Therapist responses, patient emerging personality patterns and defense mechanisms in the psychotherapy of adolescents with depressive disorders: a Psychodynamic Diagnostic Manual-2-oriented empirical investigation

Introduction: The assessment of depressive disorders is challenging in adolescence. Recently, evidence seems to support that symptom manifestations of these clinical conditions are influenced by distinct emerging personality patterns and specific levels of mental functioning of young patients, strongly related to their overall defensive style. This study explored the relationship between patients’ personality patterns, defenses, and the therapists’ responses in the treatment of adolescents with depressive disorders according to the Psychodynamic Diagnostic Manual-2 (PDM-2) framework. Method: One hundred clinicians completed the Psychodiagnostic Chart-Adolescent of the PDM-2 and the Therapist Response Questionnaire for Adolescents to provide a comprehensive assessment of psychological functioning and countertransference responses of an adolescent patient in their care. Moreover, adolescent patients filled in the Defense Mechanism Rating Scales Self-Report-30 to evaluate their defenses. Results: Four emerging personality profiles related to depressive pathology in adolescence were identified: depressive/introjective, anxious–avoidant, emotionally dysregulated, and narcissistic. The latter two subtypes were significantly correlated with a borderline personality organization, whereas the others were associated with a neurotic personality organization. Adolescents presenting with emotionally dysregulated and narcissistic personality patterns tended to use immature defenses and to evoke in the therapist negative emotional reactions characterized by anger, irritation, worry, and sense of inadequacy. Patients with depressive/introjective pattern tended to use neurotic and minor image distorting defenses, as well as to elicit less intense and negative countertransference reactions. Finally, patients with anxious–avoidant pattern mainly used neurotic defenses and evoked protective reactions in their clinicians. Conclusions: The study extends knowledge on the personality patterns and defensive functioning related to depressive disorders in adolescents, and provides a nuanced view of countertransference reactions evoked by these patients in psychotherapy. Therapists should use the information derived from an accurate psychodynamic assessment and therapeutic relationship to generate clinically meaningful diagnoses and promote treatments tailored on adolescents’ psychological functioning.