyond research studies to everyday clinical settings.
The present report focused on a comparison of ratings of the DMRS-Q and the parent DMRS
of a young woman in long-term treatment. While the case report is a demonstration of proof-
of-concept, additional systematic study will be required to differentiate fully the advantages and
limitations of each method in a variety of contexts. As a first step, a report under preparation
compares the two methods on a larger sample for purposes of examining method validation.
In the present case, defensive functioning improved over 2.5 years of psychotherapy on both
the DMRS and the DMRS Q-sort, resulting in an increase of ODF of about 0.40 points. This
improvement was above the mean amount of change in ODF (0.18, standard deviation = 0.45)
in the sample from which this case was taken (Perry & Bond, 2012). While many defense levels
moved in parallel for the two methods, slight differences were found in this case in the middle
defense levels, specifically on the neurotic defenses displacement and reaction formation, both
of which were scored as less prevalent by the DMRS Q-sort than by the DMRS.
 Defense Mechanism Rating Scales Q-Sort 463

The correlations of scores between the two methods suggested very high convergence for ODF
and high convergence for the three supercategories and their constituent seven defensive levels.
Of the two defense levels without acceptable reliability, one was clearly due to an insufficient
base rate (major image-distorting level), while in the other insufficient subject variance relative to
error contributed to a negative correlation. Overall, the similarity of the methods is encouraging,
despite the small sample of sessions on which the ratings were based.
Any incongruence between DMRS and DMRS-Q ratings warrants exploration, in case it
reflects systematic differences due to method bias (as opposed to error). The DMRS counts the
individual instances of a defense, whereas the DMRS-Q reflects a semiquantitative averaging
of a series of ordinal, essentially qualitative, observations. This difference in methodological
approaches would not necessarily result in different scores when an individual uses a defense
in a variety of ways. However, in some cases, the individual might frequently use a defense in
one stereotypical way, resulting in high proportional scores for that defense and its respective
defense level.
By contrast, the patient might score high on only one of the several Q-sort items for that
defense, while simultaneously the other manifestations of the defense would be scored low. The
result would be a lower score on the DMRS-Q, which averages those ratings, compared to
the DMRS, which sums them instead. This appears to have happened in the late sessions for
the other neurotic defense level containing displacement and reaction formation, in which the
DMRS produced a higher score. In particular, displacement is problematic in that it is the most
protean of defenses with a variety of manifestations. One patient may talk about a topic in
displacement, while another might frequently go off on tangents given an emotionally charged
topic, and another might manifest a symptom that is related to blocked affect about a topic.
Unless the patient uses some degree of all these manifestations, the DMRS Q may tend to
underrepresent the defense.
There is an opposite possibility as well. Some defenses are harder to identify at the level of the
individual instance in verbatim interviews, whereas paradoxically they are easier to see when con-
sidering the whole interview. This may be true sometimes for defenses as varied as splitting and
isolation of affect. For example, a patient who tends to discuss details of life in a manner devoid of
affect might score infrequent textual examples of isolation, whereas the defense would stand out
more strongly on the DMR-Q. In such cases, the DMRS may give consistently lower scores on
those defenses than the DMRS-Q. However, this did not appear to happen in the case presented.
The converse of the above is also possible. If an individual does not use a defense such as
splitting, but does make a number of highly charged statements about oneself or others, the Q-
sort rater might qualitatively score some degree of splitting. This appeared to have happened in
our case example, wherein no major image-distorting defenses were identified using the DMRS,
but the Q-sort indicated otherwise, although less so early than late. Thus, it is possible that the
qualitative assessment in the Q-sort statements may be somewhat vulnerable to observer bias
toward defenses that qualitatively stand out, apart from their frequency of use. To some degree
this may also be a product of the Q-sort’s forced distribution with its limit on the number of
items that can receive a score of not true at all.
A notable innovation provided by the DMRS Q-sort is the DPN, which offers a qualitative
summary of those defensive manifestations that most characterize the individual’s response to
conflicts and stress. The DMRS-Q automatically collates the 14 highest rated items (scored as
6 or 7), and orders them into three supercategories of immature, neurotic, and mature defenses
(Table 3). The DMRS Q-sort computerized system thereby provides a case narrative of the
patient’s defensive style including the most descriptive specific defensive manifestations, rather
than just the presence or absence of a defense. The parent DMRS does not offer this.
The clinical significance of the DPN is well demonstrated in the comparison of our patient
at the beginning and toward the end of her psychotherapy. Early in treatment she frequently
complained about problems and life issues, rejected others’ suggestions, and spent time justi-
fying her actions by noting external reasons to disavow her failings and responsibilities. The
manifestations of highly adaptive defenses were absent.
Near the end of the treatment she was able to respond to important conflicts or stressful
situations by seeking help from others or deciding consciously not to act upon something that
464 Journal of Clinical Psychology: In Session, May 2014

would have bad consequences. Changes in her defensive style at late treatment are also evident in
a more protean use of neurotic defenses that included greater reliance on obsessional defenses,
not descriptive at intake. Manifestation of immature defense remained, but less rigid was the use
of help rejecting complaining and devaluation, finally shifting to a more various use of a wider
range of defense mechanisms.

Conclusion and Future directions

While the present report is limited to a single case, the comparison of both the DMRS and
DMRS-Q on sessions early and late in treatment demonstrates the potential utility and validity
of the DMRS-Q. Report of comparison of the two methods on larger samples is the next step,
one report of which will be forthcoming. Further studies may result in some winnowing of the
number of DMRS-Q items, which may then decrease the amount of time required to score it,
currently somewhat less than an hour on average.
Additional questions remain to be addressed. To what degree is reliability or accuracy of
the DMRS-Q dependent on training or is it adequate when used by clinicians without special
training? Does change on the DMRS-Q correlate significantly with other changes in symptoms
and functioning as predicted by the theory of defenses? Does improvement on the DMRS-Q
partway through therapy predict subsequent outcome at termination and follow-up? Would
therapists find that the DPN improves their management and interpretation of the patient’s
defenses?
To the degree that the DMRS-Q does prove helpful in these ways, it will contribute to the
assessment of psychopathology as well as further inform our understanding of the process and
outcome of psychotherapy. Our current and future work will address these issues.

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