Psychiatric Times On-Line Version, 12:12, 23-27, Special Edition, October 2005.

Introduction

Psychotherapy has an interesting but paradoxical twist to it in the therapist's attempt to provide help. When one goes to a surgeon for example to remove a lump, the patient recognizes that they have a lump and they agree to the surgeon's attempt to remove it. With a psychological problem, however, the patient may recognize that they have some problem, but they often do not see it as a result of their own life-strategies (defense mechanisms or personality styles), and in trying to protect themselves with these defenses, the patient may actually sabotage their own therapy.

Even if they do have some insight into their maladaptive use of defenses, patients often show resistance to change their life-strategies, and prefer that things would go smoother in the world using the same life-strategies that they have been using up to now. In fact, the patient may seek validation on their style from the therapist, or even advice on how to make their maladaptive defenses work better. Can you imagine a patient with a lump telling the surgeon to remove the lump but at the same time try to convince the surgeon why it is better to live with the lump? If you read on this may become clearer.

This is where the unconscious nature of defenses; and the resistance to change one's defenses comes into play. Resistance is also often unconscious as patients may provide many rationalizations on why their maladaptive life-strategies are valid, even in the face of significant psychosocial troubles arising from these defenses as seen from the outside. The work of the therapy needs to overcome these barriers in order to move forward.

These maladaptive life-strategies have been used by the patient both in their past as well as in their present relationships, so it is no surprise that these personality styles will also manifest in the relationship with the therapist. It is the therapist's challenge to find the common thread that runs through the patient's interpersonal style and then guide the patient to using new and more adaptive life strategies. The therapist attempts to remains neutral in attitude and does not disclose personal material to the patient; and in this way tries to keep their counter-transference issues out of the session. The therapist and patient can then begin to create a picture of the patient's personality style without undue influence of the therapist's style. If the patient's insight is poor and/or their defenses are of a certain quality that leads to dissatisfactions in the therapy, the defenses themselves can sabotage the help they need in fixing the defenses.

Examples

A few concrete examples may help to understand these concepts:

The Terminator: This person uses the defense of rejecting others to protect themselves from the pain of being rejected first. They may have had some childhood experiences of feeling abandoned in love, care, or attention. They set-up relationships so that they can relive a pattern of rejecting others. They find faults with others, often not getting into or terminating intimate relationships early on, and complain that they can't find the right partner. They tend to engage in relationships that clearly have problems from the start in terms of the personality style, age, or background of the partner, thus planting the seeds for their next termination, and they may report conflict and terminations with prior therapists. They often make detailed rationalizations about why their relationships do not go well.

In the sessions the patient may fault-find with the therapist and complain that the therapist is not caring enough, especially if the therapist does not side with their misery and instead attempts to have them see how their tendency to reject others is actually undermining their own needs. They may request a significant amount of time from the therapist in phone calls or emails in-between the sessions in order to satisfy their underlying needs; however this will also lead to complaints that the therapist does not care enough when it seems that the therapist does not respond to each contact in a caring fashion and/or begins to put limits on the contacts.

Eventually this patient's rejecting nature will cause them to "fire" their therapist and terminate the therapy. The complaints　about the therapist may also grate on the therapists own counter-transference self-esteem issues and the therapist may subtly or overtly reject the patient. Needless to say, the problem itself has sabotaged the therapy of the problem. The therapist may be able to manage this patient by getting them to see their rejecting nature in a neutral fashion, not too early in the therapy, but also not when it is too late.

The President: This person uses the defense of exhibiting greatness to protect themselves from the pain of feeling diminished. They may have had some childhood experiences of ungratified or invalidated strivings from their family or peers. They always need to show strength in everything they do, connect themselves with important persons, devalue others, and try very hard to be important themselves, i.e. to become the class president or the company president (of course not all class or company presidents use greatness as their major defense).

These persons can become very aggravated when they are not the center of attention or at the top of their social group, and challenges to their greatness or rejection 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.

In the sessions, the patient will look for validation of their greatness from the therapist and seek advice from the therapist on ways to gain more greatness rather than seek ways to change their life strategies. They may subtly or openly devalue the therapist. If the therapist's counter-transference causes them to retaliate to the devaluations, or if the patient thinks the therapist is not validating them, or when the therapist attempts to guide them to use other life strategies because the ones they have been using are not the best ones or explores their underlying low self esteem, they may begin to feel diminished and are at risk to terminate the therapy before they have really started on the process to improve the underlying problem.

Sometimes this type of person will invest their defense of greatness in becoming a great patient who will read all about their problem and gain a considerable amount of psychological knowledge for the purpose of both gaining validation from and protecting themselves from feeling diminished compared with the therapist, and of course so great that they can profess that they have completely eliminated their problem of low self esteem. Needless to say, the problem itself has sabotaged the therapy of the problem. It may be possible to enlist the patient's sense of greatness to the advantage of the therapy if the therapist can convince them that great people are those that are able to really look at themselves and accept they use greatness as a defense against low self-esteem.

The Air Traffic Controller: This person uses the defense of controlling others to protect themselves from aggravation of being controlled. They may have had some childhood experiences of controlling or authoritarian parents. They tend to try to control others, especially in intimate relations or in the work place, and have conflict with people in these areas; this often being the main reason they have come for therapy.

