Tuesday, April 24, 2007


I frequently use psychiatric and psychological concepts to describe behavior in this blog, and because of that, many people accuse me of labeling anyone who disagrees with me politically as having a mental illness.

This is not true; and it suggests that most of these critics know little about psychiatry, psychiatric diagnoses, or psychological defenses.

While I do believe that some of the people I describe might indeed have a mental illness; and that some are, in fact, perfectly healthy but simply malevolent or evil; it is simply not the case that by exposing certain psychological defense mechanisms that explain their behavior, I am giving the political opposition a medical/psychiatric diagnosis. Nevertheless, if a particular diagnosis fits, I am perfectly content to let them wear it.

In discussing psychological defense mechanisms, what I am trying to do is understand how and why people behave in the way that they do. Describing psychological defenses is not the same thing as "making a diagnosis" for one very simple reason. All humans utilize psychological defenses, all the time. Both Democrat and Republican; Left and Right. Good and Bad.

Psychological defenses are involuntary, regulatory coping processes.

By themselves, defenses are not evidence of "illness". When used, they may appear to be "sick," evil, or even irrational, but basically, they reflect a creative adaptation to the world.

George Vaillant, a brilliant researcher in this area, and a Professor of Psychiatry at Harvard, uses the analogy that defenses mechanisms are deployed in a fashion similar to physical symptoms-- such as a fever, cough or elevated white blood cell count. All of the latter physical symptoms occur when an individual is coming down with an illness.

Vaillant points out that the body reacts to the environment with these physiological responses in order to prevent or ameliorate the attacking illness. Without these normal physiological responses, we would be at the mercy of many illness and die.

In similar fashion, the psychological defenses are employed by the ego to respond to a threatening reality. With varying levels of success, our defense mechanisms ameliorate, distort and/or transform reality in order to protect our psychological self. The healthier and more mature defenses are a remarkably creative synthesis of our conflicts, needs and external reality; a synthesis that enable us to both give and receive pleasure in life.

Some defenses may be considered "immature" or even completely out of touch with reality; while others are "mature". This is not necessarily a value judgement, since it only reflects the fact that throughout development from childhood to adulthood; certain psychological strategies are generally discarded in favor of healthier and more effective strategies. The difference between the two types--mature and immature--is that the psychotic and immature defenses may cause considerable human misery and are, in the long run, not particularly adaptive or healthy. In some cases, they can even distort or warp reality to such an extent, that the person using the defense puts his life (and possibly others lives) at stake.

This is a very high price to pay to avoid a reality that is unpleasant or unacceptable.

Thus, when I see the predominance of "immature" strategies (e.g. projection, fantasy, acting out)--and/or some of the more primitive and potentially psychotic strategies (denial, distortion, paranoia)--being used by supposedly grownup adults, I begin to look around for explanations of their conduct that are not being acknowledged.

When I observe such strategies being used by large groups or even nations, I cringe; because the liklihood of a large number of deaths and considerable human misery is an almost inevitable outcome.

The careful observation and analysis of behavior is what I do for a living. I am very good at it; and I enjoy my profession. By helping people become aware of what they are doing that wreaks so much havoc in their life, I help them to change their behavior and therefore their lives. By pointing out and helping them to understand some of the unconscious motivations and conflicts they have, I help them to understand the psychological defenses they have employed which may be getting in the way of their pursuit of happiness.

By making the unconscious conscious, they begin to understand why they are behaving irrationally and why they have problems in their life. The goal is to get them to abandon those defenses that are distorting reality and holding them back; and to develop a new synthesis so that even their conflicts are put to a positive and productive use in their life.

Of course, the old joke about "how many psychiatrists does it take to change a lightbulb" is appropriate here: "just one....but the lightbulb really has to want to change." Many people are very pleased not to have to change and conform to reality. They will maintain their dysfunctional defenses no matter what the cost. Self reflection and insight are too dangerous for such people, and death is preferable to altering their beliefs or fantasies about the real world. Clearly, their distress about the possibility of changing themselves or their beliefs is far greater than any potential consequences they might experience by using an immature, unhealthy and dysfunctional psychological defense to avoid reality.

But the people who come to see me are generally in considerable distress from their symptoms and want to change (of course, that doesn't mean they will do so easily, unfortunately). When there is a physiological/biological component to this type of dysfunction, I may from time to time, prescribe medication so that their nervous system can optimally cope with the real world. This levels the playing field, so to speak; but even when medication is prescribed, only by looking at all the factors that come into play in an individual life--Biological, psychological, and social--am I able to help individuals change the course of their life. It is rarely only a "chemical imbalance" (although sometimes it is). The example I use with my medical students is the following:

A woman who comes to see me is profoundly depressed and suicidal because her husband beats her and her marriage is hell. She meets all the diagnostic criteria for a major depressive disorder, and it is clear that the prescription of an antidepressant might be very helpful. In fact, that is what the woman wants.

However, even if I prescribe the medication, I must gently point out to her that no amount of medication for her is going to change her husband's behavior. Only by changing her own behavior can she change things in her marriage-- e.g., she can leave him; she can demand that he get help; she can suggest conjoint counseling--whatever. Or, she can accept that he will continue to behave a certain way (beating her) and accept that. But the medicine will not magically make any of these things happen. All it will do is give her the physiological strength to cope better. She can accept this reality. Or, she might use denial and continue to believe that medication for her will change her husband's behavior. She might use fantasy to pretend that when her "illness" is cured, her husband will realize what a wonderful person she is and stop beating her up; she might use hypochondriasis, developing migraine headaches or other more serious symptoms that keep her away from her husband; she could be passive-aggressive, buying her spouse his favorite alcoholic drink that is the frequent disinhibitor that leads to him hitting her; she might use displacement and blame her husband's employer --who doesn't appreciate him--for her husband's aggressive behavior toward herself.

