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By Douglas Berger, M.D., Ph.D.
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Psychiatric Times
Issue 12October 2005

Vol. XXII

Psychotherapy has an interesting paradoxical twist to it
in the therapist's attempt to provide help. When one
goes to a surgeon, for example, to remove a lump, thepatient recognizes they have a lump and agrees tohave the surgeon remove it. With a psychologicalproblem, however, patients may recognize that they
have some problem, but they often do not see it as aresult of their own life strategies (defenses orpersonality styles), and in trying to protect themselveswith these defenses, patients may actually sabotage
their own therapy.
Even if they do have some insight into theirmaladaptive use of defenses, patients often show
resistance to changing their life strategies. They would
prefer that things go smoother in the world using thesame life strategies they have been using up to now.
In fact, patients may seek validation on their style fromthe therapist or even advice on how to make theirmaladaptive defenses work better. Can you imagine apatient with a lump telling the surgeon to remove thelump but at the same time trying to convince thesurgeon why it is better to live with the lump?

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All ScalesThis is where the unconscious nature of defenses, andthe resistance to changing one's defenses, comes into㫄㪿㫋㫄㫃㪑㪽㫀㫃㪼㪑㪆㪆㪚㪑㪳㪛㫆㪺㫌㫄㪼㫅㫋㫊㩼㪉㪇㪸㫅㪻㩼㪉㪇㪪㪼㫋㫋㫀㫅㪾㫊㪳㪻㫆㫌㪾㪳㪤㫐㩼㪉㪇㪛㫆㪺㫌㫄㪼㫅㫋㫊㪳䊈䉾䊃ሽ࿷㪳㪡㪸㫇㪸㫅㪧㫊㫐㪺㪿㪳㪘㪹㪅㪅㪅 㪉㪇㪇㪐㪆㪈㪉㪆㪉㪋㪛㪼㪽㪼㫅㫊㪼㫊㩷㪚㪸㫅㩷㪪㪸㪹㫆㫋㪸㪾㪼㩷㫋㪿㪼㩷㪫㪿㪼㫉㪸㫇㫐

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Display Ad Rates/Sizes㪉㪆㪍㩷䊕䊷䉳play. Resistance is often unconscious in patients asthey may provide many rationalizations on why theirmaladaptive life strategies are valid. This resistancemay occur even in the face of significant psychosocial
troubles arising from these defenses as seen from theoutside. The work of the therapy needs to overcome
these barriers.
These maladaptive life strategies have been used by
the patient both in past and present relationships, so it
is no surprise that these personality styles will also
manifest in the relationship with their therapist. It is
the therapist's challenge to find the common threadthat runs through the patient's interpersonal style andthen guide the patient to use new and more adaptive
life strategies. The therapist attempts to remain neutral
in attitude and does not disclose personal material tothe patient. In this way therapists try to keep theircountertransference issues out of the session. Thus, thetherapist and patient can begin to create a picture of
the patient's personality style without undue influenceof the therapist's style. If the patient's insight is poor
and/or their defenses are of a certain quality that leads
to dissatisfaction in the therapy, the defenses
themselves can sabotage the help the patient needs tofix their defenses.
Concrete Examples
The terminator. These patients use the defense of
rejecting others to protect themselves from the pain ofbeing rejected first. They may have had some childhood
experiences of feeling abandoned. They set up
relationships to relive patterns of rejecting others. Theyfind faults with others, often not getting into or
terminating intimate relationships early on andcomplain that they cannot find the right partner. They
tend to engage in relationships that clearly haveproblems from the start, thus planting the seeds fortheir next termination. They may report conflict andterminations with prior therapists. They often makedetailed rationalizations about why their relationships
do not go well.
These patients may fault-find with the therapist andcomplain that the therapist is not caring enough,especially if the therapist does not side with theirmisery and instead attempts to have them see how
their tendency to reject others is actually undermining
their own needs. They may request phone calls or emails between sessions in order to satisfy theirunderlying dependency needs; however, this will also
lead to complaints that the therapist does not careenough when the therapist begins to put limits on thesecontacts.
Eventually these patients' rejecting nature will cause
them to "fire" the therapist and terminate therapy.
Complaints about the therapist may also grate on the㫄㪿㫋㫄㫃㪑㪽㫀㫃㪼㪑㪆㪆㪚㪑㪳㪛㫆㪺㫌㫄㪼㫅㫋㫊㩼㪉㪇㪸㫅㪻㩼㪉㪇㪪㪼㫋㫋㫀㫅㪾㫊㪳㪻㫆㫌㪾㪳㪤㫐㩼㪉㪇㪛㫆㪺㫌㫄㪼㫅㫋㫊㪳䊈䉾䊃ሽ࿷㪳㪡㪸㫇㪸㫅㪧㫊㫐㪺㪿㪳㪘㪹㪅㪅㪅 㪉㪇㪇㪐㪆㪈㪉㪆㪉㪋㪛㪼㪽㪼㫅㫊㪼㫊㩷㪚㪸㫅㩷㪪㪸㪹㫆㫋㪸㪾㪼㩷㫋㪿㪼㩷㪫㪿㪼㫉㪸㫇㫐㪊㪆㪍㩷䊕䊷䉳

