Introduction
Defense mechanisms form part of the uniqueness of each individual’s personality and provide a framework of understanding that is required in therapeutic treatment. Although their influence is evident in an individual’s everyday functioning, only a relatively narrow group of specialists, especially from psychodynamic branches of psychotherapy, focuses on them. In general, they can be considered a sufficiently theoretically clarified phenomenon with a historical background in the development of their concept, yet their potential for effect and influence in maintaining distorted reality in mental disorders remains as intense as in the past. The topicality of defense mechanisms is pointed to by several foreign scientific articles and monographs (Vaillant, 2012; Beresford, 2012; Perry, Bond, 2012; Jamilian et al. 2014; Cramer, 2015; Ciocca et al., 2017; Petraglia, Bhatia, Drapeau, 2017; Euler et al., 2018; Babl et al. 2019) that focus not only on the diagnostic area, which can serve to improve the detection of defense mechanisms, but also on findings regarding the effectiveness of selected types of psychotherapy in reducing undesirable defenses. In this context, a need emerged to address this area of interest also in the domestic setting. Pointing to the possibilities of diagnostic work in the psychotherapeutic process for mapping defense mechanisms and to the possibilities of working with defensive mechanisms represents an important role in the treatment of mental disorders, not only for psychodynamically oriented psychotherapists. Since depressive disorder in Slovakia represented in 2018 the most frequent psychiatric hospitalization in institutional and outpatient facilities (National Center for Mental Health, 2019), these relations apply to depressive disorders due to the possible practical application of this knowledge.
Defense mechanisms
Defense mechanisms are described as both pathological and adaptive mental processes that are unconscious parts of what is seen and experienced as an individual’s character (Cabarkapa, Dedić, 2002). They are used by everyone, but in varying intensity and at different levels of maturity. They mainly perform the function of personality protection (Carvalho et al., 2013) and serve to ease anxiety and cope with internal and external conflicts. They are part of the structural model of personality in the psychoanalytic concept, which deals with the system of Ego, Id and Superego. In a simplified form, Ego as the executive function of personality in consciousness corrects the demands of the unconscious that come from Id and the moral imperatives that come from Superego. If Id or Superego is at risk of getting out of Ego’s control, Ego defends itself through defense mechanisms that have proven useful during the individual’s psychical development. At this point, it is important to highlight the developmental phenomenon of defense mechanisms, which begins to form in early childhood. Cramer (2007) proposed a developmental theory of defense mechanisms based on two general assumptions. The first assumption is that different defense mechanisms predominate at different developmental periods of an individual, similar to Piaget’s developmental theory, which assumes that different cognitive operations are characteristic of different developmental periods. The second assumption is that each defense mechanism has its own developmental trajectory, namely, the defense emerging and predominating in one developmental period becomes less important over time, followed by the emergence and increasing importance of a new defense, and this process repeats itself with the new defense. Vaillant (1992) proposed a four-level hierarchical model of defense mechanisms, in which he places at the lowest level the least mature, psychotic level occurring in childhood and in psychotic disorders (denial, omnipotence, distortions, projection illusion, splitting), followed by the immature level occurring in adolescence (autistic fantasy, projection, passive aggression, hypochondriasis, acting out), then the neurotic level in neurotic disorders (intellectualization, reactive formation, undoing), and finally the mature level in healthy adults (humor, suppression, sublimation, anticipation). It is especially notable that the more severe the psychological symptoms in patients, the more immature defenses are used, which raises the question of how this happens. Cramer (2007) considers that this may be the result of regression to a lower level of functioning or that these individuals failed to develop mature defense styles such as humor (open expression of feelings without an unpleasant effect on others and gaining pleasure instead of unpleasant affects with the result of tension relief), suppression (a conscious decision not to deal with a conscious impulse or conflict and instead to postpone the affective reaction), sublimation (indirect or channelled expression of instincts without adverse consequences or loss, when felt instincts are recognized, modified, and directed toward a confronted object in an acceptable way with the result of a creative, healthy, socially acceptable, or beneficial solution of internal conflicts), and anticipation (preventing psychical anxiety by anticipating emotional reactions to potentially stressful thoughts or events, which allows consideration of alternative responses) and instead remain fixed at an earlier developmental stage of defense.
