Olson Et Al 2011

Psychiatry 74(2) Summer 2011
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Addressing and Interpreting Defense Mechanisms in Psychotherapy: General Considerations

Trevor R. Olson, J. Christopher Perry, Jennifer I. Janzen, Jonathan Petraglia, and Michelle D. Presniak
Defense interpretations are commonly used techniques that clinicians employ more frequently than transference interpretations. How and when clinicians interpret defenses, however, has received little empirical examination. In an effort to facilitate the empirical study of defense interpretation, we reviewed 15 works by noted authors who gave a prominent role to interpreting defenses in discussing clinical work in general patient populations. Our goal was to identify and systematize distinct themes from these authors that might be testable hypotheses. We identied 74 themes related to the interpretation of defenses in psychotherapyfor example, interpreting too frequently diminishes the emotional impact of interpretationwhich we organized into 17 distinct categories (e.g., factors associated with positive outcome). We subsequently selected 19 themes that were readily operationalizable as hypotheses and examination of which would advance clinical practice. These hypotheses address issues such as when, in what order, and how to interpret defensive material and what successful outcomes would be. We then describe prototypes of research designs, employing naturalistic observation, randomized controlled trials, or experimental laboratory studies, which could investigate these important hypotheses. Overall, this report codies current clinical maxims and then provides future research directions for determining how clinicians can most effectively address defenses in psychotherapy. Defense mechanisms have been a central feature of psychoanalytic observation and theory since the publication of The Neuro-psychoses of Defence (S. Freud, 1894/2001). The decades following led to many additional theoretical contributions, including an early systematization of defenses by Anna Freud (1937/1966). Later work completed the systematization of the hierarchy of defenses based on their usual level of adaptiveness (Hilsenroth, Callahan, & Eudell, 2003; Perry, 1993; Perry & Cooper, 1989; Vaillant, 1995). The hierarchy of adaptation has informed research leading to
Trevor R. Olson, J. Christopher Perry, Jennifer I. Janzen, and Jonathan Petraglia, are afliated with the Institute of Community and Family Psychiatry, Sir Mortimer B. DavisJewish General Hospital and McGill University, Montreal, QC. Trevor R. Olson and Michelle D. Presniak are with the Fit for Active Living Program, Saskatoon City Hospital, Saskatoon, SK. Address correspondence to Dr. Perry at The Institute of Community and Family Psychiatry, 4333 Chemin de la Cte, Ste-Catherine, Montral, Qubec, H3T 1E4, Canada. E-mail: jchristopher.perry@mcgill.ca This work was supported by the Utting Fellowship for Studies in Depression, Department of Psychiatry, Sir Mortimer B. DavisJewish General Hospital. 2011 Guilford Publications, Inc.
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empirical contributions on the relationship of defensive functioning to diagnoses (Perry & Cooper, 1986); other aspects of symptoms, behavior and general functioning (Hilsenroth et al., 2003; Perry & Hoglend, 1998), and improvement in dynamic psychotherapy (Bond & Perry, 2004; Despland, de Roten, Despars, Stigler, & Perry, 2001; Drapeau, de Roten, Perry, & Despland, 2003; Hersoug, Sexton, & Hoglend, 2002; Hoglend & Perry, 1998; Perry & Bond, 2009); and psychoanalysis (Roy, Perry, Luborsky, & Banon, 2009). A number of good reviews of research on defenses detail the breadth of ndings (Cramer, 2006; Perry, 1993; Vaillant, 1995). In a recent review of the state of psychodynamic psychotherapy, Cortina (2010) noted that the basic psychoanalytic concept of defensive processes has been continually accumulating empirical support from diverse research areas, including neuroimaging studies and research on cognitive avoidance and retrieval errors. Despite these advances in the understanding of defensive processes, the clinical work with defenses, often called the interpretation of defense, has not received the same degree of systematic attention or research. Indeed, our search of the literature has revealed theoretical and clinical discussions of what the clinician should do in confronting aspects of patients defenses, but there has been no systematic review of the literature and summation of clinical ideas capable of being tested as hypotheses. By contrast, another cornerstone of psychoanalysis, the study of transference, has received good theoretical (e.g., Greenson, 1967), observational (e.g., Crits-Cristoph, Cooper, & Luborsky, 1988), and even experimental studies (e.g., Hoglend et al., 2006; 2008). This report is a step toward addressing this disparity. Although central in the theoretical and clinical work of psychoanalysis and dynamic psychotherapy, defenses have been emphasized somewhat differently, depending on the theoretical position of the author. Kernberg (2001) summarized differences among the various psychoanalytic schools over the past,
to which we selectively add comments about defenses. The psychoanalytic mainstream derived from classical psychoanalysis, and later ego-psychology emphasized defenses in response to drives or impulses, super-ego or conscience, reality concerns, and the conicts among these. Common defense terms used included sublimation, repression, isolation, undoing, reaction formation, denial, projection, and acting out. Kleinian and British object relations analysts added that certain defenses were oriented toward handling conicts presented by the activation of internalized object representations of self and other, including defenses such as splitting and projective identication. Self-psychology and the relational and inter-subjectivist approaches arose from a view that narcissistic disorders constituted a group between borderline and neurotic conditions. In narcissistic disorders, problems with an enfeebled self were associated with the use of self-objects and particular defenses, which could play a reparative role in treatment (Kernberg, 2001; Kohut & Wolfe, 1978). Defenses related to this included idealization, omnipotence, and devaluation, which were viewed as attempts to reinforce regulation of the self and selfesteem. Kernberg (2001) proposed that these theoretical differences are not so much contradictory but complementary views of psychoanalytic psychology and treatment. Similarly, our understanding is that the different schools do not contradict one anothers view of defensive functioning as much as they add breadth to the understanding of the role that defenses play, depending on the type of personality pathology and the current situation or circumstances. Still one cannot escape the impression that in recent literature the type of transference or interpersonal schema is viewed as more central than the associated defenses. If the interpretation of defenses played a minor role in psychotherapy and analysis, the relative lack of systematic empirical study of defenses in treatment would be understandable. We have studied the prevalence of defense and transference interpretations in
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two samples which bear directly on the issue of the relative frequency of both types of interpretations. In a sample of adults with recurrent depression randomized to receive 20 sessions of either dynamic psychotherapy or cognitive behavioral therapy (CBT), we (JCP, unpublished data) rated the therapists interventions from transcripts of sessions 3 and 14 using an established instrument, the Psychodynamic Intervention Rating Scales (PIRS; Cooper, Bond, Audet, Boss, & Csank, 2002). For dynamic psychotherapy, the mean prevalence of defense interpretations was 14.8% (range 2.7%24.5%) of all interventions, excluding acknowledgments (e.g., mmhm, uh huh). By contrast, transference interpretations accounted for only 0.9% (range 0.0%2.9%) of all interventions. Although interpretations were overall less frequent in CBT, a similar pattern emerged, where the prevalence of defense interpretations (mean = 4.1%; range = 1.0%10.9%) was considerably higher than the prevalence of transference interpretations (mean = 0.2%; range = 0.0%0.7%). In a separate study of the Penn Psychoanalytic Collection (Roy et al., 2009), we rated two sessions each at the 10% and 90% point of completion of 17 psychoanalyses. At the 10% treatment mark, defense interpretations accounted for a mean of 7.9% of analyst interventions (excluding acknowledgments; range 0.0%20.4%), and transference interpretations accounted for an additional 5.9% (range 0.0%39.8%). At the 90% treatment mark, defense interpretations accounted for a mean of 14.2% of analyst interventions (range 4.8%34.2%), and transference interpretations accounted for an additional 7.6% (range 0.0%24.3%). Across these studies, the ratio of defense to transference interventions ranged from 1.3 (early psychoanalytic session) through 1.9 (late psychoanalytic sessions) to 16.4 (shortterm psychotherapy sessions) and up to 20.5 (CBT). These data suggest that defense interpretations are more prevalent than transference interpretations across a range of psychotherapies.
While prevalence is not necessarily indicative of their relative mutative role, the differences do suggest that further study of defense interpretations is warranted. However, we rst need to review and systematize the theoretical literature on the interpretation of defenses prior to formulating these as hypotheses and testing their validity. Because this undertaking encompassed a plethora of material, this report focuses on general points about the interpretation of defenses, especially in general treatment populations, while subsequent reports will focus on special considerations in the interpretation of defenses across other specic character types. Because the focus of this report is on the interpretation of defenses, it is important to lay at least a minimal foundation about defenses while referring the reader to references cited in the introductory paragraph for more specic ndings. As one of us (JCP) was a participant in the committee that devised the denition of defense mechanism for the Diagnostic and Statistical manual of Mental Disorders, Fourth Edition (DSMIV) Appendix B (American Psychiatric Association, 1994), and tested the provisional defense axis (Perry et al., 1998), we begin with its denition that defenses are automatic psychological processes that protect the individual against anxiety and from the awareness of internal or external dangers or external stressors (American Psychiatric Association, 1994, p.751). Some or all aspects of defensive functioning occur out of the individuals awareness or are unconscious. This is in contrast to the rationale that a person may state as the basis for the action. Further, the determinants of defensive functioning are usually not evident and the effects may not be rational, in the persons best interest, or adaptive. Brenner (1982) rened earlier conceptualizations of specic defense mechanisms to include any mental function that served the purpose of reducing anxiety or unpleasant affect. Consequently, his theory allowed for a broader understanding of defense that eliminated the need for specic mechanisms used solely for defensive pur-
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poses (e.g., repression, displacement, etc.). While other mental functions can be used defensively at times, defense mechanisms are distinct in that they are specic to this function (e.g., Sandler & A. Freud, 1985). For this reason, we focus on more traditionally dened defense mechanisms for this report. These characteristics make defenses a very important focus of treatment, insofar as an aim is to improve adaptation to life.
MEthOD
We began by conducting a literature search for clinical and theoretical works related to the clinical work with defenses, usually dubbed the interpretation of defenses. We conducted searches of the PsycInfo, Medline, and Psychoanalytic Electronic Publishing databases, but were disappointed in the few relevant returns. For example, while a PsycInfo search (Oct. 14, 2009) for the terms Defense Mechanisms and Psychoanalytic Interpretation revealed 516 matches, few had titles or abstracts indicative of directly addressing the interpretation of defenses in therapy. We then developed a second strategy of taking clinical and theoretical authors known to have commented on defenses (e.g., Fenichel, 1945; Gray, 1994; Greenson, 1967; Reich, 1933/1972; Sandler & A. Freud, 1985) and then working through some of their major writings to develop additional sources. While many authors commented on defenses, we only selected those who devoted a major part of their attention to them. In addition, those authors largely discussing interpreting defense use in a particular character type were saved for our subsequent reports on that topic. As a result of focusing on authors who devote a large portion of their attention on defenses and those who write on general strategies, the authors cited in the present report wrote from a primarily ego psychology point of view. In subsequent reports (e.g., on borderline personality), a wider variety of theoretical perspectives
(e.g., object relations) will be more heavily represented. We systematically noted in tabular format any comments about how to deal with defenses in clinical work and potential outcomes of those interventions. Each of the identied comments was then systematically arranged into six groups. The rst consisted of comments about dealing with defenses across all patient groups or general neurotic characters. These data are the subject of this report. The remaining comments were divided into separate tables by the psychoanalytic character type (or its closest relative DSM-IV diagnostic group). These included: borderline (or borderline personality organization), narcissistic, depressive-masochistic, hysterical, and obsessional (compulsive or obsessive-compulsive personality). These will be the subject of separate reports. Other character types were noted but omitted for relative dearth of material, including schizoid, paranoid, and psychopathic (antisocial). For the present report, we independently and blindly grouped together similar comments and labeled the broad categories they represented (e.g., patients level of awareness). We then engaged in an iterative process of identifying those broad categories upon which we all agreed and then repeated the process with the remaining material until all were classied. This resulted in 17 categories. We subsequently recognized that the categories themselves reected four different areas of phenomena, and we presented each overarching domain in one of four tables. These reect the characteristics of the patient and defense material (see Table 1), characteristics of the therapist (see Table 2), characteristics of the treatment (see Table 3), and general characteristics affecting outcome of defense interpretations (see Table 4). Next, two of the authors took the comments within each category and identied underlying themes (i.e., testable hypotheses). Each of the two authors extracted themes for half of the categories and then independently checked and commented on the other half of the themes. Disagreements were resolved by
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discussion until a consensus was reached. Finally, any themes not primarily related to the interpretation of defenses (e.g., general therapeutic techniques, denitions, transference interpretations) were omitted. This resulted in a minimum of one (e.g., Individual Defenses) and a maximum of 10 (e.g., Factors Associated with Negative Outcome) themes per category. We then took the combined comments in each theme and selected one verbatim quotation to represent the theme, usually from the author who made the point most clearly or concisely, then appended the other relevant citations as additional evidence. One difculty we experienced in developing testable hypotheses that were accessible to most psychotherapy researchers was in trying to convey concepts originally expressed in psychoanalytic terminology, especially writings that used older theoretically derived terms. In some circumstances we maintained aspects of the original language to preserve meaning for readers familiar with the terminology, especially when a ready substitute was not available. As such, we present a list of several terms and their approximate meaning. The term reasonable ego can be understood as the rational part of the individual that desires to get well. The term ego-syntonic is used to convey that the defense is seen as acceptable, normal, and not distressing to the individual and consistent with their sense of self, whereas the term ego-dystonic or ego-alien conveys the opposite. The term transference can be understood as reactions of a patient toward his or her therapist that stem from the patients other important relationships rather than from the real relationship between the patient and therapist. Similarly, the term countertransference is used to convey the concept of the therapists reaction to the patients transference, including the inuence of the therapists personal issues that may relate to his or her reaction to the patient. The term intrapsychic content is broadly used to refer to internal states or processes, including thoughts, feelings, conicts, motives for de-
fending, and representation of relationships with others. Finally, the term resistance can be conceived of as mental or physical behavior by the patient that consciously or unconsciously interferes with progress in the therapy in order to prevent anxiety associated with continued therapy. An additional terminological difculty we experienced was related to the way the terms defense and resistance were used throughout the literature. Laplanche and Pontalis (1973, p. 396) note that Freud often equated the analysis of defense and resistance in the context of treatment, but otherwise refused to equate the two concepts. Nonetheless, within the session, many authors consider defense and resistance as indistinguishable. To address this issue, we included comments by authors who discussed resistance but who shied away from the explicit use of defense terminology. As such, in the present report, the terms resistance interpretation and defense interpretation are synonymous. One exception is that we retained resistance as a category in the results because at times defenses have the specic aim of delaying progress in therapy and therefore preventing the breakdown of other defenses. We felt that it was meaningful to retain this concept separately despite the otherwise interchangeable use of resistance and defense.
REsuLts
For this report we read 15 works by noted authors who gave defense mechanisms a prominent role when discussing psychotherapy. Usually these authors wrote about treatment in general, rather than on a treatment of a specic diagnostic type, such as borderline personality. In total, we found 74 themes representing 17 categories, which we grouped into four broad domains. To improve readability, these themes and categories are presented in Tables 1 through 4 and will not be discussed in detail here. Rather, a brief description of the four broad domains
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TABLE 1. Characteristics of the Patient and Defense Material