therapist's own countertransference self-esteem issues,and the therapist may subtly or overtly reject thepatient. The therapist may be able to manage thesepatients by getting them to see their rejecting nature ina neutral fashion, not too early in the therapy, but also
not when it is too late.
The president. These patients use the defense ofexhibiting greatness to protect themselves from the painof feeling diminished. They may have had somechildhood experiences of ungratified or invalidated
strivings from their family or peers. They always need toshow strength in everything they do, connect
themselves with important people, devalue others andtry very hard to be important themselves, e.g., tobecome the class president or the company president.
These patients can become very aggravated when they
are not the center of attention or at the top of theirsocial group, and challenges to their greatness orrejection from partners who are tired of their grandiosity
are often the reason they have come for help. They
often have a detailed rationalization on why they only
need more greatness in order to gain mental stability.
These patients will look for validation of their greatness
and seek advice from the therapist on ways to gain
more greatness rather than ways to change their life
strategies. They may subtly or openly devalue thetherapist. If the therapist's countertransference causes
them to retaliate the devaluations or if these patients
think the therapist is not validating them or when thetherapist attempts to guide them to use other life
strategies or explores their underlying low self-esteem,
these patients may begin to feel diminished and are at
risk of terminating the therapy before they have really
started to improve the underlying problem.
Sometimes these patients will invest their defense ofgreatness in becoming a great patient. They will read allabout their problem and gain a considerable amount ofknowledge of psychology to gain validation from andprotect themselves from feeling diminished comparedwith the therapist. They profess that they havecompletely eliminated their problem of low self-esteem.
It may be possible to enlist these patients' sense ofgreatness to the therapy's advantage if the therapist
can convince them that great people are those that areable to really look at themselves and accept they use
greatness as a defense against low self-esteem.
The air traffic controller. These patients use the defenseof controlling others to protect themselves from theaggravation of being controlled. They may have hadchildhood experiences with controlling or authoritarianparents. They tend to try to control others, especially inintimate relations or in the workplace, and have conflictwith people in these areas. This is often the main reason
they come for therapy.