From a psychopathology perspective, the problem becomes precisely the individual’s experience of fixed use of a defense mechanism, because in early periods certain defense mechanisms such as splitting, denial, and idealization are adaptive and functional, whereas in later periods those same defenses cause difficulties because they are not able to adaptively divert experienced anxiety and tension, disrupt self-image, and lead to an inability to deal with objective reality, which can result in recurring symptoms that worsen subjective experience. McWilliams (2015); Babl et al. (2019) state that depressed patients use the following immature defense mechanisms to a greater extent, i.e., splitting, rationalization, introjection, idealization and devaluation of self and others, denial, and turning-against-self. The named defense mechanisms are presented below in relation to their influence and effects in a depressive patient:
- Splitting, the inability to integrate so-called “good” and “bad” qualities and withstand them as one whole. It is the need to attribute to people, objects, and the surrounding environment only one value without accepting multiplicity, with perception marked by black-and-white thinking: either one or the other, e.g., in a religious patient, “The outside world is bad, sick, and damaged; only in the church world will you find real values and love.”
- Rationalization, attribution of logical or socially desirable motives to whoever or whatever is acting. It mainly serves to reduce disappointment and justify behavior, e.g., a complainant patient talks about her son who has debts due to pathological gambling and is scandalized by her son’s peer group, which she believes is primarily responsible for him wasting this amount of money.
- Introjection, what is in the external environment is incorrectly detected as coming from inside the patient, e.g., in a patient after the death of a parent, an internalized critical part of the parent can persist as if it were still inside the patient. This critical part is a way of staying connected to the absent parent, instead of accepting the loss and grieving.
- Idealization and devaluation; due to damaged self-esteem there is increased need to idealize others with whom one compares oneself, which carries with it a subsequent feeling of inferiority, unworthiness, and humiliation.
- Denial, direct negation most often expressed verbally: “That did not happen!” Another example is when a patient denies problems in a partner relationship and perceives the partner as equally available as before, even though various signs of infidelity are manifest in the relationship.
- Turning against oneself, turning negative feelings and attitudes toward oneself, which serve to gain greater control over situations that in reality are not really under control, e.g., a patient cannot influence that a partner is dependent on alcohol, so he may build an internal belief that if he becomes a better partner, more competent at work and at home, the partner will stop drinking.
Psychodiagnostics
Psychodiagnostics as a discipline of scientific psychology primarily serves to objectify psychical experience and to study interindividual differences in personality that manifest in behavior in different fields of activity. It is most often applied for clinical purposes in healthcare, especially in the field of clinical psychology, where it focuses diagnostically on symptomatology of various mental states and behavioral patterns. In psychotherapy, psychodiagnostics, i.e., test methods, tend to be placed in the background, and emphasis is placed on the treatment process itself with the use of clinical observation and interview methods. The outcome of psychotherapy is then reflected in symptom improvement of the treated person and in his or her subjective perception of improved health. Psychodiagnostics with test methods, however, offers significant benefits for psychotherapy as well, namely:
- provides objectification of treatment outcomes with psychometric indicators,
- allows measurement of achieved change,
- facilitates the beginning of treatment by relatively quickly orienting to the foundations of personality structure, its specifics, conflicts, dynamics of experiencing, resources, coping methods, information-processing methods, and evaluation of such as a predictor of possible future interpersonal reactions.
A psychodiagnostic battery composed of rating scales, questionnaire, and projective methods appears suitable in the case of a depressive patient, which makes it possible to capture complex information on the basis of which a clinical judgment or hypothesis about the treatment process and its direction can be created. Especially from the perspective of the activity of defense mechanisms, psychodiagnostic early detection proves helpful and useful. Several methods serve to detect defense mechanisms, namely: from projective methods—the Rorschach method, Thematic Apperception Test (the manual for identifying defenses was prepared by Cramer (1986), which identifies immature defense mechanisms: denial, splitting, and idealization), from self-assessment methods: Lifestyle Index (Life Style Index), Inventory of Personality Organisation (Inventory of Personality Organisation), Profile of Defense Mechanisms (Defense Mechanisms Profile), Abbreviated version of DSQ-40 Defense Style Questionnaire (Czech version translated by Červenková (2005), Short form- Defense Style Questionnaire). The latter DSQ-40 questionnaire was created in accordance with the DSM IV and DSM III-R Diagnostic and Statistical Manual of Mental Disorders and is therefore potentially more relevant for psychopathology and clinical research. The questionnaire contains 20 defense mechanisms, where four defenses relate to mature style (sublimation, humor, anticipation, and suppression), four relate to neurotic style (undoing, pseudo-altruism, idealization, and reaction formation), and 12 relate to immature style (projection, passive aggression, acting out, isolation, devaluation, autistic fantasy, denial, dissociation, splitting, rationalization, displacement, and somatization).
