Case 1: Changes in Defenses With Good Outcome
“Ms. N” was a student in her mid-20s who sought psychotherapy after cutting herself in an impulsive suicide attempt. She had major depressive disorder, in remission at intake, superimposed on dysthymic disorder with onset at age 5. During her teens, she developed mild obsessive-compulsive disorder (obsessions only), followed by bulimia nervosa, alcohol and substance abuse and dependence, and panic disorder. After a sibling’s suicide, she developed posttraumatic stress disorder. She had significant borderline and avoidant traits, with milder depressive, dependent, and passive-aggressive traits.
Ms. N experienced her mother as caretaking and well meaning but ineffective, and she felt guilty making requests of her. She and her father got along well, but he was alcoholic and a spendthrift. After an accident, he lost his job, bankrupting the family. Ms. N never suffered abuse or physical neglect, but the household lacked consistent rules.
As a teen she began drinking and using drugs to numb feelings of guilt, and she became promiscuous. When sober, she became self-conscious with fears of rejection and being judged. This prevented her from pursuing certain jobs, or even going to a public beach.
Early in Treatment
The following selections are from Ms. N’s fifth therapy session. The patient opened the session expressing various concerns, and then expressed concern about a comment the therapist made the previous session.
Pt: You mentioned last time that—it was our fourth session and you mentioned that I missed the first one. [Repression] It was not—it was not because I didn’t want to be here, it’s just—it really—it’s just to show you how sometimes I don’t even know which day of the week I am at. [Passive aggression] It’s not because I say, “Oh, well, you know, maybe…” and I want to know how you—how you analyze the fact that I missed the first. I feel a pressure…
Th: [Interprets defense] Well, you felt that it was in your best interest to be here, but you forgot. So there’s this conflict between knowing what’s in your best interest…
Pt: But it’s not forgetting, it’s just [pause] I—I really feel a pressure about that.
The patient initially rejected the therapist’s interpretation, explaining that she felt that the therapist was placing pressure on her. Sensing the patient’s concern about the therapist’s reaction to her, the therapist asked her about her perception, then offered a transference and defense interpretation.
Th: [Question] Do you think I’m mad at you for that?
Pt: [Projection] Well, not mad, but like kind of saying it just really shows “she really thinks she doesn’t need to be here.” I come here…
Th: [Interprets motives and defense] No, that’s not what I’m saying. I’m saying that part of you really wanted to be here and you waited a long time to come.
Th: In spite of how much you wanted to be here, there was another part of you that thought either it was too scary or you don’t deserve it.
The patient began to explore both her anxiety within and outside of therapy, along with her tendency to “shut down” emotionally whenever experiencing heightened anxiety and/or anger.
Th: [Interprets defenses: repression, passive aggression] Now, we’ve seen this before. When you get angry, you have a tendency to shut down.
Th: That the anger somehow goes inside of you and you can’t do anything. It paralyzes you.
Pt: [Dissociation] Yeah, totally… It like pushes me back into a box and the door closes in front of me and I have to hide. It’s weird. [Passive aggression] And it was—and my mom felt so bad about pushing the paper [referring to writing a paper for school]. I said, “Listen, it’s not you. It’s not you. Don’t—even—it’s not you, it’s me. I’m like this. I’m going through this. I know it’s me. It’s not you.”
[Reaction formation] And I had to take care of my mom also; it’s always like that. When things happen to me, I have to say—I have to like take this anger or whatever’s going on here, put it on the shelf, and then say, “Don’t worry, Mom,” and then take it back and then deal with myself. And I always have to take care of other people when I’m going through hard stuff.
Early in therapy the patient used eight defenses frequently (i.e., more than 5% per session). In descending order of frequency, they were rationalization (16%), intellectualization (12%), repression (11%), undoing (10%), passive aggression (10%), self-assertion (8%), devaluation of others (8%), and displacement (6%). Apart from self-assertion, she used three other high adaptive defenses to a lesser extent: suppression (2%), self-observation (1%), and affiliation (1%).
Later in Treatment and Outcome
Toward the end of the therapy, Ms. N’s use of immature defenses diminished considerably. She became more direct and adaptive in dealing with conflicts.
“[Self-observation] At first, [my boyfriend] used to yell—French people yell a lot. And to me, to hear a loud voice, it freezes me. And I said, ‘Why are you yelling at me?’ He said, ‘Well ‘cause I’m just explaining…’ and we realized that it’s cultural and he doesn’t have to yell… with me anyways.”
Discussing a testy conversation with a girlfriend, she described the good aspects of their relationship, saying,
“[Intellectualization] and I realized that I… it’s not a wall, it’s… I carry that with me. It’s not separate.”
Over 2.5 years, her overall defensive functioning score improved from 4.38 to 4.88, reflecting a large effect size of 1.84, although not yet attaining a healthy-neurotic level. Her repertoire of defenses improved, now including higher proportions of high adaptive and neurotic with lower proportions of immature defenses. In descending order of frequency, they were intellectualization (15%), displacement (13%), rationalization (13%), undoing (11%), repression (8%), self-assertion (5%), and passive aggression (5%). Apart from self-assertion, Ms. N now used five other high adaptive defenses to a lesser extent: suppression (4%), self-observation (2%), anticipation (2%), altruism (2%), and affiliation (1%).
Ms. N’s therapy lasted 117 sessions over about 3 years. She made no suicide attempts, and her suicidal ideation disappeared entirely by 2 years and remained recovered. Two-thirds of the measures, on which Ms. N was initially not well, improved. Overall, we considered her very improved over her 6.7 years of follow-up.
