It is often helpful to give some concrete examples in order illustrate how the Core Issue-Defense Paradigm works. All the cases below are modified versions of real persons in order to protect confidentiality. You might find it easy to conceptualize how one's core issues, defenses, and the results of these defenses interact if you jot them down in a diagram fashion as you read the descriptions. Although some diagnoses are also mentioned in the cases below regarding personality style, Dr. Berger believes it is more helpful to understand the mechanisms of one's particular style rather than simply the definition of a diagnosis which often does not adequately describe the complexities of each individual.

Case 1: Let's start off with relatively straight forward case of a 35 year-old Western man who works as a stock broker in Tokyo. His dad was very strict and critical. He likes sports cars, lots of money, likes to date many woman at once (has never been in a serious relationship), only goes out with beautiful women, idealizes connections he has to people of power, criticizes others who don't have the things he has, and tends to boast about his various abilities. He gets enraged when he is not being noticed or is slighted. He has never had any prior psychiatric treatment.

He comes into the session with a chief complaint that his three girlfriends have found out about each other and they are all angry at him and want to break-up with him. He wants advice from me on what he can do to keep them all in the relationship and states that he is feeling very "unstable". What are his troubles, defenses, and core issues? First, his troubles can be divided into active troubles: the problems with the three girls, and inactive troubles: he has never been able to get into a serious relationship with a woman as he is so focused on being admired by many at once, and people don't want to be his friend because his boasting pushes people away. His major maladaptive defenses include grandiosity (boasting and needing to be connected with great things like sports cars and only beautiful women), need to be admired (and consequently exploiting the women for this end), projection and devaluation (projects his own self devaluation into others), and over-idealization of others in order to "borrow" their greatness to help prop-up his own self esteem. He gets enraged when his grandiosity needs are not met which is his last ditch attempt (a regression to an even more immature defense when the first-line defenses fail) to protect himself from having a more uncomfortable core issue feeling state arise. His core issues seem to include feeling unvalidated and belittled but we don't have enough information yet. His feeling "unstable" is a signal of the core issues bubbling up through the failed defenses.

How will I treat him? Just giving him advice on how to keep the girls (which I don't really have the ability to do anyway) only reinforces his maladaptive defenses; and his asking for help with this indicates a resistance he has to change the defensive structure he has used for years. This resistance is an important feature of defenses as one does not want to give them up easily. He is also not really aware that this defense is maladaptive and this is because the defenses are often unconscious, another important feature of defenses. Once we can get him to see the whole picture of his core issues and how his use of maladaptive defenses results in subsequent troubles, only then can he begin to engage in seeing how he needs to rework his defensive structure and deal with some painful feelings he may have about himself on a more unconscious level, and that tend to bubble up when his defenses fail. We will do this by discussing the major themes in his life from the past (especially how his critical dad may have made him feel belittled), his present relationships, his relationship style with the therapist, and information from his dreams. He will need a lot of praise and support from me to get through the initial phase of hurt from the three girls who have basically left him. Group therapy might also be a useful way for him to get a view of himself from the other group members who can gently encourage him to see the way he comes across. Most psychiatrists would describe this man as having a Narcissistic Personality.

Case 2: An American man in his 30's came to see me for depression. He was a software engineer who had lost his job and was quite depressed with sleep disturbance and loss of appetite and suicidal feelings. He had also lost interest in his girlfriend and wanted to break up with her, as had happened to him with every previous girlfriend when the relationship got closer. Most of his girlfriends had a non-assertive style and were dependent on him for affection. He seemed very caring and kind to others and he emphasized his desire to cooperate with his therapy to improve himself. He couldn't believe that he had lost his job because he felt he was a good "team player" at work.

His depression responded well to antidepressant medication. Over the course of therapy, however, he would sometimes not show-up for sessions or come late, and he would be very apologetic for this, but yet note how much he needed help. He would also anger his bosses at work by not showing up or coming in late or not doing what he was told, and he eventually he lost more jobs and had a long period of unemployment without searching for a new job as actively as he could. He was finally able to engage in a committed relationship with a woman who was very strong-minded and harshly criticized his passivity. His mother was an alcoholic and would often belittle and control him when he was a child. His dad also had treatment for depression.

