challenging defenses

One of the therapist’s key functions is to evaluate the patient’s personality. When patients present in therapy with symptoms as their chief complaint, such as reported “knots” in their stomach, depressive rumination, nightmares, etc., then it’s likely their personality is generally adaptable. In other words, most patients present to therapy to talk about and work through their own symptomology. However, there are certain personality types that claim other people are the source of their distress. In that case, they’re either in a highly dysfunctional relationship or the therapist is dealing with a disordered personality (Lester, n.d.).

Cain presents with “knots” in his stomach. It’s easy to assume that his personality is intact. However, when he starts condemning others in session, that assumption becomes questionable. Cain reports, “I hate people and often fantasize about leaving everyone to live alone in the forest.”

The therapist initially seeks to normalize the statement, “Sages, wisdom-seekers, and monks across the span of centuries have done exactly that,” to give Cain the benefit of the doubt, he may be experiencing a natural phenomenon of the spirit.

On the other hand, what does he mean when he says, “I hate people” and how will “living alone in the forest” assist him in developing beyond that stuck point? It’s likely that the Desert Fathers, who spent their entire adult lives meditating in caves, did so for a more noble reason, not because they hated people. Either way, the therapist’s initial response is to first normalize the patient’s presentation, then consider the alternative, quietly. The patient and therapist are still in the evaluation stage of the treatment process, and any interpretation of the patient’s personality is severely premature considering the limited data collected, thus far.

A note is made that the patient likely avoids connection with other people, and to collect a more robust constellation of character, the therapists asks, “What do you hate about people?”

“They’ve all betrayed me. I don’t trust anyone.”

Considering Karpan’s drama triad (Karpman, 1968), the patient is clearly making a statement of victimhood in which an other(s) has betrayed him. Two diagnoses present themselves. First, Cain has characteristics of a disordered personality. Alternatively, there’s a chance Cain has been harmed by a perpetrator and has something akin to PTSD. In some cases, both may be accurate depictions of the patient’s presentation. Psychological trauma, particularly during developmental sensitive periods, can potentiate an underlying predisposition and contribute to the emergence of disordered personality characteristics (Zanarini et al., 1997; Johnson et al., 1999; Paris, 2000; Widiger & Trull, 2007). Either way, it’s far too early to determine which is the most pertinent. The therapist’s responsibility at this stage of the therapeutic process is to focus exclusively on data collection.

The conversation continues, “Can you tell me about the betrayal?”