Psycho-Oncology Psycho-Oncology 19: 209–215 (2010) Published online 9 March 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.1558 Communication skills training and clinicians’ defenses in oncology: an exploratory, controlled study Mathieu Bernard 1Ã , Yves de Roten 1 , Jean-Nicolas Despland 1 and Friedrich Stiefel 2 1 Institute of Psychotherapy, University Hospital of Lausanne, Lausanne, Switzerland 2 Service of Liaison Psychiatry, University Hospital of Lausanne, Lausanne, Switzerland Abstract Objective: The underlying mechanisms modifying clinician’s communication skills by means of communication skills training (CST) remain unknown. Defense mechanisms, defined as psychological processes protecting the individual against emotional stress, may be a mediating factor of skills improvement. Methods: Using an adapted version of the Defense Mechanism Rating Scale—Clinician, this study evaluated clinicians’ defense mechanisms and their possible modification after CST. Interviews with simulated patients of oncology clinicians (N 5 57) participating in CST (pre-/post- CST with a 6-month interval) were compared WITH interviews with the same simulated patients of oncology clinicians (N 5 56) who did not undergo training (T1 and T2 with a 6-month interval). Results: Results showed (i) a high number (mean 5 16, SD 5 6) and variety of defenses triggered by the 15-min interviews, (ii) no evolution difference between groups, and (iii) an increase in mature defenses after CST for clinicians with an initial higher level of defensive functioning. Conclusions: This is the first study describing clinicians’ defensive functioning; results indicate a possible mediating role of defenses in clinician–patient communication. Copyright r 2009 John Wiley & Sons, Ltd. Keywords: cancer; defense mechanisms; communication skills; physician–patient relationship; oncology Introduction Communication has been recognized as a central element of cancer care [1]; some of its aspects, such as breaking bad news, communication in end of life care or error disclosure are perceived as highly stressful by oncology clinicians [2–4]. Ineffective communication contributes to patients’ confusion and uncertainty, and increased difficulty in asking questions, expressing feelings and understanding information [5,6], and to clinicians’ lack of job satisfaction and emotional burnout [7]. On the other hand, effective communication contributes to patient’s psychological adjustment and quality of life [5,8,9], adherence to treatment [9], enhanced information recall [8] and patient satisfaction [8,10], as well as clinician satisfaction and reduced levels of profession-related stress [7]. Based on these findings, communication skills training (CST) for oncology clinicians has been widely developed over the last decade. Recently, three systematic reviews on the effectiveness of CST [11–13] reported increased confidence of clinicians, and improvement of specific skills. Little is known, however, about the underlying mechanisms mediating these improvements. While several studies have pointed out the emotional difficulties encountered by oncology clinicians in the context of strong affective load and confronta- tion with the patient’s distress [3,4,14,15], a more detailed description of how clinicians respond to these challenges is lacking. A possible framework to investigate these issues is the concept of defense mechanisms. Operating without conscious effort and triggered by anxiety-provoking situations, defenses contri- bute to the individual’s adaptation to and protec- tion from stress [16]. Usually described in patients, for example as denial when facing threatening news, defenses operate also in clinicians under distress. Different types of defense mechanisms have been described [17] and classified depending on their degree of adaptation to or distorting of reality, ranging from ‘immature defenses’, such as projection or denial, to ‘mature defenses’, such as displacement or intellectualization [17,18]. While patient’s defense mechanisms are extensively stu- died in psychotherapy research [19], they have never been investigated in clinicians, not even in psychiatrists or psychotherapists. However, clinicians also protect themselves, as do patients, by means of defense mechanisms in * Correspondence to: Institut Universitaire de Psychothe´rapie,Baˆtimentles Ce`dres, Site de Cery, 1008 Prilly, Switzerland. E-mail: Mathieu.Bernard@ chuv.ch Received: 6 November 2008 Revised: 2 February 2009 Accepted: 2 February 2009 Copyright r 2009 John Wiley & Sons, Ltd.