㫄㪿㫋㫄㫃㪑㪽㫀㫃㪼㪑㪆㪆㪚㪑㪳㪛㫆㪺㫌㫄㪼㫅㫋㫊㩼㪉㪇㪸㫅㪻㩼㪉㪇㪪㪼㫋㫋㫀㫅㪾㫊㪳㪻㫆㫌㪾㪳㪤㫐㩼㪉㪇㪛㫆㪺㫌㫄㪼㫅㫋㫊㪳䊈䉾䊃ሽ࿷㪳㪡㪸㫇㪸㫅㪧㫊㫐㪺㪿㪳㪘㪹㪅㪅㪅 㪉㪇㪇㪐㪆㪈㪉㪆㪉㪋㪛㪼㪽㪼㫅㫊㪼㫊㩷㪚㪸㫅㩷㪪㪸㪹㫆㫋㪸㪾㪼㩷㫋㪿㪼㩷㪫㪿㪼㫉㪸㫇㫐㪋㪆㪍㩷䊕䊷䉳Patients may get in power struggles about scheduling,
cancellation policy or other issues, and begin to argue
about the therapist's opinions and complain that thetherapist will never see things their way. They need tofeel they are right about everything; tend to beargumentative; want the therapist to validate theirrationale in arguments they have had with others; will
not easily agree to see the types of defenses they use;and eventually terminate the therapy before thetherapist can begin to address the process of how to getbetter. The therapist's countertransference may provokecounter-arguments with these patients.
The therapist may be able to enlist these patients' need
to be correct by praising them about how they seem tousually be on the mark and that the challenge now is tosee if they can be on the mark about the analysis of
their own deficits.
The invisible patient. These patients use the composite
defense of obedience and passive defiance to protect
themselves from the aggravation of being controlled orbelittled. They may have had belittling or authoritarianparents. They seem to be very compliant andcooperative on the surface, but on deeper interaction
they are withholding and uncooperative and seem tohave a wall around themselves against real intimacy.
They tend to not show up for important events, are latefor work, do not complete chores they agree to do atwork or with significant others, and have conflict withpeople in these areas; this usually being the reason they
have come for therapy.
Patients may often be late for sessions, not show for thesessions and often be in arrears with fees. They set up
relationships so that they can relive a pattern of being
oppositional to a scolding person in authority (e.g.,spouse, boss, therapist). They will often use
intellectualization and rationalization to describe their
behavior, and while they ostensibly agree witheverything the therapist has said, there is no effective
change in their life strategy. If the therapist does not
terminate the therapy because of either reasonable oroversensitive (countertransference) reactions to thesepatients because of their invisibility (e.g., poor
attendance, late fees), these patients may eventuallyterminate the therapy using an excuse such as "work or
family duties" that are 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, where thetherapist tells the patient that the problem is unfixable
and that the therapy should focus on how to live withthe defiance, will engage this patient in a defiant standto fix the problem.
The rubber cement patient. These patients use the㫄㪿㫋㫄㫃㪑㪽㫀㫃㪼㪑㪆㪆㪚㪑㪳㪛㫆㪺㫌㫄㪼㫅㫋㫊㩼㪉㪇㪸㫅㪻㩼㪉㪇㪪㪼㫋㫋㫀㫅㪾㫊㪳㪻㫆㫌㪾㪳㪤㫐㩼㪉㪇㪛㫆㪺㫌㫄㪼㫅㫋㫊㪳䊈䉾䊃ሽ࿷㪳㪡㪸㫇㪸㫅㪧㫊㫐㪺㪿㪳㪘㪹㪅㪅㪅 㪉㪇㪇㪐㪆㪈㪉㪆㪉㪋㪛㪼㪽㪼㫅㫊㪼㫊㩷㪚㪸㫅㩷㪪㪸㪹㫆㫋㪸㪾㪼㩷㫋㪿㪼㩷㪫㪿㪼㫉㪸㫇㫐㪌㪆㪍㩷䊕䊷䉳

