Psychiatric Times 
October 2005
Vol. XXII
Issue 12
Psychotherapy has an interesting 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 they have a lump and agrees to have the surgeon remove it. With a psychological problem, however, patients may recognize that they have some problem, but they often do not see it as a result of their own life strategies (defenses or personality styles), and in trying to protect themselves with these defenses, patients may actually sabotage their own therapy.
Even if they do have some insight into their maladaptive use of defenses, patients often show resistance to changing their life strategies. They would prefer that things go smoother in the world using the same life strategies they have been using up to now. In fact, patients 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 trying to convince the surgeon why it is better to live with the lump?
This is where the unconscious nature of defenses, and the resistance to changing one's defenses, comes into play. Resistance is often unconscious in patients as they may provide many rationalizations on why their maladaptive life strategies are valid. This resistance may occur 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.
These maladaptive life strategies have been used by the patient both in past and present relationships, so it is no surprise that these personality styles will also manifest in the relationship with their 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 use new and more adaptive life strategies. The therapist attempts to remain neutral in attitude and does not disclose personal material to the patient. In this way therapists try to keep their countertransference issues out of the session. Thus, the therapist and patient can 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 dissatisfaction in the therapy, the defenses themselves can sabotage the help the patient needs to fix their defenses.
Concrete Examples
The terminator. These patients use 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. They set up relationships to relive patterns of rejecting others. They find faults with others, often not getting into or terminating intimate relationships early on and complain that they cannot find the right partner. They tend to engage in relationships that clearly have problems from the start, thus planting the seeds for their next termination. They may report conflict and terminations with prior therapists. They often make detailed rationalizations about why their relationships do not go well.
