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July 2006
Vol XXIII No 8
Your subscription = includes 14=20 exciting issues per year.
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Defenses Can Sabotage the Therapy

By Douglas = Berger, M.D.,=20 Ph.D.

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Psychiatric Times October 2005 Vol. XXII Issue 12

Psychotherapy has an interesting paradoxical twist to it in the = therapist's=20 attempt to provide help. When one goes to a surgeon, for example, to = remove a=20 lump, the patient recognizes they have a lump and agrees to have the = surgeon=20 remove it. With a psychological problem, however, patients may recognize = that=20 they have some problem, but they often do not see it as a result of = their own=20 life strategies (defenses or personality styles), and in trying to = protect=20 themselves with these defenses, patients may actually sabotage their own = therapy.

Even if they do have some insight into their maladaptive use of = defenses,=20 patients often show resistance to changing their life strategies. They = would=20 prefer that things go smoother in the world using the same life = strategies they=20 have been using up to now. In fact, patients may seek validation on = their style=20 from the therapist or even advice on how to make their maladaptive = defenses work=20 better. Can you imagine a patient with a lump telling the surgeon to = remove the=20 lump but at the same time trying to convince the surgeon why it is = better to=20 live with the lump?

This is where the unconscious nature of defenses, and the resistance = to=20 changing one's defenses, comes into play. Resistance is often = unconscious in=20 patients as they may provide many rationalizations on why their = maladaptive life=20 strategies are valid. This resistance may occur even in the face of = significant=20 psychosocial troubles arising from these defenses as seen from the = outside. The=20 work of the therapy needs to overcome these barriers.

These maladaptive life strategies have been used by the patient both = in past=20 and present relationships, so it is no surprise that these personality = styles=20 will also manifest in the relationship with their therapist. It is the=20 therapist's challenge to find the common thread that runs through the = patient's=20 interpersonal style and then guide the patient to use new and more = adaptive life=20 strategies. The therapist attempts to remain neutral in attitude and = does not=20 disclose personal material to the patient. In this way therapists try to = keep=20 their countertransference issues out of the session. Thus, the therapist = and=20 patient can begin to create a picture of the patient's personality style = without=20 undue influence of the therapist's style. If the patient's insight is = poor=20 and/or their defenses are of a certain quality that leads to = dissatisfaction in=20 the therapy, the defenses themselves can sabotage the help the patient = needs to=20 fix their defenses.

Concrete Examples

The terminator. These patients use the defense of rejecting = others to=20 protect themselves from the pain of being rejected first. They may have = had some=20 childhood experiences of feeling abandoned. They set up relationships to = relive=20 patterns of rejecting others. They find faults with others, often not = getting=20 into or terminating intimate relationships early on and complain that = they=20 cannot find the right partner. They tend to engage in relationships that = clearly=20 have problems from the start, thus planting the seeds for their next=20 termination. They may report conflict and terminations with prior = therapists.=20 They often make detailed rationalizations about why their relationships = do not=20 go well.

These patients may fault-find with the therapist and complain that = the=20 therapist is not caring enough, especially if the therapist does not = side with=20 their misery and instead attempts to have them see how their tendency to = reject=20 others is actually undermining their own needs. They may request phone = calls or=20 e-mails between sessions in order to satisfy their underlying dependency = needs;=20 however, this will also lead to complaints that the therapist does not = care=20 enough when the therapist begins to put limits on these contacts.

Eventually these patients' rejecting nature will cause them to "fire" = the=20 therapist and terminate therapy. Complaints about the therapist may also = grate=20 on the therapist's own countertransference self-esteem issues, and the = therapist=20 may subtly or overtly reject the patient. The therapist may be able to = manage=20 these patients by getting them to see their rejecting nature in a = neutral=20 fashion, not too early in the therapy, but also not when it is too = late.

The president. These patients use the defense of exhibiting = greatness=20 to protect themselves from the pain of feeling diminished. They may have = had=20 some childhood experiences of ungratified or invalidated strivings from = their=20 family or peers. They always need to show strength in everything they = do,=20 connect themselves with important people, devalue others and try very = hard to be=20 important themselves, e.g., to become the class president or the company = president.

