Working with defences in therapy
Patients usually come for therapy wanting help in understanding a certain pattern of behaviour or why they feel so intensely about something that has happened to them. In relating their predominant narrative, we listen for the manifest content, that is, the factual story and sequence of events of who did what to whom, yet as we have seen, there is usually another, latent level of meaning with unconscious dynamics at play (see also Chapter 8 on unconscious communications). A key competence in psychodynamic work is the ability to recognise and work with defences. When we encounter problematic behaviour, we need to uncover the underlying conflict and how the patient makes use of different defence mechanisms in an attempt to cope with it by keeping the conflict outside of conscious awareness, as far as possible. However, these attempts are not wholly successful. Freud (1914a) posited a dynamic unconscious in which repressed contents return to conscious awareness. The material the patient is attempting to repress, threatens to erupt into consciousness, usually in a disguised form, such as a physical symptom, feeling, dream, slip of the tongue or other manifestation of latent content.
Houi to interpret the patient’s use of defences
Malan (2001), building on Menninger’s (1958) work, has usefully conceptualised a heuristic for working with defences and anxiety in psychotherapy, namely the ‘triangle of conflict’ as shown in Figure 6.2. The triangle represents the relationship between the three core elements involved in working with defences: defence, anxiety and the underlying hidden feeling. The triangle is placed upside down on its apex to indicate that there is an underlying element to the other two sides of the triangle, in this case the concealed or repressed affect. Malan linked this triangle with a second triangle, the triangle of person, reflecting the transference dynamics between the therapist, other current or recent relationships, and the parent or
Figure 6.2 Adapted from Malan’s triangle of conflict Source: Malan, 2001, p. 90
sibling. It can be considered that the tasks of the psychodynamic therapist are summarised within these two heuristics. We will discuss further the relationship between the triangle of person and the triangle of conflict in Chapter 9.
When making interpretations about the patient’s anxiety and defence, it is advisable for the therapist to work from left to right, starting with naming and observing the defence before moving on to linking it to the expressed anxiety. Only once this has been understood, can we move towards making links with the hidden feeling. By then, the patient has become more conscious of their behaviour and we have a foundation on which to begin to hypothesise about the less apparent, repressed feelings.
By way of example, let us return to Zara, whose history and psychodynamic formulation we introduced in Chapter 5. One of her defences was her tendency to minimise her distress and be superficially cheerful and helpful to others, even if at her own expense. The therapist may make an observation such as, “I noticed that you just made light of something, feeling it is indulgent to complain”, thus observing the defence of reaction formation. The therapist can then link the defence to Zara’s anxiety by saying, for example, “I can see that this is a way you try to protect yourself from the painful realities”. This allows space to explore further those painful realities and the feared responses. The therapist can then go on to link this to the hidden feeling, by adding, “You fear being a burden to others, and so minimise your distress, but this takes you away from knowing about the needy part of you who wants to be close to others, but fears abandonment”.
It is important to stress that the therapist can only proceed to explore these hidden feelings when the patient indicates their willingness to engage at this level. So, while this example proceeds from defence to anxiety to hidden feeling, this series of interpretations may take place over a series of sessions, depending on the individual dynamics of the patient. Malan (2001) describes how the therapist needs to be engaged in an internal reflective process when considering when and how to make an interpretation with a patient. He reminds us that an interpretation is not a mechanical technique that can be learnt as a formula; rather it is “essentially intuitive and subconscious” (p. 84). The therapist has to reflect on what is communicated in the room verbally and non-verbally, as well as their theoretical knowledge and understanding, together with self-awareness of their own mental states in order to offer an interpretation to the patient. This involves reflective engagement with the following aspects of the session (Malan, 2001, p. 84):
- • The depth of rapport between the patient and therapist and the extent to which the patient seems in touch with their feelings
- • The possible nature of the hidden feeling or impulse
- • How accessible these feelings may be (i.e. are they bubbling just below the surface?)
- • The intensity of anxiety or emotional pain that is invested in them, and
- • Whether the patient may be able to bear hearing it at that moment in time.
The therapist may need to sit with a period of not knowing before moving to interpret. Some gradual exploration is needed, with the therapist learning from the feedback that the patient gives them. This may be observable through changes in the depth of rapport or further emotional engagement of the patient. If a tentative interpretation is well-received, it usually leads to a deepening of rapport and this indicates that the therapist may well be on the right track. We pay careful attention to the direction of the patient’s response to the interpretation to sense whether what we have said has facilitated the patient’s ability to explore further and gain additional insight themselves. If on the other hand, rapport falls off, this may indicate that the therapist may be on the wrong track, or they maybe intervening with an interpretation too soon. Interpretations can’t be rushed or forced because they will create the opposite effect, resulting in an even more defended patient and reducing epistemic trust.