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Psychotherapy and defense mechanisms

Last updated: May 11, 2021

Summarytoggle arrow icon

Psychotherapy is the use of psychological methods to help patients modify undesirable emotions, attitudes, and behaviors. The most common types of psychotherapy are psychoanalysis, behavioral therapy, cognitive therapy, cognitive behavioral therapy, dialectical behavioral therapy, motivational interviewing, group therapy, couples therapy, family therapy, and schema therapy. Psychoanalytic theory has its origin in Freud's topographic and structural theories. According to Freud, defense mechanisms help individuals to mediate their reactions to internal emotional conflicts triggered by external stressors. Defense mechanisms are categorized into four levels: pathological, immature, neurotic, and mature defenses. This article examines mature defense mechanisms, which manifest in healthy adults, as well as pathological, neurotic, and immature defense mechanisms, all of which are associated with psychiatric disorders.

Overview of common psychotherapies [1]
Psychotherapy Indications Typical duration Description Techniques
Psychoanalysis
  • 3–5 times per week for years
  • Focuses on creating awareness of repressed feelings and experiences
  • Aims to resolve conflicts in the subconscious
Psychodynamic psychotherapy
  • Once weekly for 6 months to years
  • Focuses on developing insight (e.g., by uncovering past unresolved conflicts, unconscious patterns of interpersonal relationships)
  • Aims to change current behaviors, feelings, and thoughts
Supportive psychotherapy
  • Days to years (open-ended)
  • The weekly frequency is flexible and determined by the severity of symptoms and/or disease and the patient's progress.
  • Focuses on identifying maladaptive behavioral patterns and problematic interpersonal relationships
  • Aims to help the patient improve negative thinking and/or cope with stressors and life challenges
Interpersonal therapy
  • Once weekly for 12–16 weeks [2]
  • Focuses on identifying and analyzing problematic interpersonal relationships
  • Aims to improve communication skills and self-control
  • Medical model
  • Identification of connections between the disease manifestation and life events
Behavioral therapy
  • Brief
  • Focuses on helping the patient to identify, reflect on, and change maladaptive behavior that is triggered by specific stimuli
  • Aims to teach the patient possible alternatives to maladaptive behavior
  • Usually combined with cognitive therapy as cognitive behavioral therapy
Cognitive therapy
Cognitive behavioral therapy (CBT)
  • Usually for approx. 16 weeks
  • Twice weekly for the first 4 weeks
  • Once weekly for the remaining 12 weeks
  • Focuses on changing distorted, harmful, irrational, or ineffective beliefs, attitudes, and behavior patterns
  • Aims to help the patient identify unhelpful and distorted thoughts and behavior patterns
  • A combination of cognitive therapy and behavioral therapy
Dialectical behavioral therapy (DBT)
  • Once weekly for approx. 16 months
  • Focuses on teaching new skills (e.g., relaxation techniques)
  • Aims to change severe unhealthy behavior (typically emotional regulation)
Motivational interviewing
  • Approx. 2–4 sessions

Group therapy

  • Once weekly for months to years
  • Focuses on direct interaction
  • Aims to form a support network for individuals with similar diseases or difficulties
  • Psychoeducation
  • Supportive techniques
  • Cognitive techniques
Family therapy
  • Once weekly for months to years
  • Focuses on identifying family dysfunctions and individual problems that affect the entire family
  • Aims to reduce conflict
  • Psychoeducation
  • Addressing boundaries
  • Cognitive behavioral techniques
Couples therapy
  • Sexual disorders
  • Motivated couples not suffering from a severe mental illness
  • Weeks to years
  • Focuses on improving communication between couples
  • Aims to reduce conflicts
  • Conjoint therapy
  • Concurrent therapy
  • Collaborative therapy
  • Four-way therapy
Schema therapy
  • Long-term treatment: twice weekly for up to three years
  • Focuses on improving the patient's sense of self worth
  • Aims to diffuse harmful potential of maladaptive schemas

Psychoanalysis [3]