Quotation Reference
Theme
1. Level of Awareness We interpret from the surface to the depth; handling the resistances before the content and the ego aspects before the id. Greenson, 1978, p. 524 Fenichel, 1941, p. 44; Fenichel, 1945, p. 25, 537; Fenichel, 1953, p. 322; Fenichel, 1954, p. 20; Gray, 1994, p. 177; Greenson, 1967, p. 67, 77, 137-145; Greenson, 1978, p. 217, 524; Rangell, 1985, p. 149; Reich, 1933/1972, p. 41, 308-309; Reid, 1980, p. 85 Fenichel, 1941, p. 45; Fenichel, 1953, p. 324; Fenichel, 1954, p. 20; S. Freud, 1895/1964, p. 282; Greenson, 1967, p. 72, 137-145; Reid, 1980, p. 97 Fenichel, 1945, p. 537, Fenichel, 1954, p. 20; S. Freud, 1895/1964, p. 282; Gray, 1994, p. 178; Greenson, 1967, p. 72, 98, 138-142
1. Start with interpreting material easily observable to the patient, then progressively move to more unconscious components, like motive and history.
2. Interpretation must be done slowly by interpreting only a little deeper than the patient is currently aware of. When we demonstrate to a patient the fact that he is setting up a defense, what its nature is and why, how, and against what he is employing it, we are really training his ego to tolerate instinctual derivatives, which are made less and less distorted. Fenichel, 1954, p. 20 There is no point in uncovering the repressed if it will meet the same defensive forces which caused it to be repressed in the rst place. A change must be made in the resisting agency. Greenson, 1967, p. 137
We should avoid too deep and too supercial interpretations. Fenichel, 1941, p. 45
3. Initially pointing out that something defensive is going on will help get the patient working with you.
4. Proper interpretation of the material brought to consciousness will resolve the conict and allow it to remain conscious.
Greenson, 1967, p. 137-145
2. State Versus Trait Observation and interpretations should be made at a point of least resistance, addressing relatively inconsequential areas rst and avoiding the underlying wish and attendant anxiety. Reid, 1980, p. 85 We have already said that where this type of defense prevails, it is particularly urgent that we work rst to release the personality from its rigidity because it is in this that the pathogenic energies are really bound. Fenichel, 1941, p. 67 We must reect that a psychical resistance, especially one that has been in force for a long time, can only be resolved slowly and by degrees, and we must wait patiently. S. Freud, 1895/1964, p. 282 Fenichel, 1945, p. 537-538; Fenichel, 1953, p. 326; Greenson, 1967, p. 118, 126; Reid, 1980, p. 85, 97; Wolberg, 1977, p. 592 Fenichel, 1941, p. 67; Fenichel, 1953, p. 325-326
5. Interpret defenses that are least entrenched rst.
6. Interpret character defenses rst.
7. Character resistances must be resolved by repeated interpretations over longer periods of time.
Fenichel, 1945, p. 472; S. Freud, 1895/1964, p. 282; Greenson, 1967, p. 72, 118; Reich, 1933/1972, p. 54
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TABLE 1. (continued)
If a patient feels a resistance is alien to him, he is ready to work on it analytically. One of the crucial early steps in analyzing a resistance is to convert it into an ego-alien resistance for the patient. Greenson, 1967, p. 36 Before demonstrating a resistance to a patient, the therapist should wait for it to recur several times...It is only after a resistance has presented itself repeatedly that it is possible to clarify and confront and get the patient to treat the resistance as ego-alien. Chessick, 1974, p. 197-198 As the working alliance develops, as the patient identies with the analysts working attitudes, the resistance will be perceived as an ego-alien defensive operation within the patients experiencing ego. This shifts during the course of the analysis in accordance with the uctuations of the working alliance. Greenson, 1967, p. 78 Chessick, 1974, p. 197-198 Fenichel, 1941, p. 52; Fenichel, 1945, p. 539; Greenson, 1967, p. 36
3. Ego-syntonic Versus Ego-dystonic
8. Use interpretations to convert ego-syntonic defenses to ego-dystonic to get the patient to work on them.
9. A resistance should appear several times before an interpretation is made to facilitate the change of ego-syntonic resistances to ego-dystonic.
10. As the working alliance develops, interpretations are more able to make resistances become more ego-dystonic.
Fenichel, 1945, p. 538; Greenson, 1967, p. 78, 96, 118
4. Level of Emotional Arousal The anxiety that the interpretation produces should allow optimal energy for working through and should not be so uncomfortable that insuperable defenses are raised. Reid, 1980, p. 99 The analysts indispensible ally in this work is the patients reasonable ego. It must be present or it must be evoked by the analysts interventions; otherwise one has to wait for the emotional storms to subside and for the reasonable ego to return. Greenson, 1967, p. 123 When affects are completely lacking the defensive function of this lack is relatively easy to demonstrate. One need then only guard against the mistake of analyzing contents which to the patient would be interesting conversation, while no work at all would be done at points decisive from the economic viewpoint. Fenichel, 1941, p. 94 Reid, 1980, p. 99
11. Interpretations should raise some anxiety but not so much that the patient becomes much more defensive.
12. A reasonable ego must be present or evocable in order for an interpretation to be effective.
Fenichel, 1941, p. 94; Greenson, 1967, p. 123, 147-148; Perry & Bond, 2005, p. 533
13. When affect is absent, focus interpretation on the defensive function not the content.
Fenichel, 1941, p. 94
5. Individual Defenses Each defense is a signal of distress, and reading it correctly allows the therapist to estimate how much distress the patient is feeling, how the patient is trying to protect him- or herself, what motives or conicts may underlie the defensive activity, and whether the therapist should respond more supportively or interpretively. Perry & Bond, 2005, p. 532 Perry & Bond, 2005, p. 532, 538; Rangell, 1985, p. 168
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14. Identifying specic individual defenses can be necessary for successful interpretations.
6. Intrapsychic Content Our principle is: No interpretation of meaning when a resistance interpretation is still to come. Reich, 1933/1972, p. 29 For we must operate at that point where the affect is actually situated at the moment; it must be added that the patient does not know this point and we must rst seek out the places where the affect is situated. Fenichel, 1941, p. 44 The defensive attitudes of the ego are always more supercial than the instinctual attitudes of the id. Therefore, before throwing the patients instincts at his head we have to rst interpret to him that he is afraid of them and is defending against them, and why he does so. Fenichel, 1953, p. 334 It is especially important to approach instinctual attitudes which represent defensive purposes from the viewpoint of defense rst. Fenichel, 1954, p. 191 When we demonstrate to a patient the fact that he is setting up a defense, what its nature is and why, how, and against what he is employing it, we are really training his ego to tolerate instinctual derivatives, which are made less and less distorted. Fenichel, 1954, p. 20 Whether one begins with the affect or the event, or the fantasy, one eventually arrives at the history of the affects or events or fantasy. Greenson, 1967, p. 117 Fenichel, 1941, p. 45; Fenichel, 1953, p. 335; Fenichel, 1954, p. 21; Greenson, 1967, p. 139; Rangell, 1985, p. 149-150; Reich, 1933/1972, p. 26, 29 Chessick, 1974, p. 209; Fenichel, 1941, p. 44-45;
15. Interpret the patients resistance before interpreting the psychological content they are defending against (Interpret resistance before content).
16. Interpretations should be linked to the patients dominant affect, including where affect is expected but is absent.
17. Interpret affect before motives (e.g., wishes).
Fenichel, 1953, p. 334; Reid, 1980, p. 96
18. Interpret method (e.g., the defense used) before motives and conicts.
Fenichel, 1945, p. 25; Fenichel, 1954, p. 114, 116, 190; Reid, 1980, p. 96 Fenichel, 1945, p. 537-538; Fenichel, 1954, p. 20; Reid, 1980, p. 86
19. The therapist must make the patient aware that he or she is using a defense, how it operates, and what is being defending against in order to improve the patients adaptive handling of motives.
20. Interpretation must eventually include the patients historical experiences related to the defense.
Fenichel, 1945, p. 537; Greenson, 1967, p. 96-97, 117, 122; Greenson, 1978, p. 247
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The uncovering of a single historical event is only the beginning of an interpretation. To work it through, we have to try to uncover all the important experiences which were formative in regard to a certain piece of a patients behavior. Greenson, 1978, p. 247 We rst make it clear that he is warding off something, then how he is going about it, what means he is employing to do it (character analysis), and only much later, when the analysis of the resistance has progressed sufciently, he is told or nds out for himself what the defense is directed against. Reich, 1933/1972, p. 71 After we have discovered the motives for his defence, to deprive them of their value or even to replace them by more powerful ones. S. Freud, 1895/1964, p. 282 S. Freud, 1895/1964, p. 282; Greenson, 1967, p. 72 Chessick, 1974, p. 209; Greenson, 1967, p. 97-98, 107, 118, 121-122; Greenson, 1978, p. 243; Reich, 1933/1972, p. 4, 71 Greenson, 1978, p. 245-248
21. Working through should include interpretation of the historical experiences that occurred across multiple points in time and developmental periods.
22. A complete interpretation makes the patient aware of his or her defenses or resistance, what they are defending against, and the relevant causal current and historical experiences.
23. After the motive is discovered, the goal is to use interpretations to deprive the defense of its functional value or replace the defense with a more adaptive one.
7. Interpersonal Content (A. Transference or Therapist; B. Other Objects or Persons) A necessary precondition for working through is that the patient permits himself to regress and develop a transference neurosis. Greenson, 1978, p. 252 The analysis of resistances must always include the analysis of the transference resistance. Greenson, 1967, p. 112 The technically valid rule is that in order to attack them successfully, we must rst change character resistances into transference resistances. Fenichel, 1941, p. 68 Often, to be sure, following the removal of a layer of the defense apparatus, liberated affects begin to ow, together with the infantile material pertaining to them. The analyst would deprive himself of every further possibility of completely breaking down the armor, however, if, in this intermediary phase, he did anything more than extract from the owing material what directly relates to the contemporary transference situation. Reich, 1933/1972, p. 308 Unnecessary attention to the reality outside the analytic stage of the mind can strengthen the resistance against the patients involvement in the analytic process. Gray, 1973, p. 486 The analyst oversees the patient in analysis and in his life. the analyst notes and brings into the analysis transferences, defenses, and resistances occurring in the extra-analytic life of the patient, current as well as past. Rangell, 1985, p. 149 Greenson, 1978, p. 252