These patients can become very aggravated when they are not the = center of=20 attention or at the top of their social group, and challenges to their = greatness=20 or rejection from partners who are tired of their grandiosity are often = the=20 reason they have come for help. They often have a detailed = rationalization on=20 why they only need more greatness in order to gain mental stability.

These patients will look for validation of their greatness and seek = advice=20 from the therapist on ways to gain more greatness rather than ways to = change=20 their life strategies. They may subtly or openly devalue the therapist. = If the=20 therapist's countertransference causes them to retaliate the = devaluations or if=20 these patients think the therapist is not validating them or when the = therapist=20 attempts to guide them to use other life strategies or explores their = underlying=20 low self-esteem, these patients may begin to feel diminished and are at = risk of=20 terminating the therapy before they have really started to improve the=20 underlying problem.

Sometimes these patients will invest their defense of greatness in = becoming a=20 great patient. They will read all about their problem and gain a = considerable=20 amount of knowledge of psychology to gain validation from and protect = themselves=20 from feeling diminished compared with the therapist. They profess that = they have=20 completely eliminated their problem of low self-esteem. It may be = possible to=20 enlist these patients' sense of greatness to the therapy's advantage if = the=20 therapist can convince them that great people are those that are able to = really=20 look at themselves and accept they use greatness as a defense against = low=20 self-esteem.

The air traffic controller. These patients use the defense of=20 controlling others to protect themselves from the aggravation of being=20 controlled. They may have had childhood experiences with controlling or=20 authoritarian parents. They tend to try to control others, especially in = intimate relations or in the workplace, and have conflict with people in = these=20 areas. This is often the main reason they come for therapy.

Patients may get in power struggles about scheduling, cancellation = policy or=20 other issues, and begin to argue about the therapist's opinions and = complain=20 that the therapist will never see things their way. They need to feel = they are=20 right about everything; tend to be argumentative; want the therapist to = validate=20 their rationale in arguments they have had with others; will not easily = agree to=20 see the types of defenses they use; and eventually terminate the therapy = before=20 the therapist can begin to address the process of how to get better. The = therapist's countertransference may provoke counter-arguments with these = patients.

The therapist may be able to enlist these patients' need to be = correct by=20 praising them about how they seem to usually be on the mark and that the = challenge now is to see if they can be on the mark about the analysis of = their=20 own deficits.

The invisible patient. These patients use the composite = defense of=20 obedience and passive defiance to protect themselves from the = aggravation of=20 being controlled or belittled. They may have had belittling or = authoritarian=20 parents. They seem to be very compliant and cooperative on the surface, = but on=20 deeper interaction they are withholding and uncooperative and seem to = have a=20 wall around themselves against real intimacy. They tend to not show up = for=20 important events, are late for work, do not complete chores they agree = to do at=20 work or with significant others, and have conflict with people in these = areas;=20 this usually being the reason they have come for therapy.

Patients may often be late for sessions, not show for the sessions = and often=20 be in arrears with fees. They set up relationships so that they can = relive a=20 pattern of being oppositional to a scolding person in authority (e.g., = spouse,=20 boss, therapist). They will often use intellectualization and = rationalization to=20 describe their behavior, and while they ostensibly agree with everything = the=20 therapist has said, there is no effective change in their life strategy. = If the=20 therapist does not terminate the therapy because of either reasonable or = oversensitive (countertransference) reactions to these patients because = of their=20 invisibility (e.g., poor attendance, late fees), these patients may = eventually=20 terminate the therapy using an excuse such as "work or family duties" = that are=20 only more displays of passive defiant behavior.

Standard approaches to gain insight may be of help. In some patients, = however, the passive defiance may be so ingrained that a paradoxical = approach,=20 where the therapist tells the patient that the problem is unfixable and = that the=20 therapy should focus on how to live with the defiance, will engage this = patient=20 in a defiant stand to fix the problem.

