• Clinical science

Psychotherapy and defense mechanisms

Abstract

Psychotherapy is the use of psychological methods to assist people to modify undesirable emotions, attitudes, and behaviors. Types of psychotherapy include psychoanalysis, behavioral therapy, cognitive therapy, cognitive-behavioral therapy, dialectical behavioral therapy, motivational interviewing, group therapy, couples therapy, and family therapy.

Defensive mechanisms are the primary tools of the ego that are used to mediate an individual's reaction to internal emotional conflicts triggered by external stressors. We discuss the following categories: mature, neurotic, and immature defense mechanisms. These mechanisms may manifest in various psychiatric disorders.

Overview of psychotherapies

  • Definition: use of psychological methods to assist people to modify undesirable emotions, attitudes, and behaviors

Overview table of important psychotherapies (for an exhaustive list see “details of psychotherapy”)

Psychotherapy Indications Typical duration Main objective/features
Psychodynamic psychotherapy
  • Weekly sessions for 6 months to years
  • Focuses on changing current behaviors, feelings, and thoughts by analyzing past experiences
Supportive psychotherapy
  • Days–years
  • Focuses on empathy, guidance, reinforcement, and encouragement
Interpersonal therapy
  • Depressive disorders
  • Weekly sessions for 12–16 weeks
  • Focuses on understanding problematic interpersonal relationships
Cognitive-behavioral therapy (CBT)
  • 6 weeks to 6 months
Dialectical behavioral therapy (DBT)
  • Once weekly for ∼ 16 weeks
  • Teaching new skills (e.g., relaxation techniques) to change unhealthy behavior
Motivational interviewing
  • ∼ 2–4 sessions
  • Showing support for optimism and self-efficacy
  • Focuses on showing empathy through reflective listening

References:[1][2][3][4][5][6]

Details of psychotherapy

Psychoanalysis

Psychodynamic psychotherapy

  • Indications: : anxiety disorders
  • Duration: weekly sessions for 6 months to years
  • Main objectives/features
    • Focuses on changing current behaviors, feelings, and thoughts by analyzing past experiences
    • Aims to reveal the unconscious mind
    • Therapist aims to keep their own personality neutral

Supportive psychotherapy

  • Indications: : anxiety disorders
  • Duration: days–years
  • Main objectives/features
    • Focuses on empathy, guidance, reinforcement, and encouragement
    • Aims to build patient defenses, self-esteem, and improve functioning (i.e., in social environments)

Interpersonal therapy

  • Indications: : depressive disorders
  • Duration: weekly sessions for 12–16 weeks
  • Main objectives/features
    • Focuses on understanding problematic interpersonal relationships (e.g., unresolved grief or conflicts) and/or life situations (e.g., change in jobs, geographical move)
    • Aims to enable better control over mood and behavior

Behavioral therapy

  • Indications
    • Obsessive-compulsive disorders
    • Phobias
  • Duration: : brief; usually combined with cognitive-behavioral therapy
  • Techniques
    • Based on learning theoretical alternatives to maladaptive behavior
    • Conditioning
      • Classical conditioning: a response evoked by a certain stimulus (e.g., ringing a bell at meal time provokes salivation in dogs)
      • Operant conditioning: learned behavior following positive or negative reinforcement (e.g., opening the front door when the doorbell rings because a guest is expected)and likewise decrease in behavior following positive or negative punishement (e.g., prison sentence following a crime may cause a decrease in crime)
    • Deconditioning
      • Systemic desensitization: increasing the level of exposure to anxiety-provoking stimuli while performing relaxation techniques
      • Flooding and implosion: exposing a patient to real (flooding) or imagined (implosion) anxiety-provoking stimuli until the patient achieves complete relaxation in that situation
      • Biofeedback: providing physiological information to patients to improve relaxation
      • Token economy: rewarding positive behaviors
      • Aversion therapy: using a nonrewarding stimulus to demote negative behaviors

Cognitive therapy

Cognitive-behavioral therapy

  • Indications
  • Duration: 6 weeks to 6 months
  • Techniques
    • Combines cognitive therapy and behavior therapy
    • Aim is to change distorted, harmful, irrational, or ineffective beliefs, attitudes, and behavior patterns that lead to impairment of function
    • Teaches skills and strategies that help the patient to alter abnormal behaviors
    • Uses homework to implement new skills; may use a diary or chart to monitor progress

Dialectical behavioral therapy

  • Indications
  • Duration: once weekly for ∼16 weeks
  • Techniques: requires the therapist to understand the patient's problem and teach new skills (e.g., relaxation techniques) to change unhealthy behavior
    • Mindfulness: A complex field that revolves around raising patient mindfulness regarding their thoughts, feeling, and actions.
    • Emotional regulation: Patients are taught to become aware of their emotions and to rationally assess these.
    • Distress tolerance: Patients are taught to better handle crises and stressful situations.
    • Interpersonal effectiveness: Patients are taught to recognize and assert their needs without coming into conflict with others.