A.24. The development of transference is a precondition to resistance analysis.
A.25. The interpretation of resistance must at some point address aspects of transference.
Fenichel, 1954, p. 189, 210; Greenson, 1967, p. 112; Greenson, 1978, p. 245-248 Fenichel, 1941, p. 67-68; Fenichel, 1945, p. 538; Fenichel, 1954, p. 210; Greenson, 1967, p. 258 Reich, 1933/1972, p. 308
A.26. Bring character resistances into the transference.
A.27. After defense interpretations begin to improve defensive functioning, then transference interpretation must be utilized to solidify the change.
B.28 Defense interpretations should not address nontherapy relationships.
Gray, 1973, p. 477, 486
B.29 Defense interpretations should address nontherapy relationships.
Fenichel, 1941, p. 96; Rangell, 1985, p. 149, 168
8. Other External Factors Whatever reality factors compound a resistance, the reality factors have to be adequately acknowledged (Marmor, 1958). If one does not do so, the patient will cling all the more vociferously to the reality element of the resistance and will spend his time trying to convince the analyst of the logic of his argument. Greenson, 1967, p. 119 Greenson, 1967, p. 119
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30. The therapist must acknowledge external reality factors or they will become incorporated into the resistance.
9. Resistance There is no point in uncovering the repressed if it will meet the same defensive forces which caused it to be repressed in the rst place. A change must be made in the resisting agency. Greenson, 1967, p. 137 One of the crucial early steps in analyzing a resistance is to convert it into an ego-alien resistance for the patient. Greenson, 1967, p. 36 In the rst place, we must reect that a psychical resistance, especially one that has been in force for a long time, can only be resolved slowly and by degrees, and we must wait patiently. S. Freud, 1895/1964, 282 Small and temporary resistances can be handled merely by keeping quiet and letting the patient overcome his resistance. Greenson, 1967, p. 147 Greenson, 1967, p. 36 Greenson, 1967, p. 137-145
31. Resistances must be resolved through interpretation early so repressed material can emerge without being repressed again.
32. As resistance develops, interpret it early on to make it ego-dystonic.
33. In order to resolve resistances, interpretations must be developed over time with gradually increasing complexity.
Greenson, 1967, p. 72; S. Freud, 1895/1964, p. 282
34. Not all resistances need to be interpreted; the patient may be able to resolve small ones himself.
Greenson, 1967, p. 146-147
10. Past Versus Present Psychoanalytic elaboration of an interpretation is an attempt to trace the different genetic sources of a piece of behavior. Greenson, 1978, p. 245 Fenichel, 1945, p. 537; Greenson, 1967, p. 96-97, 117, 122; Greenson, 1978, 245-252
35. Interpretations of defenses and resistance must eventually explore how they developed.
11. State of the Therapeutic Alliance A working alliance must be present or evocable before one embarks on the deep analysis of resistance. It is a prerequisite for interpretation. Greenson, 1967, p. 123 As the working alliance develops, as the patient identies with the analysts working attitudes, the resistance will be perceived as an ego-alien defensive operation within the patients experiencing ego. Greenson, 1967, p. 78 Fenichel, 1945, p. 537; Greenson, 1967, p. 123; Greenson, 1978, p. 252-254 Greenson, 1967, p. 78, 96, 118;
36. A good working alliance is required for effective interpretation.
37. A strong working alliance will facilitate the effect of interpretations on making ego-syntonic resistance become ego-dystonic.
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A working alliance with me was then achieved and he himself could then analyze his inappropriate transference reaction to me. Greenson, 1967, p. 142 Fenichel, 1945, p. 26; Greenson, 1967, p. 123, 136-146; Greenson, 1978, p. 214-215
38. Use reasonable ego and working alliance to facilitate collaboration for interpretations.
12. Order of Interpretation Speculation about these issues is the rst step in the modication of resistances, modication which should begin with those which are least entrenched, most recently formed (intercurrent), and/or acutely blocking the uncovering process. Reid, 1980, p. 86 In order to analyze a resistance, for example, the patient must rst be cognizant that a resistance is at work. Greenson, 1967, p. 98 The question, Why is the patient resisting? can be reduced to: what painful affect is he trying to avoid. The answer to this question is closer to consciousness usually than the answer to the question what instinctual impulses or traumatic memories make for the painful affect. Greenson, 1967, p. 107 In applying this principle to the chronic defensive attitudes, we see rst of all that we can only reach the repressed instincts by gradually undermining the opposing defenses, which can always be demonstrated earlier than the repressed impulses themselves. Fenichel, 1954, p. 116 I shall start with the clarication of the motive for resistance because, all things being equal, it takes precedence over the mode of resistance, since it is more productive. Greenson, 1967, p. 107 It does not matter which of the two we pursue, the motive or the mode of resistance. Greenson, 1967, 107 Whether one begins with the affect or the event, or the fantasy, one eventually arrives at the history of the affects or events or fantasy. Greenson, 1967, p. 117, The steps and order of the various steps vary from hour to hour and from patient to patient. One can pursue only what seems to be the most promising avenue of exploration at a given time. Greenson, 1967, p. 123 In order for an insight to be effective, it is necessary for it to be repeated many times; single interpretations do not produce lasting changes. Greenson, 1978, p. 244 Fenichel, 1953, p. 325-326; Greenson, 1967, p. 126-128; Rangell, 1985, p. 162; Reid, 1980, p. 86; Wolberg, 1977, p. 592
39. Start working with defenses that are blocking the therapy process.
40. First step is to bring the presence of a defense to the patients awareness.
Fenichel, 1941, p. 35, 77; Fenichel, 1945, p. 537; Fenichel, 1953, p. 334; Fenichel, 1954, p. 190; Gray, 1994, p. 177-178; Greenson, 1967, p. 98, 107, 118, 121-122; Greenson, 1978, p. 215; Reich, 1933/1972, p. 4, 30, 71 Fenichel, 1953, p. 334; Greenson, 1967, p. 107-109, 121-122; Reid, 1980, p. 96
41. Second step is to point out the underlying Affect.
42. Third step is to do Method (type of defense) before fourth step which is Motive.
Fenichel, 1941, p. 52, 77; Fenichel, 1945, p. 25, 537; Fenichel, 1954, p. 114, 116, 188-191; Greenson, 1967, p. 98, 118; Greenson, 1978, p. 215; Rangell, 1985, p. 165; Reich, 1933/1972, p. 4, 30, 71; Reid, 1980, p. 96 Greenson, 1967, p. 107, 121-122
43. Third step is to do Motive before the fourth step which is Method (type of defense).
44. Order of third and fourth step doesnt matter for Method and Motive.
Greenson, 1967, p. 107 Fenichel, 1941, p. 52, 77; Fenichel, 1945, p. 537; Fenichel, 1954, p. 188-191; Greenson, 1967, p. 96, 117, 121-122; Greenson, 1978, p. 215; Reich, 1933/1972, p. 85 Greenson, 1967, p. 107, 117, 118, 122, 123
45. The fth step is to uncover the origin (historical experiences) of the defense.
46. Order of what is interpreted is exible, depending on the patient.
47. To produce lasting change it is necessary to repeat interpretations across similarly themed material to ensure generalization.
Fenichel, 1941, p. 97; Greenson, 1967, 121-122; Greenson, 1978, 230-232, 244-245; Reich, 1933/1972, p. 30
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of material is presented, introducing each of the four tables. The 74 Themes The rst broad domain of categories is Characteristics of the Patient and Defense Material (Table 1). This domain encompasses most of the categories (12 of 17) identied from the literature and most of the themes (47 of 74), which is indicative of the proportional focus that the source authors had regarding this area. The second broad domain of categories is Characteristics of the Therapist (Table 2). Given that psychotherapy is a two-person endeavor and given the nding that the therapists characteristics account for up to 8% of the variance of psychotherapy (Kim, Wampold, & Bolt, 2006), it is not surprising that characteristics of the therapist emerged as an important category mentioned by authors. What was perhaps most surprising about this category, however, was that it was mentioned relatively infrequently. It was noted only by two authors and resulted in only a single theme, which was a cautionary one to ensure that interpretations are not used as part of a countertransference reaction. In addition to characteristics of the individuals within the treatment, we also found a domain of defense interpretation categories that were related to Characteristics of the Treatment itself (Table 3). Again, this domain was relatively small and contained only references to timing of interpretations across the session or treatment in general. Finally, the fourth broad domain of categories was General Characteristics Affecting Outcome of Defense Interpretations (Table 4). This domain was divided into the categories of factors associated with negative outcome and factors associated with positive outcome. These two categories contained a combined 15 themes, which is indicative of the reasonable frequency with which the source authors focused on potential outcomes of a therapists defense interpretations.
Identication of Important Themes for Empirical Investigation A major focus of this paper was to identify themes that could be tested empirically from the theoretical literature on defense interpretation. After identifying the 74 themes above, we further examined them with the aim of identifying those with the highest clinical relevance and which could be operationalized with currently available methods. These are the hypotheses that, if tested, could produce ndings with the greatest possibility of shaping and improving clinical practice in the immediate future. All ve authors reviewed the 74 themes, selecting those meeting the above criteria. We then had a series of discussions and selected 19 by unanimous consensus. These themes are identied below along with their corresponding theme number from the tables for ease of cross comparison. These 19 selected themes are presented in three general categories: ego defense interpretations, object relational themes, and process of defense interpretation. Ego defense interpretations. The rst eight themes we selected have at their core an ego psychological view of defense interpretation. The themes are: (theme 1) start with interpreting material easily observable to the patient, then progressively move to more unconscious components like motive and history; (theme 3) initially pointing out that something defensive is going on will help get the patient working with you; (theme 5) interpret defenses that are least entrenched rst; (theme 6) interpret character defenses rst; (theme 8) use interpretations to convert ego-syntonic defense to ego-dystonic to get the patient to work on them; (theme 11) interpretations should raise some anxiety but not so much that the patient becomes much more defensive; (theme 14) identifying specic individual defenses can be necessary for successful interpretations; and (theme 17) interpret affect before motives. These themes
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Table 2. Characteristics of the Therapist