  • Indications
  • Duration: 3–5 times per week for years
  • Description
    • Focuses on improving awareness of repressed feelings and experiences
    • Aims to resolve conflicts in the subconscious (e.g., by studying dreams)
    • A strong therapeutic alliance (i.e., the bond between therapist and patient) is important for successful psychoanalysis therapy.
    • Countertransference: a complication in which the therapist projects unconscious feelings onto the patient (e.g., the therapist sees the patient as a sibling)
  • Techniques
    • Transference: The patient projects unconscious feelings about significant persons in their childhood onto the therapist (e.g., the therapist is treated as a parental figure). The therapist can gain insight into personal conflicts by interpreting these feelings.
    • Free association: The patient describes all thoughts that spontaneously occur during the therapy session.
    • Dream interpretation: identifying representations of the patient's urges and fears in their dreams to gain insight into subconscious conflicts

Psychodynamic psychotherapy [6]

  • Indications
  • Duration: once weekly for 6 months to years
  • Description
    • Similar to psychoanalysis but with less of an emphasis on dream analysis
    • Focuses on developing insight into and changing current behaviors, feelings, and thoughts by analyzing past experiences
    • Aims to gain insight into unconscious mental processes
    • The therapist aims to remain as neutral as possible, to allow the patient to develop their own interpretations.
  • Techniques
    • Patient education: informing the patient about their condition and about the principles of psychodynamic therapy
    • The therapist takes a very thorough history to identify stressors and core patterns in the patient's behavior.
    • Promoting a strong therapeutic alliance

Supportive psychotherapy [7]

  • Indications
  • Duration
    • Open-ended, from days to years
    • The weekly frequency is flexible and determined by the severity of symptoms and the patient's progress.
  • Description
    • Focuses on identifying maladaptive behavioral patterns and problematic interpersonal relationships
    • Aims to help the patient maintain hope and cope with life challenges
    • Aims to improve the patient's self-esteem, adaptive skills, and behavioral functioning (i.e., performance in social environments)
  • Techniques
    • Promotion of a strong therapeutic by following a patient-centered approach (i.e., expressing interest, empathy, and acceptance)
    • The therapist provides reinforcement, encouragement, and guidance on available resources.
    • Patient counseling (often used as an adjunctive treatment)

Interpersonal therapy [2]

  • Indications
  • Duration: weekly sessions for 12–16 weeks
  • Description
    • Focuses on identifying and analyzing problematic interpersonal relationships (e.g., unresolved grief or conflicts) and/or life situations (e.g., change in jobs, geographical move)
    • Aims to improve communication skills and control over mood and behavior
  • Techniques
    • Medical model: The disease the patient suffers from (e.g., depressive disorder) is a clinical syndrome distinct from the patient's personality and should be explained similarly to other medical conditions (e.g., diabetes).
    • Identifying connections between the disease manifestation and life events (e.g., the connection between the death of a loved one and the development of an eating disorder)

