Vaillant – Ego Mechanisms of Defense
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Anna Freud (1937) extended the concept of altruism to cope with a far broader range of interpersonal vicissitudes than just being “in love.” She memorably pointed out altruism’s defensive roots when she reminded Joseph Sandler, “Altruism comes from the badness in our hearts” (Sandler 1985, p. 429).
Again, hinting at a hierarchy of defenses, Freud went on to maintain that „defensive processes are the psychical correlative of the flight reflex. … Humour can be regarded as the highest of these defensive processes. It scorns to withdraw the ideational content bearing the distressing affect from conscious attention as repression does, and thus surmounts the automatism of defence.“ (p. 233)
In addition, internal medicine now appreciates that so-called infectious disease is often not caused by the bacteria as much as it is a result of the idiosyncratic adaptive response of the host to the infectious agent. The same principles hold true in psychiatry. In psychiatry it is often not the stressor but the patient’s idiosyncratic response that leads to disease. By deciphering defenses we can understand the underlying “pathophysiology” of our patient’s disorder, and thus defenses may be viewed as the building blocks of much psychopathology. This is but one reason why defenses should be included as a diagnostic axis and as part of every diagnostic formulation.
Second, internal medicine appreciates that almost half of all visits to general physicians are made by patients with functional disorders in other words, by patients with psychiatric illness or problems in living who have displaced, projected, repressed, or transformed these problems into serviceable medical complaints (Vaillant et al. 1970; Von Korff et al. 1987).
Indeed, the only psychiatrist ever to win a Nobel Prize was Julius Wagner von Jaurreg for using malaria to give his syphilitic patients a high fever.
By the time she was medication-free, she had broken off the above relationship and started dating a very different man who respected her as an equal. … That is not to say that her obsessions completely disappeared. On the contrary, although they were no longer crippling or inhibiting her functioning, they were still present from time to time. But now the patient almost welcomed these occasional intrusions as signals from her subconscious that there was something she was not addressing in her life a warning that her old submissive habits were returning. (Morstyn 1988, pp. 190-191)
However, by carelessly threatening an immature defense, a clinician can evoke enormous anxiety and depression in the patient and rupture the therapist-patient relationship. Indeed, there is the rub. Any attempts to challenge immature defenses should be mitigated by strong social supports (e.g., Alcoholics Anonymous), or the patient’s defense needs to be replaced by alternative defenses usually from the neurotic or intermediate level. For example, fantasy can evolve into isolation; projection can evolve into reaction formation; and hypochondriasis can evolve into displacement (Vaillant 1977).
For years I have demonstrated to our own residents the subjective nature of the epithet “borderline” by asking each of them to list what they considered the six most salient characteristics of the “borderline” individual. Year after year there is little consensus. As with beauty, the definition of “borderline” lies in the eyes of the beholder.
In other words, pill taking is rarely helpful for patients with personality disorders, but anybody’s sense of object constancy, self-esteem, self-efficacy, and empowerment is helped by giving pills to others.
In every interaction with self-defeating patients, however, it is important to avoid humiliating comments about foolish, inexplicable behavior. Nobody’s pride is easier to wound than a person who continually shoots himself or herself in the foot.
Such patients are often imaginative, if inadvertent, liars, but they benefit from having a chance to ventilate their own anxieties. In the process of free association they often “remember” what they “forgot”, and through psychotherapy their self-serving lies can evolve into the acknowledgment of painful truths. Therefore, dissociation and neurotic denial are best dealt with if the clinician uses displacement and talks with the patient about the same affective issue but in a less-threatening context. Empathizing with the denied affect, without directly confronting the patient with the facts, may allow the patient himself or herself to reintroduce the original painful topic.
For example, abstinence from drugs is achieved through a process analogous to mourning: slowly the depended-upon substance is replaced with other loves.
Although altruism was used by many men and women with unhappy childhoods to master adult life, sustained use of altruism was never noted among those COLLEGE men who were ever found to manifest severe depression as adults. Instead, the most-depressed men were most likely to use displacement, dissociation (i.e., neurotic denial), reaction formation, and passive aggression (i.e., turning anger against themselves).
Repression The individual deals with emotional conflicts, or internal or external stressors, by being unable to remember or unable to be cognitively aware of disturbing wishes, thoughts, or experiences. In contrast to isolation, the affective component often remains in consciousness.