Journal of Abnormal Psychology

1994, Vol. 103, No. 1.44-50

Copyright 1994 by the American Psychological Association Inc

0021-843X/94/S3.00

Ego Mechanisms of Defense and Personality Psychopathology

George E. Vaillant
It is often not just life stress but also a person's idiosyncratic response to life stress that leads to
psychopathology. Thus, despite problems in reliability, the validity of defenses makes them a valuable diagnostic axis for understanding psychopathology. By including a patient's defensive style as
part of the diagnostic formulation, the clinician is better able to comprehend what seems initially
most unreasonable about the patient and to appreciate what is adaptive as well as maladaptive about
the patient's defensive distortions of inner and outer reality. Clinical appreciation of the immature
defenses (e.g., hypochondriasis, fantasy, dissociation, acting out, projection, and passive aggression)
is particularly useful in classifying and caring for individuals with personality disorders.

In no area of psychology is the need for a synthesis of frames

of reference greater than in the field of personality psychopathology. Two vantage points are in special need of integration.
First, there is the descriptive, categorical classification system of
personality disorder, epitomized by Axis II of the third edition
of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-III; American Psychiatric Association, 1980). Second,
there is the more inferential, psychodynamic viewpoint of personality shaped by mental conflict and ego mechanisms of defense. After all, if both phenomenology and pathophysiology are
important in the understanding of disease, they are both crucial
in the understanding of personality disorder. Nineteenth-century medical phenomenologists viewed pus, fever, pain, and
coughing as evidence of disease; 20th-century pathophysiologists regard these same symptoms as evidence of the body's
healthy efforts to cope with physical or infectious insult. In similar fashion, much of what modern phenomenologists classify as
mental disorders may be reclassified as the outward manifestations of the mind's adaptive efforts to cope with psychological
stress.
For example, hypochondriasis and somatization are treated
as discrete disorders in the DSM-III. According to the DSMIII the hypochondriacal individual complains of an illusory disease, and the individual afflicted with somatization disorder
complains of illusory symptomsa hair-splitting distinction
without justified empirical foundation. It may be more useful
to view both reactions as reflecting defense mechanisms, not
diseases. Hypochondriasis and its associated help-rejecting
complaining often conveys unconscious reproach and devaluation. Hypochondriasis makes the observer annoyed. In contrast,
somatization characterized by the defense mechanism of displacement often results in secondary gain and may serve as a
means of communicating an unconscious, or at least unverbalized, affective state. Somatization often captures the observer's
attention. When the distinction between somatization and hypochondriasis is made in this way, it becomes clinically useful.
In his efforts to lay the groundwork for the 10th edition of

the International Classification of Diseases, Norman Sartorius

(Sartorius, Jablensky, & Regier, 1990), the director of the Division of Mental Health of the World Health Organization, wrote
that
research during the past two decades failed to provide evidence
that could help to create disease concepts and disease entities in
p s y c h i a t r y . . . . Other ways of thinking about health and disease,
mind and body, mental and physical, individual and social are
needed . . . . I believe that in selected instances a return to the
allegedly outdated Meyerian reaction patterns and Freudian defense mechanisms is warranted, (p. 2)