Theme 13. Countertransference Reactions 48. Avoid making interpretations based on countertransference reactions. It is important not to play into the resistance of the patient by using the same kind of resistance he does. Greenson, 1967, p. 123 Greenson, 1967, p. 123; Perry & Bond, 2005, p. 532 Quotation Reference
concern how defense interpretation relates to the patients internal psychological functioning. They provide some general guidance at the most basic level before defenses are further complicated by the effect of object representations triggered by real life interpersonal experiences. Object relational themes. The next six themes concern interpretation when defenses occur in the explicit context of a relationship with the therapist or others. The themes are: (theme 26) bring character resistances into the transference; (theme 27) after defense interpretations begin to improve defensive functioning, then transference interpretation must be utilized to solidify the change; (theme 28) defense interpretations should not address nontherapy relationships; (theme 29, which contradicts theme 28) defense interpretations should address nontherapy relationships; (theme 30) the therapist must acknowledge external reality factors or they will become incorporated into the resistance; and (theme 36) a good working alliance is required for effective interpretation. These themes acknowledge that defensive functioning often occurs in an interpersonal context both in and outside of treatment. They indicate how the therapist should handle interpretation in situations where objects and their internal representations are inextricably linked to the defenses at issue. By testing these hypotheses, we can further elucidate the importance of interpreting defenses in various interpersonal contexts. Process of defense interpretation. The nal ve themes address the process of therapy, the specications of when, how often, and
in what order material should be interpreted to increase the likelihood of success. The themes are as follows: (theme 47) to produce lasting change it is necessary to repeat interpretations across similarly themed material to ensure generalization; (theme 49) interpretation is better at the beginning of the session; (theme 57) in middle sessions, increase the use of defense interpretations; (theme 59) in late sessions, interpret motive and historical experiences of the defense; and (theme 65) interpreting too frequently diminishes the emotional impact of interpretation. These themes represent issues which clinicians regularly face regarding what to do when. Empirical investigation of these issues will provide a rmer basis for decision making for clinicians than theory, clinical instinct, or intuition otherwise might.
DiscussiON
Our aim was to review the literature relating to the interpretation of defense mechanisms to determine what ideas could be garnered for future empirical research. We summarized 15 theoretical works relating to the interpretation of defense mechanisms in psychotherapy and developed 74 themes. Next, we identied 19 of these themes that we believe have a combination of high clinical relevance and testability using current empirical methods of investigation. We now discuss the outcome of this effort, including how some of these identied themes could be empirically investigated and some important limitations.
Table 3. Characteristics of the Treatment