Psychotherapy
Within psychotherapeutic treatment, it is important to realize that maturity of defenses leads to optimal adaptation, especially because they allow conscious perception of feelings, thoughts, and their consequences, i.e., they do not dismiss affective experience and support an optimal balance between conflicting motives. Maladaptive (neurotic and immature) defense mechanisms represent a dysfunctional way of coping with anxiety, with possible short-term effectiveness but with a tendency to disrupt an individual’s self-image and reality. They affect physical health (somatoform manifestations) as well as mental health in terms of psychopathology. A basic psychoanalytic concept says that better mental health is not achieved by somehow getting rid of primitive desires and impulses, but rather by managing them in a more diverse and adaptive way (Metzger, 2014). So how can we help patients function at a higher level of adaptive defensive functioning and is it even possible for psychotherapy to act on defense mechanisms?
Changes in defensive functioning were studied by Vaillant, who pointed to the capacity for a shift in defenses from maladaptive to more adaptive level. Similar research findings were reached by other authors as well (Bond et al., 2004; Mullen et al., 1999). The most recent randomized controlled study by Babl et al. (2019) showed that over 25 ± 3 therapeutic sessions, implemented as Cognitive-Behavioral Psychotherapy + integrated elements from Emotion-Focused Therapy (Emotion-Focus Therapy) or Cognitive-Behavioral Psychotherapy + treatment components of Self-Regulation Theory, in patients with depression, anxiety, and adjustment disorder, led to a reduction of immature defenses. Changes in defenses occurred in a shift from immature to neurotic and eventually to mature, just as Vaillant proposed in his four-level hierarchical model.
In practical terms, psychotherapeutic process involves helping patients to gradually rid themselves of maladaptive defense mechanisms and replace them with healthy and adaptive ones that are at the top of Vaillant’s four-level hierarchical model, i.e., humor, anticipation, suppression, and sublimation. It is important to identify the types of defense mechanisms that a patient uses and then clinically address the underlying problems in the patient that require use of immature defenses. Therefore it is desirable for patients to become aware of characteristic defense mechanisms, because it is difficult to help a depressed patient who avoids his or her anger without interpretation of immature defense, since such a patient will not perceive his or her anger as destructive and will not be prevented from turning anger against self. If a patient describes self-harm, then the psychotherapist should understand this in defensive language, i.e., show the result of introjection and aggression turned inward, how it manifests, and help with setting limits and a more active approach that would not confront behavior, but encourage the patient to replace problematic defense mechanisms with a more adaptive defense. As Metzger (2014) shows, for example, the use of mature defense mechanism—humor proves effective, as it can enable a patient to transform from a very immature defense to a more mature one by using tactful humor, which is less harmful to them. Thus, humor appears clinically useful, because it can turn an important moment into a surprise, by authenticity, and create an atmosphere in which the patient is able to “hear” a complex interpretation or “see” the problem in a new light. Its potential is precisely in its ability to seize that immature defense and hear where it is directed, for example, by a direct question about the patient’s anger toward parents, which can be associated with denial of anger.
Conclusion
It is appropriate in treating patients to consider preference for defense mechanisms, both from the viewpoint of psychotherapeutic treatment as well as monitoring changes in defensive functioning as progress and treatment outcomes, which can at the same time serve as feedback for both parties in the therapeutic relationship. The psychotherapist should master the technique of uncovering defense mechanisms, especially in patients who tend to rely mostly on immature defense. From a practical perspective, it appears important to highlight the fact that defense mechanisms play an important role in the pathological process of the personality of a depressed patient, and that it is necessary to take into account both the interpsychic (in terms of rigidity in using maladaptive defense mechanisms) and the intrapsychic dimension (in terms of interpersonal area) of the treated person.
As Gabbard (2005) says, everyone, without exception, uses defense mechanisms, which attests to the dynamic principle that points out that the boundary between mental health and illness is not sharp. A person’s profile of typical defense mechanisms is therefore a good barometer of his or her mental health.
Author: PhDr. Miroslava Smolová
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