If she listens to what I am telling her, she might use anticipation and begin to plan to leave the situation at home an go someplace else. She might then find she has a knack for helping women who have abusive husbands and train to be a counselor (altruism); or find that she has acting ability and play the lead in a local production of "Cat on A Hot Tin Roof" (sublimation).

In fact she could use ANY of the many psychological defenses to help her cope with her problem.
Psychological defense mechanisms give people the psychological strength to cope with the vissictitudes of an ever-changing and often unpredictable reality. Some defenses are more useful than others for that purpose and one of the goals of mature adult functioning is to abandon the immature and problematic strategies that can only ultimately make things worse and which provide little pleasure in their life.

Probably the best description of defenses that I have ever read comes from George Vaillant, in his book The Wisdon of the Ego: (pg. 17 - 18)

1. Defenses reflect creative synthesis. The mind creates a perception that was not there before and that did not come just from external reality. In this regard, defensive behavior resembles art.
2. Defenses are relatively unconscious and their deployment is relatively involuntary.
3. Defenses distort inner and/or outer reality.
4. Defenses distort the relationship between affect and idea and between subject and object.
5. Defenses are more often healthy than pathological.
6. Defenses often appear odd or startling to everyone but the user.
7. Over time defenses often mature and allow the mentally "ill" to evolve into the mentally well.

Let me offer a concrete illustration of a defense--a photograph of a rainbow, if you will, obtained through my metaphorical telescope, the Study of Adult Development. I was interviewing an internist who had participated in the study for thirty years. He told me with vividness and enthusiasm, about his hobby: growing tissue cultures in his basement. He then told me with still more enthusiasm that the cells for one of these tissue cultures had been taken from a lesion on his mother's leg. He described his interest in tissue cultures as if it were the most ordinary pursuit in the world. But I have yet to describe his hobby to an audience without an uneasy ripple of laughter sweeping the room. Audiences have found the fact that this doctor was growing his mother's cells in his basement, as a child might raise flowers, extraordinary, even pathological. In short, the doctor saw his own behavior as normal; outsiders saw it as odd and, as we so often view other people's religion, politics, and dreams, possibly improper. Thus their laughter.

But anyone can have an unusual hobby. What mad this internist's avocation particularly noteworthy was that near the end of the interview he revealed to me--in the most matter of fact way--that his mother had died only three weeks earlier. Knowing that he had been very fond of her, I asked him how he had coped with her death. He said that, since he was a physician, he had spent his time comforting his father. On a conscious level, this man had rationalized --and he was good at rationalizing--that he had borne the grief o flosing his mother by caring for another person. Put differently, by his self-report he had used altruism as a coping strategy. Had I been interested only in conscious coping strategies, I too might have classified his means of mastering his mother's death as altruism. Instead, Ilocated his source of solace by makinig a connection of which he himself was probably unaware. I deduced that the knowledge that somehow his mother was still alive and living in his basement might be providing a secret source of comfort. Certainly he had described his scientific hobby to me with an enthusiasm and a warmth usually allotted to people and to art. Certainly, he had described the loss of his mother by death with the blandness usually allotted to leaves dropping off a tree in autumn--or to tissue cultures.

In short, defenses are creative, healthy, comforting, coping, and yet often strike observers as downright peculiar. But that is why defenses--like immune mechanisms--serve adaptation. That is why defenses integrate experience by providing a variety of filters for pain and mechanisms for self-deception. Defenses creatively rearrange
the sources of conflict so that they become manageable.

We may not be able to help which defenses our egos deploy in every situation. Sometimes, when reality is threatening enough or our conflicts are intense enough, even the most mature individual may find him or herself using the more immature defenses like denial and projection. What matters is that we make a practice of examining our own behavior and appreciating the underlying issues and motivations that drive it. Or to put it another way, we reflect on those subtle factors that may be controlling our behavior outside our completely conscious awareness (and therefore our control) and make them fully conscious. This is called developing insight and self-awareness. It is probably the equivalent of the "holy grail" in psychiatric practice, and we psychiatrists are forever encouraging our patients to go on such quests of self-discovery.

By making the unconscious conscious, we gain control over our lives and are able to make choices and attack problems based on a clear view of reality. Yes, we may make the wrong choice, or screw up in dealing with the problem even so; we may even discover some unpleasant truths about ourself. But when our psychological defenses are distorting or obscuring reality to begin with, we are far more likely to ignore a problem or pretend that it doesn't exist and then suffer even more serious consequences.

Maladaptive psychological defenses that bring ourselves and others a great deal of unhappiness and misery, can evolve into mature and adaptive responses to the world that both enhance and protect our lives. Human beings are remarkable creatures. Sometimes their capacity for self-deception and delusion seems unlimited; and sometimes their incredible creativity and ingenuity in coping with all the trials and travails that life throws at them is worthy of appreciation and even awe.

Other posts that are relevant:
Psychological Defense Mechanisms--A Review

Strategies for Dealing with Denial-I
Strategies for Dealing with Denial-II
Strategies for Dealing with Denial-III

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