In the sessions, the patient may get in power struggles with the therapist about scheduling, cancellation policy etc., and begin to argue with the therapist about the therapist's opinions and complain that the therapist can never see things their way. They need to feel that they are right about everything, tend to be argumentative, want the therapist to validate their rational 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 the therapist can begin to address the process of how to get better. The therapist's counter-transference may provoke counter-arguments with the patient and one needs to look out for this.

Needless to say, the problem itself has sabotaged the therapy of the problem. The therapist may be able to enlist the patient's need to be correct by praising them that they seem to usually be on the mark, and that the challenge now is to see if they can be on the mark about the analysis of their own deficits. (The use of the name "Air Traffic Controller" is just for the metaphor of controlling, not to imply of course that Air Traffic Controllers have this style).

The Invisible Patient: This person uses the composite defense of obedience and passive defiance to protect themselves from the aggravation of being controlled or belittled. They may have had belittling or authoritarian parents. They seem to be very compliant and cooperative on the surface, but on deeper interaction they are withholding and uncooperative, and seem to have a wall around themselves against real intimacy. They tend to not show up for important events, are late for work, do not complete chores they agree to do at work or with significant others, and have conflict with people in these areas; this usually being the reason they have come for therapy.

In the therapy, the patient may often be late for sessions, not show for the sessions, 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 (spouse, boss, therapist, etc.). They will often use intellectualization and rationalization to describe their behavior, and while they ostensibly agree with everything 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 or over-sensitive (counter-transference) reactions to the patient because of their invisibility (poor attendance, late fees, etc.), the patient may eventually terminate the therapy using an excuse such as "work or family duties" that are only more displays of passive defiant behavior.

Needless to say, the problem itself has sabotaged the therapy of the problem. 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 the therapist tells the patient that the problem is unfixable and that the therapy should focus on how to live with the defiance will engage this type of patient in a defiant stand to fix the problem.

The Velcro Patient: This person uses the defense of clingy "object hunger" (intense persistence to avoid separation from significant others) in order to protect themselves from the fear of being alone. They may have had some childhood experiences of feeling abandoned, or in reverse, of never practicing being on their own. Some children are also born with intense interpersonal needs that can develop into a maladaptive style when mixed with a particular upbringing.

These persons often get into and/or stay in relationships that are clearly unhealthy from the start causing conflict that brings them to therapy; or they may present to therapy when their partner proposes a break-up. They may get involved with partners who are inappropriate for them; i.e., they are married persons who are interested in affairs, violent or promiscuous persons, etc. It is not necessarily that these patients are "looking for" difficult people, but that because most people would avoid entering or continuing in these unhealthy relationships, these potential partners naturally do not realize relationships until they come across a needy person who is willing to cross these hurdles and stick with them like Velcro. The patients themselves also tend to have trouble realizing relationships because the intensity of their neediness pushes people away and that is one reason they also have trouble forming healthy relationships. They may have a repertoire of rationalizations for their behavior.

In the sessions, the patient will implore the therapist to help them find ways of improving a destructive relationship, or they will try to get the therapist to convince their partner not to break-up with them rather than look at ways to change their maladaptive defensive strategy. They may request a significant amount of time from the therapist in phone calls or emails in-between the sessions in order to hold on to a connection with the therapist to tide themselves over their pain; or to push for the therapist to give them the answer on how to prevent a break-up.

These patients are mainly interested in having their defense of object hunger work better for them and will terminate the therapy when they sense that the therapist can not or will not collude with their determination to promote their defense of clingy neediness. The therapist may react to try to save these patients too much and thus break boundaries by trying to give too much concrete help, or they may devalue the patient because their clingy behavior becomes annoying to the therapist.

Again, the problem itself has sabotaged the therapy of the problem. In addition to insight into the nature of their defenses, a potential method of therapy for these patients is to encourage them to tolerate activities they can do without a partner, while allowing the patient 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 bad relationships.

Conclusion

While some patients exhibit only one of the major traits exampled above, some patients of course may have a mix of the different styles. I have purposely avoided the use of diagnoses here in order to keep the focus on the interpersonal mechanisms involved rather than a label. Everybody has some amount of one style or another, no matter how subtle. The examples above are also not an exhaustive list of potential life-strategies. In addition, this page is mainly a description using personality styles and does not discuss situations complicated by depression or other psychiatric illnesses.

I hope you can now see how the problem itself can sometimes sabotage its own therapy. It takes a considerable amount of courage to admit that one's personality style needs changing so it is natural that one will have resistance to this endeavor. This is the challenge that faces the psychotherapist and the patient in the sessions. Many patients do of course get better without sabotaging their therapy, the purpose of this page is only to highlight the problems that may arise.

If the therapist can gain the trust of the patient and effectively explain the way therapy can work and the pitfalls involved, then progress can be made. It is often not easy for the therapist to articulate this process; and if the patient is relatively mature and uses rationalization and other intellectual defenses (as in the examples above) that "hide" the more underlying defense, these patterns can be subtle and not evident to the therapist until it is too late. This is one reason to put this very important topic on the home page.

Further Reading

The Psychiatric Interview in Clinical Practice, by Roger A. MacKinnon M.D. and Robert Michels M.D.. W.B. Saunders Company (1971).

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.