The rubber cement patient. These patients use the defense of = clingy=20 "object hunger" (intense persistence to avoid separation from = significant=20 others) in order to protect themselves from the fear of being alone. = They may=20 have had some childhood experiences of feeling abandoned or, in reverse, = of=20 never practicing being on their own. Some children are also born with = intense=20 dependency needs that can develop into a maladaptive style when mixed = with a=20 particular upbringing.

These people often get into and/or stay in relationships that are = clearly=20 unhealthy from the start, causing conflict that brings them to therapy; = or they=20 may present to therapy when their partner proposes a breakup. They may = get=20 involved with partners who are inappropriate for them (e.g., violent, = alcoholic,=20 promiscuous). It is not necessarily that these patients are "looking = for"=20 difficult people, but because most people would avoid entering or = continuing in=20 these unhealthy relationships, these potential partners naturally do not = realize=20 relationships until they come across a dependent person willing to cross = these=20 hurdles and stick with them. The patients also tend to have trouble = realizing=20 relationships because the intensity of their neediness pushes people = away. They=20 may have a repertoire of rationalizations for their behavior.

These patients will implore the therapist to help them find ways of = improving=20 a destructive relationship or try to get the therapist to convince their = partner=20 not to break up with them rather than change their maladaptive defensive = strategy. They may request phone calls or e-mails from the therapist = between=20 sessions to hold on to a connection with the therapist to tide = themselves over=20 their pain. They may push for the therapist to give them the answer on = how to=20 prevent a breakup.

These patients are mainly interested in having their defense of = object hunger=20 work better for them and will terminate the therapy when they sense that = the=20 therapist cannot or will not collude with their determination to promote = their=20 defense of clingy dependency. The therapist may react by trying to save = these=20 patients too much and thus break boundaries by trying to give too much = concrete=20 help, or the therapist may devalue these patients because their clingy = behavior=20 becomes annoying to the therapist.

Again, the problem itself has sabotaged the treatment of the problem. = In=20 addition to giving insight into the nature of their defenses, a = potential method=20 of treatment for these patients is to encourage them to tolerate = activities they=20 can do without a partner. However, patients still need to use the = therapeutic=20 relationship as a transitional object that can help them move out of bad = relationships and/or to help them avoid getting into future bad=20 relationships.

Conclusion

While some patients exhibit only one of the major traits exampled = above, some=20 patients may have a mix of the different styles. I have purposely = avoided the=20 use of diagnoses here in order to keep the focus on the interpersonal = mechanisms=20 involved rather than a label. Everybody has some amount of one style or = another,=20 no matter how subtle. The examples above are also not an exhaustive list = of=20 potential life strategies. In addition, this paper is mainly a = description using=20 personality styles and does not discuss situations complicated by = depression or=20 other psychiatric illnesses.

One can see how the problem itself can sometimes sabotage its own = treatment.=20 It takes a considerable amount of courage to admit that one's = personality style=20 needs changing, so it is natural that one will have resistance to this = endeavor.=20 This is the challenge that faces the psychotherapist and the patient in = the=20 sessions. Many patients do, of course, get better without sabotaging = their=20 therapy.

If the therapist can gain the trust of the patient and effectively = explain=20 the way therapy can work and the pitfalls involved, then progress can be = made.=20 It is often not easy for the therapist to articulate this process; and = if the=20 patient is relatively mature and uses rationalization and other = intellectual=20 defenses (as in the examples above) that "hide" the more underlying = defense,=20 these patterns can be subtle and not evident to the therapist until it = is too=20 late.

Dr. Berger is in private practice and consults with pharmaceutical = companies in Tokyo.

Further Reading

MacKinnon RA, Michels R (1971), The Psychiatric Interview in Clinical = Practice. New York: W.B. Saunders Company.

Perry S, Cooper AM, Michels R (1987), The psychodynamic formulation: = its=20 purpose, structure, and clinical application. Am J Psychiatry=20 144(5):543-550.

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