Defense mechanisms refer to innate involuntary regulatory

processes that allow individuals to reduce cognitive dissonance
and to minimize sudden changes in internal and external environments by altering how these events are perceived. Defense
mechanisms can alter our perception of any or all of the following: subject (self), object (other), idea, or feeling (Vaillant,
1971). There is increasing evidence that the choice of defensive
style makes a major contribution to individual differences in
responses to stressful environments (Vaillant, 1992b). Nowhere
is Sartorius's "return to allegedly outdated defense mechanisms" as warranted as in the domain of personality disorders
(Skodol & Perry, 1993). Thus, as an aid to describing personality disorders, the revised third edition of the DSM-III (DSMIII-R; American Psychiatric Association, 1987) has included a
glossary of defense mechanisms, and the DSM-IVwi\\ probably contain hierarchically arranged defenses as an optional axis.
S. Freud (1894/1964) observed that affect could be dislocated
or transposed from ideas (by the unconscious mechanisms that
he would later call dissociation, repression, and isolation) and
that affect could be reattached to other ideas (by the mechanism
of displacement). He also noted that subject and object could
be reversed by the process that he called projection. Over a period of 40 years, Freud and his daughter (A. Freud, 1937) outlined most of the defense mechanisms of which we speak today
and identified five of their important properties: (a) Defenses
are a major means of managing conflict and affect; (b) defenses
are relatively unconscious; (c) defenses are discrete from one
another; (d) although often the hallmarks of major psychiatric
syndromes, defenses are reversible; and (e) defenses are adaptive
as well as pathological.
Some defenses (e.g., altruism and suppression) appear much

Correspondence concerning this article should be addressed to

George E. Vaillant, Division of Psychiatry, Brigham and Women's Hospital, 75 Francis Street, Boston, Massachusetts 02115.
44

DEFENSE AND PERSONALITY

Table 1
Ego Defenses Defined in the DSM-III-R, Arranged in Order
of Their Empirical Association With Global
Assessments of Mental Health
Category
Psychotic defenses
Immature defenses

Neurotic (intermediate)
defenses

Mature defenses

Defense
Denial (of external reality)
Distortion (of external reality)"
Passive aggression
Acting out
Dissociation
Projection
Autistic fantasy
Devaluation, idealization, splitting15
Intellectualization, isolation
Repression
Reaction formation
Displacement, somatization
Undoing, rationalization
Suppression
Altruism'
Humor8
Sublimation8

Note. DSM-I1I-R = revised third edition of the Diagnostic and Statistical Manual of Mental Disorders.
' Altruism, humor, sublimation, and distortion are terms used in the text
of this article but not in the DSM-III-R. b Devaluation and to a lesser
degree splitting are included under my term hypochondriasis, a term
not included in the DSM-III-R glossary.

healthier than others (e.g., projection and distortion). In the last

50 years Anna Freud (1937), George Engel (1962), Richard
Lazarus (1983), and Karl Menninger (1963), among others, deserve special credit for underscoring the need to define a hierarchy of defense mechanisms. Every one of these investigators,
however, presented a different nomenclature; no one supplied
mutually exclusive definitions; and few sought rater reliability
or provided empirical evidence beyond clinical anecdotes. This
lack of empirical study has retarded the acceptance of defense
mechanisms by academic psychology. Because it offers a tentative glossary of consensually validated definitions, the DSMIII-R is a step forward.
In the last 10 years, several empirical studies (reviewed by
Cramer, 1991, and Skodol & Perry, 1993) finally avoided these
limitations and replicated earlier studies showing that defenses
could be organized into a hierarchy of relative psychopathology
(Haan, 1977; Vaillant, 1977; Weinstock, 1967). Table 1 arranges these defense mechanisms into four general classes of
relative psychopathology. The so-called immature defenses in
Table 1 are the ones that underlie much of personality disorder.
Defense mechanisms of the class mentioned by Sartorius
must be distinguished from two other major classes of coping
response. One form of coping involves eliciting help from appropriate others, for example, by mobilizing social support. A
second form of coping includes voluntary cognitive efforts, such
as information gathering, anticipating danger, and rehearsing
responses to danger. But seeking social support and using conscious cognitive strategies are quite distinct from the more involuntary adaptive mechanisms often subsumed under the
term ego mechanisms of defense.
The use of ego mechanisms of defense usually alters percep-