Quotation Reference
Theme
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14. Time in the Session (A. Timing of Intervention, B. Pace/Rate of Interventions) Interpretation is better at the beginning of the session. Reid, 1980, p. 98 the steps and order of the various steps vary from hour to hour and from patient to patient. One can pursue only what seems to be the most promising avenue of exploration at a given time. Greenson, 1967, p. 123 interpretation means helping something unconscious to become conscious by naming it just at the moment it is striving to break through. This explains why we can only interpret at one specic point, namely, where the patients actual, immediate interests and attention is momentarily centered. Fenichel, 1953, p. 322 Interpretation is comparable to a valuable drug, which must be used sparingly if its effectiveness is not to be lost. Reich, 1933/1972, p. 39 Greenson, 1967, p. 123 Reid, 1980, p. 98
A.49. Interpretation is better at the beginning of the session.
A.50. Timing of interpretations within a session may vary depending on the person or material in the session.
A.51 Timing of interpretations must take into account the material the patient is immediately interested in and attending to.
Fenichel, 1953, p. 322; Fenichel, 1954, p. 21; Wolberg, 1977, p. 592
B.52. Use interpretations sparingly and develop them over several sessions.
Greenson, 1967, p. 122, 123; Perry & Bond, 2005, p. 536; Reich, 1933/1972, p. 38-40, 55, 68, 124
15. Time Across Session (A. Early, B. Middle, C. Late) From the very beginning, I consistently attempted to show the patient how, why, and what she was resisting. Greenson, 1978, p. 243 It is important to resist changing ones focus away from the immediacy of the material, that is, not to get caught up in the external context of the content and be distracted from listening as carefully as possible to the process occurring while the patient is speaking. Gray, 1994, p. 177 In the rst few months of analysis . when the material is quite clear, I try to make connections between past and present behavior patterns. Greenson, 1978, p. 216-217 The analysis of the character is given priority at the beginning of treatment. Reich, 1933/1972, p. 56 Exploratory and interpretive interventions may be used gingerly in the middle phase mostly to increase exploration of affectively meaningful material. Perry & Bond, 2004, p. 22 deeply engrained defenses are extremely resistant to interpretation; it may be useless to address them until late in therapy. Reid, 1980, p. 85 while the main accent in the later stages falls upon the interpretation of content and infantile experiences. Reich, 1933/1972, p. 56 Greenson, 1967, p. 67, 124-126; Greenson, 1978, p. 217, 243; Reich, 1933/1972, p. 41 Gray, 1994, p. 177
A.53. In early sessions, identify resistance through interpretation.
A.54. In early sessions, the therapist should attend to and interpret the way content is talked about rather than the content itself.
A.55. In early sessions, use interpretations to make connections between past and present behaviour patterns.
Greenson, 1978, p. 216-217
A.56 In early sessions interpret character defenses.
Reich, 1933/1972, p. 56 Perry & Bond, 2005, p. 534-535; Reid, 1980, p. 69 Reid, 1980, p. 85 Reich, 1933/1972, p. 56
B.57. In middle sessions, increase the use of defense interpretations.
C.58. In late sessions, begin interpreting character defenses.
C.59 In late sessions, interpret motive and historical experiences of the defense.
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Table 4. General Characteristics Affecting Outcome of Defense Interpretations.