Motivational interviewing

  • Indications
  • Duration: ∼ 2–4 sessions
  • Main objectives/features
    • Showing support for optimism and self-efficacy
    • Avoiding arguments between the interviewer and client
      • Involves adjusting to client's resistance
      • Avoiding direct confrontation
    • Focuses on showing empathy through reflective listening

Group therapy

  • Indications
  • Duration: 1 x week for month to years
  • Techniques
    • One or more therapists help to solve emotional difficulties associated with mental disorder, with multiple patients at once.
    • Allows direct interaction between therapists and group members, and direct interaction between patients too

Family therapy

  • Indications
  • Duration: months to years
  • Techniques
    • Identifies family dysfunctions and individual's problems that affect the entire family
    • Aim to reduce conflict and help accommodate each other within a family unit
    • Addresses too permeable (e.g., allowing a child to smoke cigarettes) or too rigid (e.g., not allowing any social contact outside of the family) boundaries

Couples therapy

  • Indications
    • Sexual disorders
    • Motivated couples who are not suffering severe mental illness (e.g., schizophrenia)
  • Duration: weeks to years
  • Techniques
    • Treatment of couple conflicts and communication problems
    • Conjoint therapy, concurrent therapy , collaborative therapy , and four-way therapy

Schema therapy

  • Indications
    • Schema therapy was developed by Jeffrey Young. It is based on the notion that people acquire certain basic schemas, i.e., mental structures that help interpret and organize information, and thereby establish certain behavioral patterns throughout the course of their lives. These schemas, in part, set the conditions for meeting psychological needs and therefore also influence behavior. Childhood trauma, for example, can lead to maladaptive schemas that are difficult to access consciously and may represent the root cause of the development of a personality disorder. Schema therapy tries to defuse the harmful potential of these maladaptive schemas.
  • Main objectives/features
    • Combination of various psychotherapeutic concepts (e.g., CBT, psychodynamic therapy, Gestalt therapy, etc.)
    • The therapist treats the patient with empathy.

References:[1][2][3][4][7]

Psychoanalytic theory

Topographic Freudian model

  • Unconscious
    • Includes primitive primary process thinking (e.g., sex, aggression)
    • Normally repressed from conscious awareness because of negative consequences (e.g., feelings of shame or guilt)
    • Prominent in children or mental illness with psychosis
  • Preconscious: : a level below conscious awareness; memories are easily called into conscious awareness
  • Conscious: : current awareness; includes secondary process thinking (e.g., mature, logical)

Structural Freudian model

  • Id: : unconscious; ; source of drive and instinctive impulses (e.g., sex, aggression)
  • Super-ego: : represents both the consciousness and the idealized self
  • Ego:

References:[1]

Defense mechanisms

Overview

  • Definition
    • Primary tools of the ego used to cope with external stressors to avoid or reduce anxiety, restrict impulses, and avoid unpleasant feelings
    • Mostly unconscious; may be healthy if used in moderation or unhealthy if used excessively
  • Classification
    • Pathological/Narcissistic: seen in children or patients with personality disorders
    • Immature: seen in children, adolescents, psychotic patients, or patients with personality disorders
    • Neurotic: seen in obsessive-compulsive or anxious patients
    • Mature: seen in normal adults

Pathological/Narcissistic defenses

Mechanism Description Examples

Splitting (psychiatry)

  • An all or nothing view about a subject or person, without a middle ground, because they are not able to integrate the good and bad images of both self and others into a cohesive whole; associated with borderline personality disorder or results in prejudice/stereotyping
  • Disliking all teachers; finding that all student counselors are all good people based on their choice of profession alone
Projection (psychiatry)
  • Attributing one's undesired feelings or thoughts to another person; may include paranoid delusions and acting on the perceptions
  • A clinician believes that a patient dislikes him, when in actuality he dislikes the patient
  • A man fears that his wife is cheating on him while he himself feels attracted to other women.
Denial (psychiatry)
  • Consciously avoiding anxiety-provoking thoughts by not accepting reality; common early response to bad news and/or associated with substance abuse
  • Refusing to acknowledge a cancer diagnosis; denying a drinking problem
Distortion (psychiatry)
  • Reshaping external reality to suit inner needs (including hallucinations, wish-fulfilling delusions) to sustain superiority/entitlement
  • A woman tells a story about how she was abandoned by her family when she actually ran away from home