Behavioral therapy

  • Indications
  • Duration: brief (5–20 sessions) [8]
  • Description
    • Focuses on helping the patient to identify, reflect, and change maladaptive behavior that is triggered by specific stimuli (e.g., fear of spiders)
    • Aims to teach the patient possible alternatives to maladaptive behavior
    • Usually combined with cognitive therapy as cognitive behavioral therapy
  • Techniques
    • Conditioning
      • A biologically potent unconditioned stimulus (e.g., the smell of food) leads to a natural, unconditioned response (e.g., salivation).
      • Classical conditioning: designed to produce an involuntary response
        • If the unconditioned stimulus is repeatedly paired with a neutral stimulus (e.g., the sound of a bell), the neutral stimulus can become a conditioned stimulus that leads to the same natural response, which is now a conditioned response (e.g., the sound of a bell leads to salivation).
        • Pavlov's dog experiment is a historical example of classical conditioning.
      • Operant conditioning: designed to produce a voluntary response (see the “Skinner operant conditioning quadrants” table below)
        • Positive reinforcement: The addition of a stimulus in response to a behavior increases the behavior (e.g., an employee begins to work more hours because he gets a salary bonus for doing so).
        • Negative reinforcement: The removal of a stimulus in response to a behavior increases the behavior (e.g., a child improves her grades in order to be excused from doing chores).
        • Positive punishment: The addition of a stimulus in response to a behavior decreases the behavior (e.g., a driver stops parking illegally in response to a fine).
        • Negative punishment: The removal of a stimulus in response to a behavior decreases the behavior (e.g., a child stops acting out because his parents take away his video games when he behaves poorly).
      • Extinction (psychology): the loss (unlearning) of a learned behavior due to discontinuation of a reward (in classical conditioning) or reinforcement (in operant conditioning)
    • Deconditioning
      • Systemic desensitization: increasing the level of exposure to anxiety-provoking stimuli while performing progressive muscle relaxation
      • Flooding: exposing the patient to real stimuli until they achieve complete relaxation in that situation
      • Implosion: exposing the patient to an imaginary anxiety-provoking stimulus until they become more comfortable with it
      • Biofeedback: using information on involuntary physiological processes to help the patient monitor and control their response to stimuli
      • Token economy: reinforcing positive behaviors by providing tangible rewards
      • Aversion therapy: using a nonrewarding stimulus to discourage negative behaviors
Skinner operant conditioning quadrants
Increased behavior Decreased behavior
Addition of a stimulus

Positive reinforcement

Positive punishment

Removal of a stimulus

Negative reinforcement

Negative punishment

Cognitive therapy [1]

  • Indications
  • Duration: brief (5–10 sessions)
  • Description
  • Techniques: relies mainly on thought exercises
    • Guided questioning: directing the patient's behavior and thought process toward a therapeutic goal by asking a series of graded questions
    • Journaling (psychiatry): The patient writes down their thoughts, feelings, and internal experiences to better understand their own ideas and emotions.
      • Self-monitoring by journaling behaviors, thoughts, and feelings (e.g., treatment for an eating disorder includes monitoring food intake by writing down every meal and the emotions/thoughts attached to eating)
      • Enables identification of triggers and problematic chains of behavior (e.g., stress-induced binge eating)
    • Cognitive restructuring: The patient identifies negative automatic thoughts (i.e., dysfunctional/negative view of the self, future, or world) in order to dispute them and eventually replace them with healthy thought processes.

Cognitive behavioral therapy (CBT) [9]

Dialectical behavioral therapy (DBT) [10]

  • Indications
  • Duration: once weekly for approx. 16 weeks
  • Description
    • Focuses on teaching new skills (e.g., relaxation techniques)
    • Aims to reduce unhealthy and self-destructive behavior
  • Techniques
    • Mindfulness: a complex field that revolves around being fully present and aware of one's thoughts, feelings, and actions (e.g., practicing guided breathing, yoga asanas, meditation)
    • Emotional regulation: The patient is taught to become aware of their emotions and to assess them rationally.
    • Distress tolerance: The patient learns to better handle crises and stressful situations.
    • Interpersonal effectiveness: The patient is trained to recognize and assert their needs without coming into conflict with others.

MEDI: Mindfulness, Emotional regulation, Distress tolerance, and Interpersonal effectiveness are techniques of DBT.

Motivational interviewing [11]

DEARS: Determine Discrepancy, Express Empathy, Avoid Arguments, Roll with Resistance, and Support Self-efficacy are techniques of motivational interviewing.

OARS: Open-ended questions, Affirmation, Reflections, and Summaries are communication skills for motivational interviewing.

