The Beginning of Wisdom Is Never Calling a Patient a Borderline; or, The Clinical Management of Immature Defenses in the Treatment of individuals with Personality Disorders

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George E. Vaillant. Journal of Psychotherapy Practice and Research. Vol 1 (2) 1992.

George Eman Vaillant is an American Psychiatrist, who has made significant contribution to the profession through his patient work in charting the adult development and longitudinal process of recovery from addiction and other psychiatric disorders. Through his extensive research work, and being the director of the Study of Adult Development for over 30 years, which has prospectively charted the lives of 724 people or over 60 years, in this seminal paper he offers a perspective to understand and respond to one of the common challenges in psychiatry – how not to react when you get provoked, dismissed, or made to feel helpless by the patient who came to seek help from you. This paper offers strategies to manage seven key defense mechanisms in working with people with disordered personality – splitting, schizoid fantasy, hypochondriasis, projection, turning against oneself, acting out, and neurotic denial.

“However maladaptive their defences may be in the eyes of the beholder, they represent homeostatic solutions to the inner problems to the user.”

The paper differentiates between the common immature defences observed in personality disorders and the neurotic defences (repression, isolation, reaction formation, displacement) commonly employed by higher functioning people. The latter cause misery for the sufferer and can be helped by accurate interpretations in therapy, whilst the former causes suffering for others and feels like an attack for the bearer when interpreted. Immature defences in personality disorders are rooted in the scripts, role-relationship models, and internalized object relations rather than conflict between forbidden id impulses and the ego. In other words, immature defences are commonly employed as a defense against objects rather than defense against intrapsychic conflcits.

Valliant offers three broad principles to enable a therapeutic environment where the immature defences can be replaced by more neurotic defences:
– Stablizing the external environment, which relates to both the social milieu and the relational environment with the psychiatrist who offers a empathic good enough mirroring or self object function for the patient, thus reducing the need to employ immature defences;
– Altering internal environment that may be afflicted by alcohol, mood disorder, or grief;
– and lastly, controlling one’s countertransference, which could be a reaction to the projections and may manifest in use of psychopharmacology, mothering, limit-setting, or interpretations.

“It is often in an effort to preserve an illusion of interpersonal constancy that individuals with personality disorders unconsciously deploy immature defences. These image-distorting defences permit ambivalent mental representations of other people to be conveniently “split”(into good and bad) or moved about and reapportioned.”

“Always, empathy toward immature defences rather than countertransference is essential in creating a holding environment within the consulting room.”

Splitting – in hospital setting, it can be addressed by anticipating the process, discussing it at staff meetings as an intellectually interesting topic. In therapy, a conducive environment should be provided for the patient to experience both the positive and negative aspects of important relationships, and respond by unconditional positive regard, safety, and firmness, all simultaneously. It can evolve into undoing and humour.

Fantasy – it can be better understood as a fear of intimacy, which needs a quiet, reassuring manner, an interest without requiring a reciprocal response, recognition of their fear of closeness, and respect for their eccentricity. It can gradually evolve in revelation of rich fantasies and struggle between the fear of clinging and fleeing from the therapist.

Hypochondriasis – the presentation conceals bereavement, loneliness, or unacceptable aggressive impulses, which can be managed by acknowledgement of the pain or insoluble dilemma as the most severe of its kind, some symbolic effort to meet the overall need for dependency, a carefully documented psychosocial history, acknowledgement and validation of past trauma, and use the metaphorical meaning of the symptoms by connecting it with the affect.

Projection – Usually a grain a truth in most projections. Practice frank acknowledgement of even minor mistakes or likely future difficulties, honesty, regard for patient’s rights, a concerned distance, and respectfully agree to disagree. One can also use the counterprojection, by acknowledging and validation patient’s perspective from the world they inhabit, avoiding eye contact and confrontation, instead looking out through the same window as the patient, and making statements that capture patient’s distress – ‘that damned chair … damn psychiatrists … damn control’ – and help the psychiatrist get out of the patient’s way without necessarily agreeing with the patient – ‘it must seem that the psychiatrists just want to analyse you all the time’. Use precise speech with paranoid patients, making a statement rather than questions – “I expect you are a Gemini”. Interpretation of feelings generate distrust, whilst wait would help the patient gradually reveal their concerns. In time it can mature into displacement and reaction formation.

Acting Out – acting of the unconscious wish or conflict to avoid conscious awareness of the idea or the accompanying affect. It must be controlled as rapidly as possible because it is frightening for the patient and the staff alike. Anything that a psychiatrist may say would be misunderstood, and the underlying conflict can only be accessed after the control. It can be replaced with more mature defence mechanism by redirecting the patient towards an affectively exciting alternative. Peer support groups can be helpful in providing the behaviours a human understanding.

“Cleckley is wrong. Acting out is no mere “mask of insanity,” but it is often a mask to grief.”

Turning against the self – consider it as an expression of covert anger rather than covert grief. Help the patient ventilate their anger and to direct their assertiveness outside rather than against the self, whilst accepting the behaviour as matter-of-fact and point out the probable consequences of passive-aggressive behaviour – ‘what do you really want for yourself?” It can be channelled into displacement and humor. Use behavioural strategies like assertiveness training, limit setting, time out when escalation of passive-aggressive struggles, and offer recovery as a special additional task.

“… it is important to avoid humiliating comments about foolish, inexplicable behaviour. Nobody’s pride is easier to wound that that of a person who continually shoots themselves in the foot.”

Dissociation/Neurotic denial – patient replaces unpleasant affects with pleasant ones; troubling affects, impulses, and wishes are disavowed and actively pushed out of consciousness, and they feel accused and devalued if anyone points out their troubles. Be calm and firm; reframe vulnerabilities as opportunities or potential strengths, use displacement and talk with the patient about the same affective issue but in a less threatening context, thus empathizing with the denied affect, without confronting with the facts.

“Paradoxical contempt and envy induced by perceiving one’s therapist as lovable can only be transformed into gratitude by sustained Rogerian unconditional positive regard and by Kohutian mirroring.”

– Each dyad must have a common language to mutually understand reconstruction of the patient’s inner life and internalized relationships.
– Rather than interpretation, immature defences respond better with an empathic Socratic enquiry, helping the patient think through the consequences of their actual or intended actions
– Facilitate patient find support peer-groups which can provide an external holding environment
– Support patients to provide rather than only receive.

“… therapists need to reframe the Axis II labels so that paranoid becomes “hypervigilant”, narcissistic becomes “in pain”, hysterical becomes “captivating”, masochistic becomes “long-suffering, schizoid becomes “independent”, and borderline becomes “post-traumatic stress disorder” – or “that patient who sure knows how to push my buttons.”

PS: You can access the full paper at

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3330289/pdf/117.pdf

Compliment this paper by:
Care Eliciting Behaviour in Man – Henderson 1974
– A case-Study in the functioning of social systems as a defense against anxiety – Isabel Menzies 1960
Personality types in Medical Management – Kahana and Bibring 1956
– Malignant Alienation: Dangers for Patients Who Are Hard To Like – Watts and Morgan 1994
– Malignant Alienation – Whittle 1997
– Management of difficult personality disorder patients – Norton 1996
– The Ailment – Main 1957
Taking Care of the Hateful Patient – Groves 1978