Perhaps the greatest problem faced by the academic social sciences is that what is measurable is often irrelevant, and what is truly relevant often cannot be measured.
The author is George Vaillant writing an editorial in the September American Journal of Psychiatry. During the late 60s, Dr Vaillant took over “the Grant Study,” which had been tracking 268 Harvard males for more than two decades. Dr Vaillant continued to follow this cohort for another four decades. Of special interest to Dr Vaillant was how these men adapted to life’s challenges as they grew older.
Adaptation is accomplished through the use of defense mechanisms, which in 1977 Dr Vaillant arranged into a hierarchy - from pathological to immature to neurotic (don’t be fooled by the term, even healthy individuals are full of neurotic tendencies) to altruistic.
If this sounds Freudian to you, Dr Vaillant pleads guilty as charged. In his editorial, Dr Vaillant informs us that the concept of defense mechanisms was the very first thing that Freud came up with back in 1894, when he branched out from the hard science of neurology into the indubitably softer one of psychiatry. Freud wrote a number of seminal papers before turning to other stuff, then in 1926 - with his daughter Anna - returned to the topic with a vengeance. In a nutshell: Defenses are a means of managing conflict and affect. It is mostly unconscious and we all engage in it. Defenses can be reversed, and they can be adaptive as well as pathological.
The DSM I of 1952 and the DSM II of 1968 were strongly derivative of Freud’s defenses, where psychiatric symptoms were seen as maladaptive responses to one’s environment. The DSM I went so far as to view hard-core psychiatric illnesses as “reactions,” as in “manic-depressive reaction,” “schizophrenic reaction,” and “depressive reaction.”
In other words, even psychosis could be seen as a pathological defense mechanism. Bullcrap, said a new generation of psychiatrists in effect. We have a pill for that.
How about anxiety, then? Psychiatry also has a pill for that. And yes, we also have the brain science pointing to an over-reactive amygdala, which drives fight or flight. But don’t we also have a tendency to bring on our own anxiety? Indeed, Anna Freud wrote a lot about that. And isn’t cognitive therapy based on the principle that we can use our mind to change our anxious and depressive thoughts? To, in effect, improve the quality of our defenses?
In his editorial, Dr Vaillant reveals that Robert Spitzer, in laying the groundwork for the “modern” DSM-III that would be published in 1980, called together a group of psychoanalysts (Vaillant included) to see if there was a way of folding defenses into the new diagnostic schema. As Dr Vaillant reports:
After several hours, it was clear that we were unable to reach consensus on a list of the important defenses or to agree on their definition or their significance for psychopathology.
According to Dr Vaillant, “the world of defenses resembled the Tower of Babel.”
In the Grant study, Dr Vaillant was able to demonstrate that as the Harvard men grew older, they increasingly favored mature defenses over immature ones. In other words, they were more inclined to default to altruism and humor and suppressing dangerous emotions than acting out or living in a fantasy world or making excuses. Nevertheless, in his editorial Dr Vaillant confesses:
I have failed to communicate how clinicians might reliably identify these evanescent defenses and how clinicians might catalyze their patients’ maturation of defenses.
“Defenses,” he says, “like rainbows and shooting stars, exist but are difficult to capture. Defenses are, after all, metaphors; they are very complex affective and cognitive styles that the brain uses to alter conflictual inner and outer realities.”
Thus, they are very DSM-unfriendly. The DSM-IV at least included defenses in its back section and in its glossary. The DSM-5 will probably drop them. Yet, we are beginning to see evidence that defenses can be applied in psychiatric practice. Vaillant’s editorial points to one such study published in the same journal issue. Certainly, improving our own defenses is worth exploring in our own recovery.
Yes, psychiatry may have a pill for bipolar. But what if you have issues over taking that pill? Or in following advice? Or of rationalizing your screw-ups? Or of accepting responsibility? No, this kind of behavior is not necessarily pathological. But employing these defenses and others may keep us trapped in our pathology. Where is the pill for that?
More to come ...
Published On: December 23, 2012
Living With6 Chronic Condition Guidelines to Live By
Facing the challenges5 Rules for Bipolar Relationships