Quotation Poor timing of interpretation is more often merely ineffective than destructive to the treatment. Reid, 1980, p. 98 Premature interpretations of the meaning of the symptoms and other manifestations of the deep unconscious, particularly of symbols [are problematic]. Compelled by the resistances which have remained concealed, the patient gets control of the analysis, and only too late the analyst notices that the patient is going around in circles, completely untouched. Reich, 1933/1972, p. 26-27 It is important not to make interpretations of resistance prematurely, since that only leads to the patient to rationalize or intellectualize, or it makes an intellectual contest of the interpretation of resistance. In either case it deprives the experience of emotional impact. Thus it adds to the resistances instead of diminishing them. Greenson, 1967, p. 122-123 The removal of a defense below the resistance, either inappropriately in life or by a premature interpretation in analysis, results in the emergence of anxiety. Rangell, 1985, p. 150 The evidence suggests, then, that the careful use of interpretation of defense and resistance can help improve the alliance and outcome of therapy, whereas aggressive use of interpretative techniques will overwhelm or threaten those patients with a lower level of defensive functioning. Perry & Bond, 2005, p. 536 Too much activity can serve to evade the emotional impact and turn analysis of resistance into a guessing game. Greenson, 1967, p. 123 the error here is that the interpretation of meaning precedes the interpretation of resistance. The situation becomes even more confused in that the resistances soon become entangled in the relationship to the analyst. Reich, 1933/1972, p. 27 Reference Reid, 1980, p. 98 Reich, 1933/1972, p. 26-27
16. Factors Associated with Negative Outcome
Theme
60. Poor timing of interpretation is ineffective.
61. Premature interpretation prevents progress in treatment.
62. Premature interpretation deprives the patient of the emotional experience and increases rather than decreases resistance.
Greenson, 1967, p. 122-123; Perry & Bond, 2005, p. 535
63. Premature interpretation leads to excessive anxiety.
Rangell, 1985, p. 150 Perry & Bond, 2005, p. 536
64. Interpreting too frequently will overwhelm patients.
65. Interpreting too frequently diminishes the emotional impact of interpretation.
Greenson, 1967, p. 123 Reich, 1933/1972, p. 27
66. Interpretation of content before resistance leads to resistance in the transference.
67. Interpretations that provoke too much anxiety may not be useful. psychological sounding interpretations may not be workable for the patient. Reid, 1980, p. 99 My experience is that taking up all the material in terms of transference early in the analysis may put certain patients into resistance and may lead to the breakdown of the analysis. Sandler & A. Freud, 1985, p. 35 Reid, 1980, p. 99 Sandler & A. Freud, 1985, p. 35
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the anxiety that the interpretation produces should allow optimal energy for working through and should not be so uncomfortable that insuperable defenses are raised. Reid, 1980, p. 99
Reid, 1980, p. 99
68. If interpretation is too complicated, then it may be ineffective.
69. Excessive early use of defense interpretations within the transference can increase resistance and lead to a breakdown in the therapy.
17. Factors Associated with Positive Outcome the anxiety that the interpretation produces should allow optimal energy for working through and should not be so uncomfortable that insuperable defenses are raised. Reid, 1980, p. 99 a valid interpretation brings about a dynamic change in the patients entire behavior, which cannot escape recognition. Fenichel, 1953, p. 329 when a patient detects on his own not only that he is resisting, but why he might be resisting, or what he might be resisting, then I feel he has made an important step in the analysis. Greenson, 1967, p. 125 With the gradual dissolution of the pathogenic defenses, the forces that have previously been repressed again nd contact with the total personality. New and more effective instinctual defenses, which do not cause neuroses, can be applied by the adult ego. Fenichel, 1953, p. 328 The evidence suggests, then, that the careful use of interpretation of defense and resistance can help improve the alliance and outcome of therapy, whereas aggressive use of interpretative techniques will overwhelm or threaten those patients with a lower level of defensive functioning. Perry & Bond, 2005, p. 536 Reid, 1980, p. 99; Sandler & A. Freud, 1985, p. 23 Fenichel, 1953, p. 329 Greenson, 1967, p. 125, 248; Perry & Bond, 2005, p. 535 Fenichel, 1953, p. 328
70. Effective interpretations produce a manageable level of anxiety for the patient.
71. Effective interpretations result in a dynamic change in patients behavior.
72. A cumulative effect of effective interpretations is that the patient begins to detect and work on their own resistance and treatment becomes more productive.
73. A cumulative effect of effective interpretation is that material is brought into awareness, integrated by the patient and more adaptive defenses replace less adaptive defenses.
74. Using the proper frequency of interpretations will improve therapeutic alliance and outcome in therapy.
Perry & Bond, 2005, p. 536
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By avoiding theoretical and era-specic terminology as much as possible (e.g., cathexis), we have attempted to make the material reviewed approachable in its scientic possibilities, including empirical testing. While our review is highly informed by a psychoanalytic perspective, our distillation into themes should be applicable within any theoretical and scientic framework. For example, level of awareness is a variable of interest in many psychotherapeutic orientations. In the conduct of cognitive behavioral therapy, the clinician attempts to make the patient aware of automatic thoughts, maladaptive assumptions, core beliefs, and/ or deeper schemas (e.g., Young, Klosko, & Weishaar, 2003) and then nd more adaptive ways of thinking and coping. Similarly, all therapeutic schools have to confront cases in which the proposed techniques need to be modied because the patient resists the usual approaches (e.g., Leahy, 2003). By addressing therapeutic issues related to defenses such as level of awareness and resistance, we intend to broaden their potential utility to practitioners and scientists from many theoretical perspectives. The 74 themes One of the most striking aspects of the 74 themes is how the literature on interpretation of defenses spans issues that touch upon such a wide variety of topics. These include topics that have largely been in the psychoanalytic theoretical framework since the outset, such as level of consciousness, affect, motive, and relationships. Several other topics are ones we perhaps highlighted, such as factors associated with negative or positive outcome. However, despite our labeling of these categories and the themes subsumed by them in functional terms, we were pleased to nd no major surprises in content of the categories or themes. We take this as a testament to the robustness of many of these ideas which, while new when proposed, appear to have formed part of the foundation of psy-
choanalytic theory of treatment. Nonetheless, the foundations of any theory still warrant empirical examination. Not surprisingly there were instances in which themes directly contradicted each other (e.g., themes 28 & 29), but these were relatively rare. These contradictory themes provide an excellent opportunity for developing hypotheses for future testing: they both cannot be true, unless a third variable moderates the conditions under which each is true. Future Directions As mentioned in the Results section, an important aim of this report was to summarize the body of clinical knowledge in this area to identify fruitful avenues for empirical research. As such, we selected 19 themes that we believe combine both clinical utility and operationalizability. In an effort to provide some initial momentum for fellow defense mechanism researchers, we describe several prototypic study designs that could be used to test some of these themes across three general types of psychotherapy research designs: naturalistic observation, randomized controlled trials (RCTs), and experimental laboratory studies. Naturalistic observation. It is likely that naturalistic observational studies of the process of psychotherapy will initially be the easiest avenue for exploration of many of these hypotheses. One such naturalistic study design could utilize a series of transcribed psychotherapy sessions across the duration of a group of individuals treatments. These sessions could then be rated to categorize therapists interventions, such as using the aforementioned PIRS. For defense and transference interpretation the PIRS also allows a rater to codify the depth of an interpretation. Defense interpretations range in depth from 1-5. A score of D1 is given when the therapist species a patients defensive process (i.e., method of defending or defense used) or species an affect. A score of D2 is
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given when both the method of defending as well as the affect is specied. If a therapist alludes to a motive for defending, then a score of D3 is given. If the therapist actually species a potential motive for defending, then a score of D4 is given. A score of D5 is given when a therapist combines specication of affect, method, and motive with a link to past relationships (i.e., makes a genetic interpretation). By using the PIRS to identify progressively deeper defense interpretations, several themes could be tested across naturalistic studies. For example, theme 1 (i.e., start with interpreting material easily observable to the patient, then progressively move to more unconscious components like motive and history) could be operationalized to hypothesize that treatments by therapists who use predominantly low level Ds (i.e., D1 & D2) in initial sessions, then progress to D3, D4, and nally D5 in later sessions, would be associated with better outcomes than treatments by therapists who utilized higher level defense interpretations throughout the treatment. A study design such as this could be quite economical if grafted onto an existing naturalistic psychotherapy study in which session transcripts are already available and in which subjects have been independently assessed on outcomes over the course of treatment and subsequent follow-up. With minor modications to the methodology, other themes (e.g., theme 17: interpret affect before motives) could be tested using similar naturalistic methods. Randomized controlled trials. RCTs are likely to follow once naturalistic studies have identied strong evidence requiring the next step of experimental validation of one or several processes that could be experimentally controlled. Some of the themes identied seem particularly well-suited for this type of investigation. For example, themes 28 (defense interpretations should not address nontherapy relationships) and 29 (defense interpretations should address nontherapy relationships) are contradictory. A study