defense of clingy "object hunger" (intense persistence to
avoid separation from significant others) in order toprotect themselves from the fear of being alone. They
may have had some childhood experiences of feelingabandoned or, in reverse, of never practicing being on
their own. Some children are also born with intense
dependency needs that can develop into a maladaptive
style when mixed with a particular upbringing.
These people often get into and/or stay in relationshipsthat are clearly unhealthy from the start, causing
conflict that brings them to therapy; or they may
present to therapy when their partner proposes abreakup. They may get involved with partners who areinappropriate for them (e.g., violent, alcoholic,promiscuous). It is not necessarily that these patientsare "looking for" difficult people, but because mostpeople would avoid entering or continuing in these
unhealthy relationships, these potential partners
naturally do not realize relationships until they comeacross a dependent person willing to cross these hurdles
and stick with them. The patients also tend to havetrouble realizing relationships because the intensity of
their neediness pushes people away. They may have arepertoire of rationalizations for their behavior.
These patients will implore the therapist to help themfind ways of improving a destructive relationship or try
to get the therapist to convince their partner not tobreak up with them rather than change theirmaladaptive defensive strategy. They may request
phone calls or e-mails from the therapist between
sessions to hold on to a connection with the therapist totide themselves over their pain. They may push for thetherapist to give them the answer on how to prevent abreakup.
These patients are mainly interested in having theirdefense of object hunger work better for them and willterminate the therapy when they sense that thetherapist cannot or will not collude with theirdetermination to promote their defense of clingy
dependency. The therapist may react by trying to savethese patients too much and thus break boundaries bytrying to give too much concrete help, or the therapist
may devalue these patients because their clingy
behavior becomes annoying to the therapist.
Again, the problem itself has sabotaged the treatment ofthe problem. In addition to giving insight into the natureof their defenses, a potential method of treatment forthese patients is to encourage them to tolerate activities
they can do without a partner. However, patients stillneed to use the therapeutic relationship as a transitional
object that can help them move out of bad relationships
and/or to help them avoid getting into future badrelationships.
Conclusion㫄㪿㫋㫄㫃㪑㪽㫀㫃㪼㪑㪆㪆㪚㪑㪳㪛㫆㪺㫌㫄㪼㫅㫋㫊㩼㪉㪇㪸㫅㪻㩼㪉㪇㪪㪼㫋㫋㫀㫅㪾㫊㪳㪻㫆㫌㪾㪳㪤㫐㩼㪉㪇㪛㫆㪺㫌㫄㪼㫅㫋㫊㪳䊈䉾䊃ሽ࿷㪳㪡㪸㫇㪸㫅㪧㫊㫐㪺㪿㪳㪘㪹㪅㪅㪅 㪉㪇㪇㪐㪆㪈㪉㪆㪉㪋㪛㪼㪽㪼㫅㫊㪼㫊㩷㪚㪸㫅㩷㪪㪸㪹㫆㫋㪸㪾㪼㩷㫋㪿㪼㩷㪫㪿㪼㫉㪸㫇㫐㪍㪆㪍㩷䊕䊷䉳

While some patients exhibit only one of the major traits
exampled above, some patients may have a mix of thedifferent styles. I have purposely avoided the use ofdiagnoses here in order to keep the focus on theinterpersonal mechanisms involved rather than a label.
Everybody has some amount of one style or another, nomatter how subtle. The examples above are also not an
exhaustive list of potential life strategies. In addition,
this paper is mainly a description using personality
styles and does not discuss situations complicated bydepression or other psychiatric illnesses.
One can see how the problem itself can sometimes
sabotage its own treatment. It takes a considerable
amount of courage to admit that one's personality styleneeds changing, so it is natural that one will haveresistance to this endeavor. This is the challenge thatfaces the psychotherapist and the patient in thesessions. Many patients do, of course, get better without
sabotaging their therapy.
If the therapist can gain the trust of the patient andeffectively explain the way therapy can work and thepitfalls involved, then progress can be made. It is often
not easy for the therapist to articulate this process; andif the patient is relatively mature and uses
rationalization and other intellectual defenses (as in theexamples above) that "hide" the more underlying
defense, these patterns can be subtle and not evident to
the therapist until it is too late.
Dr. Berger is in private practice and consults withpharmaceutical companies in Tokyo.
Further Reading
MacKinnon RA, Michels R (1971), The PsychiatricInterview in Clinical Practice. New York: W.B. Saunders
Company.
Perry S, Cooper AM, Michels R (1987), The
psychodynamic formulation: its purpose, structure, andclinical application. Am J Psychiatry 144(5):543-550.
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