What is it about?
Defense mechanisms are automatic psychological processes that help people manage anxiety, emotional distress, internal conflicts, and stressful experiences. They can vary in how flexible and adaptive they are, in their specific defensive function, and their pattern of use may change during psychotherapy. We systematically reviewed 46 studies to examine whether defense mechanisms change during therapy, whether they help predict treatment outcomes, and how they relate to other aspects of the therapeutic process. Overall, the evidence suggests that defensive functioning often shifts toward greater maturity during psychotherapy, although change is not always linear. Both a person’s initial defensive functioning and changes occurring during treatment may provide useful information about therapeutic outcomes.
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Why is it important?
Defense mechanisms may offer clinically useful information that is not fully captured by symptom measures alone. A person may experience fewer symptoms without necessarily changing the habitual ways in which they manage emotional distress and internal conflict. Assessing defenses at the beginning of therapy and monitoring how they change over time may therefore help clinicians understand patients’ personality functioning more comprehensively and tailor treatment more closely to individual needs. At the same time, the review shows that the evidence is heterogeneous and that change in defense mechanisms does not always follow a simple or linear course. Defensive functioning should therefore be considered as one component of clinical assessment and treatment planning, rather than as a stand-alone predictor of outcome.
Perspectives
When we began this work, studies on defense mechanisms and psychotherapy change were spread across different theoretical traditions, clinical populations, treatment models, and assessment methods. There was no published systematic review specifically focused on the prognostic and explanatory role of defenses in psychotherapy change. Our aim was therefore to bring the available evidence together and critically clarify what could reasonably be concluded about changes in defenses during therapy, their relationship with treatment outcomes, and their associations with other aspects of the therapeutic process. The review shows that changes in defensive functioning and changes in symptoms do not necessarily coincide perfectly. Psychotherapy may foster more mature and flexible ways of managing emotional distress and internal conflict, but this process can be gradual, uneven, and not always detectable through a single measure or at a single assessment point. Observing defense mechanisms may therefore offer a clinically meaningful perspective on change that complements, rather than replaces, symptom assessment. In my opinion, the main value of this review lies in organizing a fragmented literature into a framework that may be useful for both research and clinical practice. I hope it will encourage more longitudinal studies using repeated assessments during therapy and follow-up, and ultimately contribute to a more complete understanding of therapeutic progress and to more individualized treatments.
Dr. Oronzo Mazzeo
San Raffaele Telematic University – Rome
Read the Original
This page is a summary of: Defense mechanisms and psychotherapy change: A systematic review., Clinical Psychology Science and Practice, June 2026, American Psychological Association (APA),
DOI: 10.1037/cps0000366.
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