Group therapy

  • Indications
  • Duration: once weekly for months to years
  • Description
    • Aims to form a support network for individuals with similar diseases or difficulties
    • Allows direct interaction between therapists and patients, and direct interaction between patients
    • Certain groups can be peer-lead and do not need to have a therapist present (e.g., Alcoholics Anonymous).
  • Techniques: one or more therapists help the group to solve emotional difficulties using various techniques

Family therapy [12][13]

  • Indications
  • Duration: once weekly for months to years
  • Description
    • Focuses on identifying family dysfunctions and individual problems that affect the entire family
    • Aims to reduce conflict, improve communication skills, and help family members accommodate one another
    • Emphasizes family strengths to overcome identified dysfunctions
  • Techniques
    • Psychoeducation
      • Educating family members about a disease that affects a family member (e.g., eating disorder, schizophrenia, depression)
      • Introduce techniques that family members can use to cope with the problem.
    • Addressing boundaries that are too permeable (e.g., allowing a child to smoke cigarettes) or too rigid (e.g., not allowing any social contact outside of the family)
    • CBT techniques (e.g., improving communication skills, cognitive restructuring)

Couples therapy [1]

  • Indications
    • Sexual disorders
    • Motivated couples who are not suffering severe mental illness
  • Duration: once weekly for weeks to years
  • Description: aims to reduce conflicts and improve communication skills between couples
  • Techniques
    • Conjoint therapy: One therapist sees the couple together.
    • Concurrent therapy: Each person is seen separately by the same therapist.
    • Collaborative therapy: Each person is seen by a separate therapist.
    • Four-way therapy: Two therapists see the couple together (especially for sexual disorders).

Schema therapy [14]

Topographic Freudian model [15]

  • Conscious (psychiatry)
    • Current awareness of ongoing thoughts and experiences
    • Secondary process thinking (e.g., logic, reasoning)
  • Preconscious (psychiatry)
    • A level below conscious awareness
    • Repressed memories and/or thoughts of which one is not presently aware but are easily called into conscious awareness
  • Unconscious (psychiatry)
    • Primitive primary process thinking (e.g., sex, aggression)
    • Normally repressed from conscious awareness because of negative associations (e.g., feelings of shame or guilt)
    • Plays a more prominent role in the behavior of adult individuals with mental illness (e.g., psychosis) and in children

Structural Freudian model [16][17]

  • Id (psychiatry): unconscious; source of drive and instinctive impulses (e.g., sex, aggression, illogical)
  • Super-ego (psychiatry)
    • Represents both the consciousness and the idealized self
    • Responsible for rational and reality-oriented thought
  • Ego (psychiatry)

Carl Jung theory [18]

  • Ego (psychiatry)
    • Conscious mind
    • Current awareness of emotions, thoughts, and memories
  • Personal unconscious (psychiatry)
    • Similar to the Freudian unconscious
    • Repressed memories and complexes (an organization of an individual's thoughts, feelings, attitudes, and memories concerning a particular concept)
  • Collective unconscious (psychiatry)
    • Shared with other humans
    • Based on latent memories from the ancestral and evolutionary past, which shape the characteristics of the human species

Jungian Archetypes

Some of the most important archetypes Carl Jung proposed include:

  • Persona (psychiatry): the public presentation of the self; the real self is concealed to adapt to social norms or expectations
  • Anima/animus (psychiatry): the unconscious, countersexual aspect of the biological sex in the human psyche
  • Shadow (psychiatry): repressed and unconscious; source of instinctive, irrational impulses
  • Self (psychiatry): overarching structure of the individual; unification of male and female and of unconscious and conscious

Theory of schema therapy

  • 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 them 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.
  • E.g., childhood trauma can lead to maladaptive schemas that are difficult to access consciously and may be the root cause of a personality disorder.

Overview [19]

  • 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
  • Classification

Pathological defenses [20][21]

Overview of pathological defenses
Mechanism Description Examples

Splitting (psychiatry)

  • An all or nothing view about a subject or person
  • Affected individuals are unable to integrate positive and negative images into a cohesive whole.
  • Can affect both the sense of self and others
  • Can manifest in extreme prejudice/stereotyping
  • Associated with BPD
  • A boy dislikes his mother's best friend, who is a teacher, just because he despises all teachers.
  • A woman is convinced that all student counselors are good people based on their choice of profession alone.
Projection (psychiatry)
  • Attributing one's undesired feelings or thoughts to another person
  • In patients with paranoid personality disorder, may include paranoid delusions, and acting on these perceptions
  • Projection is a form of externalization.
  • Distinct from displacement
    • Projection: The affected individual extends emotions/thoughts about themselves to another person.
    • Displacement: The affected individual shifts emotions/thoughts about one person to a less threatening person or object.
  • Projective identification: When the individual onto whom emotions/thoughts are being projected internalizes these qualities and believes them to be true.
  • A clinician believes that a patient dislikes him when in reality he dislikes the patient.
  • A man fears that his wife is cheating on him while he himself feels attracted to other women.
Denial (psychiatry)
  • An elderly woman refuses to acknowledge a cancer diagnosis by planning a vacation despite imminent chemotherapy appointments.
Distortion (psychiatry)
  • Altered perception of external reality (e.g., hallucinations, wish-fulfilling delusions) to suit inner needs 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 [22]

