Associations of Defense Mechanisms, Countertransference and Level of Personality Functioning
Year: 2026
Type: study-registration
Abstract: The interplay between patients’ personality attributes, the quality of the therapeutic relationship, and the outcome of a therapy is complex and to date not sufficiently understood. With this study, we aim to investigate the association between defense mechanisms (DM), countertransference (CT) and the moderating role of the level of personality functioning (PF). DMs are defined as automatic psychological processes that occur largely outside of awareness and protect the individual from anxiety, the loss of self-esteem, or the integration of the self (APA, 2013; Cramer, 2015; Di Giuseppe et al., 2021). Countertransference is defined as the therapist´s emotional, cognitive and behavioral reaction towards a patient that emerge within the therapeutic interaction and are shaped by the therapist and the patient including patients personality traits (Kernberg, 1965). The level of personality functioning (measured in this study by the SCID-5-AMPD, Module I) is part of the alternative model of personality disorders and represents facets of self (identity, self-direction) and interpersonal (empathy, intimacy) functioning (APA, 2013). Over the last years, the body of research on CT has increased. CT provides important clinical information about patients and is therefore an important diagnostic tool (Löffler-Stastka et al., 2019). To date, studies in this field have mainly focused on associations between CT and psychopathology, symptom severity, personality disorders and personality traits. Greater psychopathology and a lower level of functioning have been associated with more intense negative and ambivalent CT (Colli & Ferri, 2015, Stefana et al., 2020). Studies have also shown associations of specific personality traits with specific CT reactions. For example, Tanzilli and colleagues (2016) showed that patients with borderline personality disorders tend to evoke strong ambivalent CTs in their therapists, characterized by feelings of being overly involved and working with a “special” patient. Moreover, when working with patients having pathological narcissistic personality traits, CT reactions appear ambiguous with disengagement, hopelessness on one side and parental reactions on the other (Day et al., 2025, Stefana et al., 2020). These ambivalent or simultaneous experiences of positive and negative CT reactions are often theoretically linked to underlying personality-related processes, such as defense mechanisms. Recent studies have begun to focus more specifically on associations between personality features, defense mechanisms or defensive functioning, and CT reactions (Caesar et al., 2025; Machado et al., 2015; Colli et al., 2022). A lower level of defensive functioning and a more rigid use of intermediate defense mechanisms have been associated with negative CT reactions, such as disengagement and feelings of being overwhelmed or mistreated. In contrast, a higher level of defensive functioning, characterized by a greater use of adaptive defense mechanisms, has been associated with more positive and involved CT reactions (Colli et al., 2022; Ulberg et al., 2014). Further highlighting the relevance of DMs, Caesar et al. (2025) investigated specific correlational links between individual DMs and CT. For example, the adaptive defense mechanism humor was positively associated with satisfying and positive CT reactions and negatively associated with disengaged CT. In contrast, intermediate and maladaptive defense mechanisms, such as splitting and isolation, were associated with negative and ambivalent CT reactions, including feelings of being overwhelmed and overinvolved. These findings suggest that both the type of defense mechanisms used and the overall level of personality functioning may play a crucial role in shaping CT reactions. Related constructs such as the level of personality organization, explicitly include DMs in order to better understand patients’ personality traits (Kampe et al., 2018). Therefore, the present study aims to extend our previous research by further exploring the associations between DMs and CT reactions, while explicitly considering the level of personality functioning as a moderator variable. Specifically, we examine whether the strength and direction of the associations between specific DMs and CT reactions differ depending on patients’ level of PF. Conceptually, less impairment in PF in patients is expected to be associated with more pronounced positive and confident CT and fewer intense negative and ambivalent CT reactions. In line with previous research (Colli et al., 2014; Stefana et al., 2020) less impairment in PF should correspond to more confident and engaged CT reactions and fewer helpless, overwhelmed or otherwise negative reactions and may attenuate the association between maladaptive DMs and negative or ambivalent CT reactions. Greater impairment in PF may be associated with stronger and more polarized or negative CT responses. By examining these relationships, this study seeks to improve the understanding of how DMs are associated with CT reactions across different levels of personality functioning. All assessments are conducted at baseline in both an outpatient setting and an inpatient setting, with patients being assessed prior to the start of treatment in the outpatient setting and at the beginning of treatment in the inpatient setting, thereby capturing interviewers CT reactions in an early diagnostic context. The findings are intended to further develop treatment indication recommendations and early therapeutic interventions.
Source: Open Science Framework
Language: English
Subfield: Clinical Psychology
Field: Psychology
Domain: Social Sciences
Open Access status: green
OpenAlex ID: W7220967293