Understanding this man is not as easy as in Case 1. His active troubles are his inability to keep his employment and his trouble maintaining his intimate relationships with women. His inactive troubles are not having as many friends as he could have, and not living up to his actual talents. His depression was a secondary result of all the troubles, or one could say a domino-effect trouble, although there may have been some genetic predisposition inherited from his dad. His main maladaptive defenses are an alternation of obedience and defiance because he views most relationships as a struggle for control as he did with his mother (his core issues are feeling controlled and belittled). His defiance manifests as a passive-aggression, i.e. aggravating others by acts of omission (not showing up for things, not looking for a job etc.) rather than aggressive acts of commission. He was able to make a commitment with his new girlfriend because she served as a barometer for him to fine-tune his obedience and defiance cycle: giving him reason to be defiant but yet admonishing him to cooperate. He lost interest in his previous girlfriends because they were more passively committed to him. His pride, as a defense to his sensitivity to being belittled, also gives him trouble because he becomes passive-aggressive when he feels he is not being valued at work etc.

After the acute treatment phase with antidepressant medication and supportive meetings, the psychotherapy of this man will require having him clearly see his defensive cycle and how it impairs his life. He will need to see that he does not have to view relationships as a potential struggle, and the therapist can help him with this by tolerating his challenges. As in the first case, group therapy can serve as leverage for him to break-through the barrier of resistance and denial of his pattern of defenses. Most psychiatrists would describe this man as having a Major Depression and an Obsessive Personality style because of his issues with struggles.

Case 3: A Japanese woman office lady in her early 40's wanted help in understanding her new American boyfriend. He was over 12 years younger than her, and had been sent to Japan from his company's home office. They worked at the same company and his desk was only a few rows away from hers. She said he said things like, "you don't owe me anything" and "I'm an independent guy" and she wanted me to explain to her what they meant because she felt serious about him. She complained that although he would send her some e-mails through the course of the day, he often left the office without a "goodbye e-mail". They had dates where she would quietly follow his lead, even though she had other opinions (i.e. he insisted they take a long car ride to a resort area when she knew the train was much faster). On their most recent date he suddenly said he was going to the gym. She described the current boyfriend as easily irritable, sometimes changing his plans with her suddenly. As a child her dad was always working and he would often go out with his colleagues on his days off. Her mother was more focused on her older brother's scholastic endeavors. She divorced over 10 years ago because she felt her first husband was cold and distant. Her last boyfriend of 7-years duration was an affair with a married man. She also reported occasional panic attacks of sudden high anxiety and hyperventilation that worsened when she felt a boyfriend was separating from her.

Can you determine her troubles, defenses, and core issues without reading further? Her active trouble is that she is head-long in a relationship with a man who objectively does not seem to have the same feelings for her, and her inactive trouble is that she cannot get in a healthy relationship because she has a pattern of agreeing to go out with men who are either not able to relate on an intimate basis themselves (her ex-husband), or are not logistically able or willing to get serious with her (her last boyfriend was married and her current boyfriend is clearly not interested in real intimacy). She is willing to engage with the current boyfriend in spite of the hurdles of his being a generation younger and their working in the same office with the inherent problems of mixing her private and professional business. Her major maladaptive defense is that of clinging even in the face of no real intimacy on the part of her partner. When this defense fails, she may have high anxiety or panic attacks that reflect the depth of the core issue(s) she needs to defend against. Her core issues are probably related to feeling unloved or unwanted, possibly originating from her relationship with her parents.

Treating her will not be as easy as case 1 or case 2 because she is more focused on quenching her needs for a partner (i.e. resistance to changing her maladaptive defenses) rather than looking at herself and trying to devise a different interpersonal strategy. Even after carefully explaining the mechanism of her troubles and defenses to her she still asked me, "So his saying he is 'independent' means he is not really interested in me right?" She only came to one session with this agenda and did not reschedule an appointment. She will probably contact me again only if she has a failed attempt in intimacy; at least I gave her the beginnings of a psychological tool box that she can use to help herself.