Overview of immature defenses
Mechanism Description Examples
Acting out (psychiatry)
  • Expressing unacceptable or extreme feelings and thoughts through action
  • Associated with borderline and antisocial personality disorders
  • An employee yells and throws things from his desk in response to the news of being fired from his job.
Regression (psychiatry)
  • Involuntary return to a childlike state or prior maturational stage to avoid the stress evoked at the present level of development
  • Associated with dependent personality disorder
  • Common in individuals who are feeling ill, tired, or uncomfortable (compare with fixation)
  • A previously toilet-trained child begins to wet the bed again after the birth of a new sibling.
  • A child who stopped sucking their thumb begins to do so again after being hospitalized for an upcoming surgery.
Primitive idealization (psychiatry)
  • Imposing more positive qualities on an external object or person than they actually have while ignoring their negative features
  • Common in individuals with personality disorders
  • A woman believes that her new boyfriend is absolutely flawless.
Blocking (psychiatry)
  • Temporarily or transiently inhibited thinking when feeling increased levels of stress
  • Commonly manifests when the affected individual is experiencing embarrassment
  • An individual is unable to answer a question during an 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
  • Common in individuals with anxiety disorders and/or a history of traumatic clinical experiences [23]
  • A woman with mild abdominal cramps claims to be bedridden when nobody calls her on her birthday.
Identification (psychiatry)
  • The unconscious modeling of one's behavior, characteristics, qualities, or traits, whether good or bad, on those of another person
  • May be associated with anxiety disorders
  • A young girl begins to dress more and more like her revered older cousin, without realizing it.
  • A boy who was abused by his father becomes an abusive parent.
Passive aggression (psychiatry)
  • Expressing aggression toward others indirectly in a nonconfrontational way
  • Common in children and individuals with BPD
  • An employee appears to accept critique to their work but later reacts by procrastinating and avoiding work-related messages.
Somatization (psychiatry)
  • A medical student develops headaches during a stressful board exam.
Undoing (psychiatry)
  • Trying to avoid guilt about negative thoughts or actions by engaging in the opposite behavior
  • Common in individuals with OCD
  • After a man thinks about harming another person, he becomes overly accommodating to them.
  • An individual with OCD has frequent and distressing thoughts about germ contamination and washes their hands until they're raw or bleeding.
Fixation (psychiatry)
  • The cessation of development of personality at one of the childhood stages such as oral, anal, or phallic (compare with regression)
  • May be associated with anxiety disorders
  • An individual fixated at the oral stage of development bites their nails, chews on a pen, or sucks their thumb in response to a stressful situation.
Fantasy (psychiatry)
  • Withdrawal into fantasy to resolve inner and/or outer conflicts
  • May be associated with stressful situations and personal crises
  • An elderly man in a wheelchair repeatedly suggests to his grandson that they race one another on foot.

