In these blogs I’m going to talk about common questions and issues we struggle with as therapists as part of our mission to help you help others. A lot of times people naively assume that therapy is “easy” as if all we have to do is “talk” to people. But as you know, therapy can be incredibly hard. My job in this blog is to have a dialogue with you, answering questions you raise, as we co-create this blog and our ISTDP community. So here goes. Today I’m going to talk a little about defense.
When we explore a patient’s problems we want to find out what defenses the patient uses. Why? Defenses create the patient’s symptoms and presenting problems. If we can help the patient see how his defenses create his problems, he will be much more motivated to turn against them and face his feelings instead. In that sense, defenses are the pathology creation system. It is not so much that a patient “has” depression. Rather, every ten to twenty seconds the patient uses a defense that causes depression. If the patient turns anger onto himself, dismisses, criticizes, and doubts himself three to four times a minute for sixteen hours a day, we should not be surprised that after over 2000 attacks on the self the patient feels depressed. These defenses are cruel to the patient. So it is an act of compassion for the therapist to interrupt and point out every defense that hurts the patient. Every time you point out a defense to the patient your meta-communication is this: “I don’t want you to hurt yourself.”
But even with this awareness of why we address defenses, we have to go an extra step and understand the importance of the type of defense we encounter. Why? Because the type of defense determines how and why we intervene.
Some defenses are repressive. That is, they help the patient repress a feeling.
Th: “How do you experience that anger toward your husband?”
Pt: “I think he should not have done that.”
Here the patient uses intellectualization. By focusing on her thoughts she avoids her feelings. Repressive defenses include minimization, intellectualization, rationalization, and generalization.
Another group of defenses is tactical defenses (Davanloo 1990; 2000). These defenses are tactics patients use to keep the therapist at a distance.
Th: “What is the internal emotional problem you would like me to help you with?”
Pt: “I’m not sure it’s a specific problem really. More of a general problem. It may not be a problem at all. It could be emotional I suppose.”
Here the patient uses vagueness as a tactic to keep the therapist away from him, his problems, and his feelings. Repressive defenses (used by low and moderate resistant patients) distance the patient from his feelings. Tactical defenses (used by high resistant patients) distance the patient from the therapist. Tactical defenses include vagueness, sitting on the fence, diversification (changing topics), distancing, and detaching.
A third group of defenses are regressive defenses. They are called regressive because we see a regression in the patient’s functioning.
Th: “How do you experience that anger toward me?”
Pt: “I think you are angry at me.”
Here, the patient uses the defense of projection. By projecting his anger onto the therapist, he is now afraid of the therapist (who is supposedly angry) rather than of his own anger. The projection leads the patient to have less contact with the reality of the therapist and with the reality of his own inner feelings. In these ways, we see a regression in self observing capacity. And, at worst, we see a regression in reality testing (the ability to differentiate reality from one’s fantasy). Regressive defenses include projection, splitting, externalization (projecting one’s superego onto others), discharge, acting out, and weepiness. These defenses are always signs that we must help the patient see these defenses and turn against them, and increase their anxiety and affect tolerance before they will be able to tolerate a high level of feeling. These are defenses we see in fragile, depressed, and somatizing patients.
A fourth group of defenses are known as character defenses. A character defense enacts a pathological identification. For example, a patient who felt rage at a father who always doubted her capacities dealt with her rage by identifying with her doubting father. Now whenever she feels rage, she doubts herself. Since character defenses are based on a pathological identification, we intervene differently. We always address how the patient, identified with a pathological figure, treats herself.
Th: “Do you notice how you doubt yourself?” “Do you notice how ignore your feelings?” “Do you notice how you neglect your anxiety?”
Once the patient sees these defenses, the therapist asks, “Is that a kind or cruel way to treat yourself?” “Is that helping you or hurting you?” Questions such as these help the patient see the price of her defense so she can let go of this identification. Letting go of these identifications is also called separating the ego and superego or separating the patient from his resistance. Although character defenses can have a repressive function (they keep feeling out of awareness), we must focus first on the ways an identification is enlisted in the service of defense. Otherwise, if you focus on the feeling, the patient, identified with a pathological figure, will begin to attack herself or detach from you as soon as you focus on feeling.
Next time we’ll talk about the transference resistance. Check out our upcoming webinars where you can get some detailed information to help you be more effective. In the meantime, I hope you found this discussion of defense work interesting and useful. Together we can co-create this blog. Just send your questions to firstname.lastname@example.org and I’ll answer them in future blogs. In the meantime, thanks for visiting us here at the ISTDP Insititute. Jon