Case 4: This case is an example of a complex interaction among a number of core issues. A 37 year old Irish man requests therapy because he is anxious about the prospect of getting married to his girlfriend who has begun to give him an ultimatum on marriage plans. He had been married before for a few years to a woman he liked very much, but was anxious throughout the marriage, and felt great relief when his wife found another man and broke up with him. He usually avoids searching for women and does not actively seek affairs, but will engage with attractive women who approach him. He had previously dated and had a sexual affair with a married women who was very attractive but began to call it off when she wanted to break with her husband to get serious with him. He had also recently gone on some dates with another very attractive single woman he met through work, and although she seemed ready to start a sexual affair, he did not let himself go through with this.

His mother was very controlling and needy of his attention and especially so after his parents divorced when he was a child. He reacted to this by avoiding her and began to feel antipathy towards her. His dad was a drinker and somewhat unavailable emotionally. He is a very likeable man and very much wants to bring his relationship with his girlfriend to intimate fruition. He describes his girlfriend as being quite "lovable" but not a "trophy" woman like the women in his affairs. He is generally anxious, tends to binge-drink on alcohol and is a heavy smoker.

His core issues are a combination of fear of being controlled, which he likely got from his relationship with his mother, and a desire for validation fueled by feeling inadequate both from his mother's controlling style and from his father's inability to provide positive feedback. He has tried to suppress the great affection needs he had from his mother because she was so difficult. This interplay explains why he wants the intimacy that was lacking in his own family but shies away when relationships get close because of his fears of being controlled. It also explains why he is willing to engage in affairs with women who have a built-in barrier to intimacy like married women where he can satisfy his validation (and sexuality) needs and yet be protected from intimacy and the fear of being controlled. He is more likely to engage with "trophy" women in these affairs in order to satisfy his sense of inadequacy. He has essentially made a "compromise" with all these needs he has by having a girlfriend but trying to keep her at a safe distance and having affairs with the trophy women while adjusting his distance to them just enough to satisfy his validation needs. He rarely seeks women on his own as that could expose him to the risk of rejection which would be an injury to his validation needs. His pervasive anxiety reflects the tension inherent in this compromise and his heavy drinking and smoking are a secondary effect of all the anxiety.

His major maladaptive defenses are avoidance of emotionally risky situations, passive control via the avoidance, and subtle grandiosity with the trophy women. His adaptive defenses include openness, care and compassion, desire for insight and self-improvement, and intellectual defenses. Repression of the conflicts arising from the opposing core issues of great need for intimacy and the fear of intimacy (and thus being controlled), and the formation of a compromise to attempt to fix this, have both adaptive and maladaptive qualities. While they have protected him from a number of core issues to a degree, the drawbacks are that the compromise itself causes him to suffer from anxiety and from an inability to realize final intimacy as he is always walking a tightrope between the two sides of the compromise.

Treatment will include insight and support for behavioral change. While his behaviors are conscious, his core issues and the compromise formation are largely unconscious and need to be clearly shown to him. He has an insightful and understanding way about him and this can be utilized in this regard. By using insight to see the unreasonableness of his fears, as well as the compromise that he has made as a defense, he has been able to progress in intimacy with his girlfriend while tolerating his anxiety. He still suffers waves of high anxiety on occasion under the stress of intimacy pressures from his girlfriend.

The exact diagnosis in this case is not as straight forward as the previous cases. While he exhibits a mixture of Narcissistic and Obsessive traits as in the cases above, many psychiatrists would describe this man as suffering from a Neurosis, generally defined as the process of repression of psychological conflicts leading to anxiety and contradictory behaviors. If his anxiety is severe, he might also fill the criteria for Generalized Anxiety Disorder, for which psychotherapy and possibly the addition of medication might be helpful.

The Therapeutic Alliance

At the end of the day when all the fancy psychotherapy theory is said and done, the therapist must still provide a compassionate and caring atmosphere in order to create a positive and trusting therapeutic alliance. These factors alone may help a great number of persons in emotional distress. After all, social soothing has been around for millions of years in the animal kingdom.

Reference Materials:

The Psychodynamic Formulation: Its Purpose, Structure, and Clinical Application. By Samuel Perry, M.D., Arnold M. Cooper, M.D., and Robert Michels, M.D., American Journal of Psychiatry, 1987;144:5:543-550.