Case 2: Minimal Changes in Defenses With Poor Initial Outcome
“Ms. C” was a 22-year-old single woman working in the erotic services field while studying for a helping profession. She had recently been hospitalized after a drug overdose. She had suicidal ideation most days of the week and intermittently self-mutilated. She scored in the upper ranges of several scales for borderline personality, but she also had dependent and depressive personality disorders with self-defeating and antisocial traits. Axis I disorders included major depressive, dysthymic, generalized anxiety, posttraumatic stress, and substance use disorders; her GAF at intake was 48.
During early to mid childhood Ms. C had been molested by a male second-degree relative. Both parents were emotionally neglectful, and her father would punish her by ordering her to undress and then beating her. Her mother never intervened. In her late teen years, Ms. C became addicted to heroin and cocaine under the influence of her boyfriend, who also pimped her. She was attracted to “bad boys,” who often abused then abandoned her.
Early in Treatment
Ms. C was seen weekly in psychotherapy with a male psychoanalyst for a combined total of 189 sessions over 4 years. The following exchange from the sixth session demonstrates her defensive instability.
Pt: [Repression] Sometimes I don’t even realize that I’m being mistreated until it’s too late. I just think it’s normal to feel certain ways and then I’ll find out, no, it’s wrong, so it’s—I just, I blame myself for not knowing or for putting myself in that position. [Pause] And if I don’t know, [Reaction formation] sometimes I just smile or I laugh, ’cause it’s just [laughs] if I don’t laugh, I’ll cry. [Devaluation-self] Sometimes it’s just so—it’s so sick, it’s ridiculous. It’s funny. [Passive-aggression] Sometimes I’ll recognize that I’m doing something wrong and I just—I can’t help it, I just—I see myself repeating patterns. Just it’s really confusing, ’cause then I hate myself for doing it and I hate whoever I’m with, ’cause if you loved me, then you wouldn’t do it to me, but it’s my own fault for letting you.
Th: [Interprets her motives and defenses in general terms] You’re in this rut of repeated, lousy relationships where you get abused and you have an awareness and an insight that you’re part of the pattern, because you allow it to happen. You fluctuate between blaming the other person and hating them to pieces, and hating yourself. You’re suicidal and you want to cut yourself.
Early in therapy the patient used nine defenses frequently (i.e., a mean of 5% or more per session), with immature, then neurotic defenses predominating. In descending order of frequency, they were repression (27%), displacement (12%), undoing (10%), devaluation of self (9%), acting out (7%), devaluation of others (7%), passive aggression (6%), rationalization (6%), and projection (5%).
Later in Treatment and Outcome
During session 121 at 2.5 years, Ms. C complained that the therapist had offered a requested second weekly session at a time when she had to work. The therapist failed to engage the patient in exploration of the underlying issues and the topic ended as follows.
Pt: [Intellectualization] Well, you don’t seem to understand how frustrating it is. You want me to deal with real issues, the root of everything, in 45 minutes and you’re talking to somebody that—[Devaluation-self] I can’t deal with anything, I can’t f-ing speak.
Th: [Offers his associations to the problem] I understand that the 45 minutes is not enough, but it doesn’t mean that I don’t care.
Pt: [Help-rejecting complaining] Fine, so what am I supposed to do about it?
Th: [Offers a suggestion and begins an interpretation] Try to see the reality itself. The external reality is much simpler than you think it is, although it’s painful enough.
Pt: OK, so.
Th: [Continues with interpretation of defenses] If you add on to the external reality an extra thing that somebody has to be blamed and degraded and if it’s not the other person it’s you.
Pt: But then, I think, what am I going to talk about when I come in here. I don’t want to sit here and talk bullshit like I’ve done for years.
T: [Offers his assessment as an association] I think this has been a good session.
P: [Devaluation-other] Oh, I’m glad you do, I feel like this is bullshit... I haven’t learned an eff-ing thing.
At 2 years, her course was still volatile and she made a suicide attempt. However, by 2.5 years, she exhibited a slow improvement in overall defensive functioning, with a raw change of +0.05, about one-tenth of an effect size, compared with +0.71 for the sample. Her repertoire of frequent defenses improved slightly with a greater role for neurotic defenses. In descending order of frequency, they were repression (27%), displacement (19%), undoing (9%), rationalization (7%), projection (7%), devaluation of self (7%), acting out (5%), passive aggression (5%), devaluation of others (5%), and reaction formation (5%). Her defensive functioning was still consistent with borderline personality disorder.
At 4 years, with her therapist’s encouragement, Ms. C transferred to psychoanalysis, allowing her to be seen three to four times a week, as she wished. At 5 years, the end of the formal study, she had finished 1 year of analysis. She made no further suicide attempts, and suicidal ideation was decreasing gradually. While she showed improvement on about half of her measures of symptoms and functioning, change was incremental, beginning with attaining full-time employment in the helping profession for which she had studied.
At 10 years, 5 years after the last research follow-up, we learned that Ms. C stabilized during her 3 years of analysis, and her suicidality diminished further. She married a very caring man and had a child. She occasionally took antidepressants, mood stabilizers, and methylphenidate. During analysis, she briefly attended a specialized clinic for borderline personality disorder. When a second child died during childbirth, she and her husband went for couples’ grief counseling and seemed to benefit. Since the analysis, she has never resumed self-mutilating and has made no suicide attempts. She went on to have another child, who was healthy. At 10 years, her contact with the department ended.