Neurotic defenses [24]

Overview of neurotic defenses
Mechanism Description Examples
Controlling (psychiatry)
  • Excessively attempting to manage or regulate the environment (i.e., objects or people) to minimize anxiety
  • May be associated with OCD or anxiety disorders
  • A mother does not let her child attend a friend's birthday party unless she can influence who else will attend it.
Displacement (psychiatry)
  • Shifting an emotion to a less threatening or neutral object or person
  • Distinct from projection
    • Projection: The affected individual extends emotions/thoughts about themselves to another person.
    • Displacement: The affected individual shifts emotions/thoughts about one person to a less threatening person or object.
  • Common response to acute anxiety
  • A man punches a wall after an argument with a colleague rather than confronting them.
  • A mother demonstrates feelings of anger towards her child instead of her husband, who is the actual source of her frustration.
Intellectualization (psychiatry)
  • Using abstract, rational, and/or logical reasoning to avoid affective expression and distance oneself from stress
  • Common response to emotional stress
  • A woman reacts to the diagnosis of a terminal illness with excessive investigation into the pathophysiology of and treatment modalities for the disease.
Isolation of affect (psychiatry)
  • Separating or repressing an idea from the associated effect or idea
  • Accepting reality without the accompanying emotional response
  • Common response to emotional stress or a traumatic event
Rationalization (psychiatry)
  • Offering excuses or feasible explanations in an attempt to justify behaviors, attitudes, or beliefs to avoid self-blame
  • Common in OCD
  • A student claims that she failed a grade because all her teachers dislike her, instead of admitting that she has not studied all year.
Reaction formation (psychiatry)
  • Complete denial and/or rejection of an unacceptable impulse by acting in a diametrically opposite manner to avoid anxiety-provoking thoughts
  • Associated with anxiety disorders (compare with sublimation)
  • A homosexual individual is highly critical of same-sex couples.
Repression (psychiatry)
  • Thoughts are unconsciously removed from conscious awareness.
  • Certain facts that were known and accepted at some point in life become absent from memory (compare with suppression).
  • An adult suffers a drowning experience as a child and develops an intense fear of swimming later in life, with no memory of the childhood experience.
Externalization (psychiatry)
  • Perceiving one's own personality in the external world and in external elements (including instinctual impulses, conflicts, moods, attitudes, and styles of thinking)
  • Blaming others for the way one treats themself
  • May be associated with ADHD or substance use disorders
  • A man perceives his partner as aggressive and himself as peaceful, although he is the aggressor.
  • A mother blames her son for preventing her from having friendships, although she chooses to spend all her time with her son.
Dissociation (psychiatry)
  • Temporarily modifying personal identity, memory, consciousness, or motor activity in an extreme manner to avoid emotional distress
  • The affected individual usually has partial/no recollection of the traumatic incident.
  • See “Dissociative disorders.”
  • An individual who was abused as a child feels detached from their own body when they come into contact with their abuser.
Sexualization (psychiatry)
  • Endowing an object, person, or function with sexual significance
  • Sexualization of a person is usually linked to sexual objectification of that individual.
  • A woman evaluates her partner 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
  • May be associated with anxiety disorders
  • A parent is unable to discipline a disobedient child out of fear of making them angry.

Mature defenses [25]

Overview of mature defenses
Mechanism Description Examples
Sublimation (psychiatry)
  • Shifting focus of unacceptable or unattainable impulses toward goal-directed activities
  • Typically directing impulses in a more socially acceptable direction (compare with reaction formation)
  • An athlete uses their feeling of anger to motivate their training for a marathon.
Altruism (psychiatry)
  • Serving others constructively to experience a personal vicarious experience and to cope with difficult stressors
  • Resolving guilty feelings by meeting the needs of others (compare with reaction formation)
  • A rich woman gives a homeless man her lunch.
Suppression (psychiatry)
  • Consciously postponing attention to an anxiety-provoking thought
  • A temporary reaction that is easily recalled with the right stimulus (compare with repression)
  • A resident suppresses her fear of blood during surgery to provide necessary patient care.
Humor (psychiatry)
  • Using comedy to express feelings and thoughts to lessen personal discomfort and avoid emotional distress without producing an unpleasant effect on others
  • A new employee expresses a serious situation in the form of a joke.
Anticipation (psychiatry)
  • Realistic planning or premature worrying about future discomforts
  • Associated with goal-directed behavior
  • An A-student goes over course notes in preparation for a lecture the following morning.

SASHA is a mature adult”: Sublimation, Altruism, Suppression, Humor, Anticipation are mature defenses.

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