Immature defenses

Mechanism Description Examples
Acting out (psychiatry) Expressing an unacceptable or extreme behavior to avoid the anxiety associated with suppressing the action; associated with borderline and antisocial personality disorders A person throws a temper tantrum when he/she does not get their way
Regression (psychiatry) Attempting to return to a child-like state to avoid the tension evoked at the present level of development; common in individuals who are feeling ill, tired, or uncomfortable Lying in bed in the fetal position; bringing a teddy bear to the hospital for an overnight admission
Primitive idealization (psychiatry) Imposing more positive qualities on an external object or person than they actually have A women believing that her new boyfriend is absolutely flawless
Blocking (psychiatry) Temporarily or transiently inhibited thinking while feeling increased levels of tension; may be associated with embarrassment An individual being unable to answer a question during the exam, but immediately recalls it once the exam is over
Hypochondriasis (psychiatry) Exaggerating or overemphasizing an illness to avoid responsibility or guilt associated with loneliness, bereavement, or aggressive impulses Claiming to be bed-ridden when suffering from mild abdominal cramps when actually trying to avoid going to work following the death of a loved one
Identification (psychiatry) Internalizing or conforming to the qualities of an external object or person for approval; opposite of projection A teenager dresses and behaves like his favorite celebrity
Passive aggression (psychiatry) Expressing aggression toward others indirectly through passivity, failures, or illness that affects others more than self; common in borderline personality disorder and children Avoiding answering direct questions because of feelings of annoyance towards the other person
Somatization (psychiatry) Converting psychic derivatives into real bodily symptoms; may be associated with somatic symptom disorders Developing headaches while writing a stressful exam
Undoing (psychiatry) Trying to undo a situation by engaging in a new behavior After a man thinks about harming another person he becomes overly accommodating to them
Fixation (psychiatry) Only partially adopting a child-like level of development An adult who is fixated on reading comic books or playing video games
Fantasy (psychiatry) Withdrawal into fantasy to resolve inner and outer conflicts. An elderly man who fantasizes that he is youthful and virile

Anxiety/Neurotic defenses

Mechanism Description Examples
Controlling (psychiatry) Excessively attempting to manage or regulate the environment (i.e., objects or people) to minimize or avoid anxiety A mother will not let her child attend a friend's birthday party unless she can regulate who else will attend
Displacement (psychiatry) Shifting an emotion to a less threatening object or person; individuals may become a scapegoat for others and develop phobias Punching a wall after an argument with a colleague rather than telling the colleague your true feelings; a mom showing her feelings of anger towards the child instead of the actual problem, her husband
Intellectualization (psychiatry)

Using abstract, rational and logical reasoning to avoid affective expression

Excessively investigating the pathophysiology of a terminal illness instead of reacting to the anxiety related to an early death
Isolation of affect (psychiatry) Separating or repressing an idea from the associated effect or idea; accepting reality without the accompanying emotional response Recalling traumatic events without showing any emotions
Rationalization (psychiatry) Offering excuses or rational explanations in an attempt to justify behaviors, attitudes, or beliefs to avoid self-blame; common in obsessive-compulsive disorder Saying that they failed a test because the teacher dislikes him/her instead of admitting that they didn't study
Reaction formation (psychiatry) Transforming an unacceptable impulse into its polar opposite to avoid anxiety-provoking thoughts; associated with anxiety disorders Being extremely nice to foreigners although the person is xenophobic.
Repression (psychiatry) Thoughts are unconsciously removed from conscious awareness; the facts may have been known and accepted at some point in life, but are now absent from memory A man cannot remember all traumatic events during his time in war
Externalization (psychiatry) Perceiving one's own personality in the external world and in external objects elements (including instinctual impulses, conflicts, moods, attitudes, and styles of thinking) Perceiving someone else as aggressive and oneself as peaceful, although oneself is the aggressor.
Dissociation (psychiatry) Temporarily modifying personal identity or another person's character to avoid emotional distress Reading a good book to escape the stress of reality
Sexualization (psychiatry) Endowing an object or function with sexual significance Evaluating a person based on their sexual significance only; excluding other characteristics
Inhibition (psychiatry) Consciously limiting ego functions, alone or in combination, to avoid anxiety arising out of conflict Not laughing out loud in reaction to a friend falling on their face to avoid conflict

Mature defenses

Mechanism Description Examples
Altruism (psychiatry) Serving others constructively to experience a personal vicarious experience; resolves guilty feelings by meeting the needs of others Giving the homeless man your lunch instead of eating it yourself
Humor (psychiatry) Using comedy to express feelings and thoughts to lessen personal discomfort, but without producing an unpleasant effect on others Expressing a serious situation in the form of a joke to reduce anxiety
Sublimation (psychiatry) Shifting focus of unacceptable or unattainable impulses towards goal-directed activities; typically moving towards a socially-acceptable direction Using feelings of anger to motivate studying for an exam (to spite someone) or becoming a stripper to fulfill exhibitionist fantasies
Suppression (psychiatry) Consciously postponing attention to an anxiety-provoking thought; easily recalled with the right stimulus Suppressing feelings of fear associated with the sight of blood during surgery to provide necessary patient care
Anticipation (psychiatry) Realistic planning or premature worrying about future discomforts; associated with goal-directed behavior Going over course notes in preparation for a lecture the following morning.
Asceticism (psychiatry) Eliminates pleasurable effects of experience; gratification is derived from this renunciation A priest vowing to not have sex


References:[8][9][10][11]