could be designed with three conditions: 1) a natural or free condition, in which therapists are given no direction regarding using nontherapy relationship interpretations; 2) a high nontherapy relationship interpretation condition, in which therapists are instructed to focus primarily on interpreting defenses in nontherapy relationships; and 3) an exclusive therapy relationship interpretation condition, in which therapists are instructed not to use interpretations that involve nontherapy relationships. Independent raters could verify the delity of the conditions, as in the First Experimental Study of the Transference (FEST) study of the importance of interpreting the transference (Hoglend et al., 2006). Psychotherapy transcripts could be rated with the PIRS, and defense interpretations could be examined independently to determine whether they involve relationships other than the one between the therapist and patient. Examining outcomes across treatments as well as correlating the number of nontherapy interpretations to outcome in conditions 1 and 2 with a variety of outcome indicators would help to answer whether interpreting defenses in nontherapy relationships was benecial, detrimental, or neither. Experimental laboratory studies. Several themes are suitable for investigation using laboratory studies, involving design components not typically found in psychotherapy research designs. Although much less accessible than naturalistic designs or RCTs, experimental studies can provide insights into processes that are not assessable using the other methods, thereby supplementing knowledge from naturalistic or RCT studies. Functional neuroimaging techniques (e.g., fMRI, PET), in particular, allow the study of changes in activation and linkage of brain regions that are affected by psychotherapy (Etkin, Pittenger, Polan, & Kandel, 2005). Although the use of neuroimaging has many limitations (see Beutel & Huber, 2008; Carrig, Kolden, & Strauman, 2009, for brief reviews), some studies have shown promising results (e.g., Brody et al., 2001; Paquette et al., 2003).
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One current difculty in applying neuroimaging to the study of defense mechanisms is that the experimental techniques themselves may be difcult or impossible to use in an ongoing psychotherapy without interfering with the psychotherapy process. For example, the study of changes in brain activation during psychotherapy using fMRI would require periodic interruptions in the process to scan the patients brain, which may alter the brains native processes. Because of these difculties, current research has focused primarily on pre- to post-treatment changes in brain functioning, such as metabolic or activation changes (Brody et al., 2001; Etkin et al., 2005). A more likely approach at this point for studying brain changes following defense interpretations would rely on analogues of defense interpretation, such as using an experimental situation designed to elicit a defense and followed by an experimental manipulation of an experimenters response (e.g., randomization to interpretation or noninterpretation). This basic type of design has yielded meaningful results, for instance, using emotional conict tasks in studying emotion regulation and brain activity in participants with anxiety disorders compared to controls (Etkin, Prater, Hoeft, Menon, & Schatzberg, 2010). The experimental study of the effects of defense interpretation should benet from an intermediate step, such as delineating brain activity when individuals are using defenses. At present this is largely at the stage of hypothesis generation (Northoff & Boeker, 2006). If we posit about 30 defenses, it is possible but unlikely that there is a differential, measurable, gross activation pattern associated with each. Rather there may be such patterns associated with a smaller set of defensive states of mind, within each of which the individual defenses used have a common basic aim, such as keeping an idea, or particular type of affect or motive, out of awareness. Putting issues of practicality aside, we describe one potential experimental design that relies on ecologically valid methodology already available to elicit defenses, to which
we add an experimental procedure and fMRI assessment. The Relationship Anecdote Paradigm (RAP) interview is a semi-structured interviewing technique for eliciting interpersonal vignettes (Beck & Perry, 2008), which include the participants defenses (Perry, Beck, Constantinides, & Foley, 2009). After the story details have been elicited, the interviewer asks three questions that specically focus on the emotional impact of the vignette on the respondent. We illustrate such a design using theme 3, initially pointing out that something defensive is going on will help get the patient working with you. The sequential components of the design are 1) a baseline condition (e.g., reading an emotionally neutral passage); 2) a RAP interview; 3) a post-RAP intervention with randomization either to an experimental condition (e.g., experimenter gives a low level defense interpretation, D1 or D2), or to a control intervention (e.g., experimenter offers a reection, restating what the patient said about affect); and 4) a post-intervention discussion. The dependent measures would include fMRI scans at four points: after baseline (Time 1), after the RAP (Time 2), after the intervention (Time 3), and after the discussion period (Time 4), as well as verbatim transcription of the participants work with the experimenter during the discussion period. The latter transcription would include measures of verbal productivity (e.g., word counts, duration of utterances; Beck & Perry, 2008) and exploration (e.g., the Therapeutic Alliance Analogue Scales Exploration subscale; Perry, Fowler, & Greif, 2008). It is likely that the participants use of lower versus higher defense levels will moderate the response to the intervention, which can only be examined post hoc, as the defenses used will reect the participants own repertoire. We propose testing the hypothesis in parallel using the verbal and neuroimaging data perspectives. In the verbal perspective, at a given defense level, we would expect the experimental intervention to produce greater verbal productivity and exploration in the
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discussion period than would the control intervention. The areas of increased brain activation and their linkages at each point (Time 1 to Time 4) would be correlated with the defenses identied to provide descriptive correlative data. In the neuroimaging perspective, we would expect two things. First, in both experimental and control conditions, compared to baseline, the post-RAP (Time 2) scan should show areas of brain activation associated with the level of defensiveness. Second, compared to the post-RAP scan (Time 2), the post-intervention (Time 3) scan should show activation consistent with less defensiveness in the experimental, but not the control condition. The same difference should be found comparing the post-intervention (Time 3) with the post-discussion (Time 4) scans. If the experiment is repeated, the order of presentation (experimental vs. control condition) would be balanced. Of course the verbal and neuroimaging components of the study could be conducted separately, but clearly the information gain from conducting them together would be preferable. Further thoughts on future directions. In describing the above prototypical study designs, we have aimed for simplicity to demonstrate general concepts without explicitly stating many of the important details that might be added to adequately control other variables. Moreover, further specication of the constructs might need to be made in several cases. For example, in the proposed naturalistic study, it will be important to specify whether deepening of defense interpretation level is assessed by specic conict or more generally across all conicts. Of course, we also have not described studies to examine all of the themes that are operationalizable or clinically important. Several of the themes we described could be tested in more than one of the above design types. Rather, we aimed to demonstrate how researchers might use these themes to design research projects
to test themes of particular interest or importance to their own area of interest. Finally, some of the ideal ways in which these themes might be tested are not currently feasible, or in some cases currently possible. This is especially the case with the laboratory designs using fMRI scans during psychotherapy. However, we hope that by highlighting them as areas for future research, researchers will continue to consider how this important area of science can be applied to the present issues. We hope that by extracting and explicitly stating many long-held tenets of psychotherapy, we have provided a basis from which these assumptions can be empirically examined across multiple research designs. Limitations Reviewing the literature for this report was a difcult process. Our lack of success nding suitable sources through database searches led us to rely more on our own knowledge of the literature relating to defense mechanisms and how they are addressed in psychotherapy to start the review process. Once suitable sources were obtained, we were able to follow up references cited by more recent relevant authors to develop a breadth of sources. Although this method was less systematic than we intended, we found a large degree of convergence in citations of our themes. More than half of the themes (57%) were addressed by multiple authors. Moreover, many of the single author citations were cited multiple times by the same author or were factors related to outcome, which we chose not to combine because they were very specic in nature (e.g., themes 60-63 all address poorly timed interpretations but were not combined into a single general theme). We felt these specic outcome hypotheses were easier to apply to future testing than a more general combined hypothesis. Given this degree of overlap, we believe that we have addressed the major
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theoretical points and are unlikely to have missed many substantial themes from other works. However, we acknowledge that the literature review process was imperfect, and while most of the important themes were likely captured, we have undoubtedly missed some works that may also have been referenced for these themes. A second limitation is that multiple authors described similar ideas in different language with different examples, resulting in some variations around a common theme. In most of these instances, we focused on the core idea that the authors agreed upon, thus coalescing around a single theme rather than a core theme with slight variations. As a result, some authors might nd our characterization of their support for a given theme to be largely but not perfectly correct.
CONcLusiON
This report is an early step towards the empirical study of defense interpretation. The testable hypotheses highlighted provide a beginning point for research that has the potential to directly impact clinical practice and identify factors that are important for psychotherapy outcome. Moreover, results of this research may lead to the development
of specic empirically supported guidelines for interpreting defenses. These guidelines would be particularly benecial to novice clinicians, but also to seasoned clinicians who can run into difcult or novel situations in which directions on how to proceed are needed. Currently, this knowledge is limited to clinical wisdom, based on individual experience. This report leads us to consider the role that interpretation of defenses should play in psychotherapy. Although transference interpretation has traditionally received more interest in the literature, in practice, defense interpretations are utilized more frequently by therapists. Finally, the literature related to defense interpretations is broad and covers much of the breadth of psychotherapy in general. This may be indicative that defense interpretations have been undervalued in the theoretical literature thus far. In 2000, Vaillant proposed that defense mechanisms might be a metric by which we could judge mental health, much like IQ tests are a metric by which we can measure intelligence. Like others who have reviewed the relationship of defenses to measures of adaptation, we concur. We hope that the future directions identied in this report will help guide researchers in further elucidating the role of interpreting defenses in psychotherapy.
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Psychiatry 74(2) Summer 2011

