If there is no tolerance for the conscious experience of anxiety the next stage involves identifying the strategy used by the patient to circumvent the associated psychic pain, that is, we need to identify the type of defences used. This will involve assessing whether the defences are ego-syntonic or ego-dystonic. If they are ego-syntonic, they will be harder to relinquish as the therapist will be experienced as the one disturbing or attacking an internal psychic balance, however precarious. If the defence is itself ego-dystonic, it is experienced as aversive or problematic by the patient who is often internally motivated to be relieved not only of his problem but also of the defensive solution. For example, some obsessional defences (e.g. extensive rituals) can be experienced as ego-dystonic as they severely restrict the patient in their day-to-day life and thus motivate the patient to seek help.
As we approach defences we aim to establish in our formulations whether the defences are directed internally against the awareness of threatening thoughts and feelings or externally against intimacy with others. Often they serve both functions. We remain mindful that defences exist for a good reason and hence we approach them sensitively, with due respect for the patient's need to protect himself. For example, when working with patients who dismiss attachments and detach themselves from inner experience, it will be important to understand their disavowal of emotion not just as a resistance, but also as a vital protective device. For such patients, intimacy is felt to be dangerous and the self-organisation often revolves around not expressing emotions.
In psychotherapy we explore defences as they manifest themselves in the patient's free associations, also paying attention to the way we can be woven into the patient's worries. Not uncommonly, we are experienced as the person attacking the defensive structure and we pose a threat to the patient's attempts to institute defences to protect himself.
Lisa was in her early thirties, a successful professional woman who came into therapy because of an inability to establish an intimate relationship. She related a painful early history of being ''passed around'' professional carers as her parents travelled extensively. As she was growing up she had experienced her parents as very demanding of her. She had achieved academically and was the perfect hostess, yet she found intimate relationships, especially with men, very difficult. She had only managed to sustain one sexual relationship whilst at university but since then she had remained single.
Lisa approached therapy dutifully and with precision. She was exactly on time and even a few minutes' lateness would give rise to self-reproach. She was keen to ''do it right'' and in so doing she constrained the therapeutic space. I soon became aware of ''no-go'' areas, especially in relation to her sexuality. She told me that she was wary of psychoanalysis because it was ''obsessed with sex'' and that whilst she recognised that she had some difficulties in ''that area'', she maintained that her concerns were not sexual ones. She had, however, intimated a strong attraction towards a female colleague but had quickly moved away from that as the idea of homosexuality repulsed her. She also skirted around the issue of her weight, tentatively suggesting she could do with losing a few pounds but assuring me that she was not bothered by her weight even though she was in fact quite overweight.
In one particular session, Lisa spontaneously brought up the question of dieting. Her mother had suggested that she should go to a health farm. Lisa had felt incensed by this suggestion feeling that her mother had bought into the ''whole feminine trap''. I commented that perhaps Lisa also worried about her weight but that she feared raising it in her own mind and in the session as it might open the proverbial ''can of worms'' that would lead us to think about her sexuality, something she wanted to avoid doing. Lisa, who was otherwise usually restrained in her manner, responded angrily towards me. She felt that weight and sexuality were my agenda. She said that I had let her down and that I was now imposing what I thought she should be working on. I could feel Lisa's pain behind her anger. I tried to approach this by acknowledging that my words had felt like a puncture and had left her feeling raw and exposed. Lisa' denial of any problem with her sexuality was a way of protecting herself from the anxiety her own sexual impulses elicited. My interpretation set me up in her mind as the enemy invading a very private space that she was afraid to explore and that she did not want to think about.
In some cases we may have a sense of how the patient is defending himself but be less sure as to what he is defending himself against. In these situations it may be prudent to take up the defence before that which is being defended against. For example, if the patient suppresses tears in a session, we begin by noting this before moving on to wondering about why he may need to do this. This is what is referred to as interpreting from surface to depth or from ego to id (Greenson, 1967). Generally speaking, this approach is very helpful as it gradually paves the way for the patient to explore defences and their function in his psychic economy.
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