Addressing and Interpreting Olson et al.

Addressing and Interpreting Defense Mechanisms in Psychotherapy: General Considerations

Addressing and Interpreting

Addressing and Interpreting

TABLE 1. Characteristics of the Patient and Defense Material

Greenson, 1967, p. 137-145

5. Interpret defenses that are least entrenched rst.

6. Interpret character defenses rst.

3. Ego-syntonic Versus Ego-dystonic

Fenichel, 1945, p. 538; Greenson, 1967, p. 78, 96, 118

Addressing and Interpreting

17. Interpret affect before motives (e.g., wishes).

Fenichel, 1953, p. 334; Reid, 1980, p. 96

A.24. The development of transference is a precondition to resistance analysis.

A.26. Bring character resistances into the transference.

B.28 Defense interpretations should not address nontherapy relationships.

Gray, 1973, p. 477, 486

Addressing and Interpreting

B.29 Defense interpretations should address nontherapy relationships.

Fenichel, 1941, p. 96; Rangell, 1985, p. 149, 168

32. As resistance develops, interpret it early on to make it ego-dystonic.

Greenson, 1967, p. 72; S. Freud, 1895/1964, p. 282

Greenson, 1967, p. 146-147

36. A good working alliance is required for effective interpretation.

41. Second step is to point out the underlying Affect.

46. Order of what is interpreted is exible, depending on the patient.

Addressing and Interpreting

Addressing and Interpreting

Table 2. Characteristics of the Therapist

Table 3. Characteristics of the Treatment

A.49. Interpretation is better at the beginning of the session.

Fenichel, 1953, p. 322; Fenichel, 1954, p. 21; Wolberg, 1977, p. 592

A.53. In early sessions, identify resistance through interpretation.

Greenson, 1978, p. 216-217

A.56 In early sessions interpret character defenses.

B.57. In middle sessions, increase the use of defense interpretations.

C.58. In late sessions, begin interpreting character defenses.

Table 4. General Characteristics Affecting Outcome of Defense Interpretations.

16. Factors Associated with Negative Outcome

60. Poor timing of interpretation is ineffective.

61. Premature interpretation prevents progress in treatment.

Greenson, 1967, p. 122-123; Perry & Bond, 2005, p. 535

63. Premature interpretation leads to excessive anxiety.

Rangell, 1985, p. 150 Perry & Bond, 2005, p. 536

64. Interpreting too frequently will overwhelm patients.

65. Interpreting too frequently diminishes the emotional impact of interpretation.

Greenson, 1967, p. 123 Reich, 1933/1972, p. 27

Addressing and Interpreting

66. Interpretation of content before resistance leads to resistance in the transference.

68. If interpretation is too complicated, then it may be ineffective.

71. Effective interpretations result in a dynamic change in patients behavior.

Perry & Bond, 2005, p. 536

Addressing and Interpreting

Addressing and Interpreting

Addressing and Interpreting

Addressing and Interpreting

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