45

tion of both internal and external reality and often, as with hypnosis, the use of such mechanisms compromises other facets of
cognition. Like hypnosis, defense mechanisms involve far more
than a simple neglect or repression of reality. In short, defenses
reflect integrated dynamic psychological processes for coping
with reality rather than either a deficit state or a learned voluntary strategy.
Table 2 summarizes how the defenses most closely associated
with personality disorders allow an individual to deal with sudden stress by discrete styles of denial or self-deception. The table
offers brief operational definitions of defense and a means of
distinguishing them in a mutually exclusive manner. In real life,
individuals characteristically deploy several defenses, not always from the same level. Just as forests are not made up of just
one kind of tree, or rocks of just one element, of necessity, Table
2 oversimplifies. Nevertheless, the ability to identify trees, elements, and defenses helps us to classify our complex world.
As Table 2 suggests, defenses also alter the relationship between self and object and between idea and affect. In projection,
for example, "I hate him" becomes "He hates me." In addition,
defenses dampen awareness of and response to changes in
drives, in conscience, in relationships with people, and in reality. First, defenses allow individuals a period of respite to master
changes in self-image that cannot be immediately integrated, as
might result from puberty, an amputation, or a promotion (i.e.,
changes in reality). Second, defenses can deflect or deny sudden
increases in biological drives. Awareness of instinctual wishes
is usually diminished; alternatively, antithetical wishes may be
passionately adhered to. Third, defenses enable individuals to
mitigate unresolved conflicts with important people, living or
dead. Finally, ego mechanisms of defense can keep anxiety,
shame, and guilt within bearable limits during sudden conflicts
with conscience and culture.
Unlike psychosis and neurosis, personality disorders almost
always occur within a social context. It is difficult to imagine a
hypochondriac or paranoiac becoming symptomatic on a desert
island. Thus, if neurotic symptoms are a means of coping with
unbearable instincts, the symptoms of personality disorder are
a means of coping with reactions to unbearable peoplein past
or present time. Thus, the understanding of immature defenses
requires conceptual models that focus more on attachment theory, scripts, and role-relationship models (Horowitz, 1988)
than on drives and instinctual wishes.
The projection used by a paranoid person, by which unacknowledged feelings are attributed to others, is well known. So
is the capacity of schizoid individuals to relieve loneliness by
creating fantasized human relationships within their own
minds. The capacity of histrionic personalities to disassociate
themselves from painful emotion and to replace unpleasant
with pleasant affect, as if they were on stage, is familiar. So is the
fact that passive-aggressive and masochistic individuals turn
anger against themselves in a most annoying and provocative
manner.
The mechanisms of acting out and hypochondriasis are less
familiar. In the antisocial personality, acting out reflects a process through which the direct motor expression of an unconscious wish or conflict allows the individual to remain unaware
of either the idea or the affect that the action accompanies.
Thus, acting out produces the clinical illusion that all socio-

46

GEORGE E. VAILLANT

Table 2
Scheme for a Differential Identification of Immature Defenses
Source of conflict
Style of defense
Projection
Fantasy
Hypochondriasis
Passive
aggression
Acting out
Dissociation

Affect or drive

Conscience
or culture

Externalized

Relationships
or people

Distorted
Turned on self

Exaggerated

Distorted
Taken inside
Devalued
Exaggerated

Disinhibited
Altered

Ignored
Altered

Displaced
Exaggerated

Ignored

Expression of impulse
Reality
Exaggerated

Self or
subject

Idea

Affect

Altered

Diminished
Anger becomes pain

Made object
Omnipotent

Distorted
Made object
Omnipotent

Ignored

Ignored
Altered

Object
Made self
Within self
Displaced
Ignored
Generalized

Note. From The Wisdom of Ego (pp. 36-37) by G. E. Vaillant, 1993, Cambridge, MA: Harvard University Press. Copyright 1993 by Harvard
University Press. Adapted by permission.

paths do not experience the painful affects of guilt, anxiety, or

depression. In fact, nothing could be further from the truth
(Vaillant, 1975).
Hypochondriasis disguises reproach (Brown & Vaillant,
1981). The help-rejecting complaints of a person with borderline personality that clinicians make him or her worse may conceal grief and unacceptable aggressive impulses. By exaggerated
focus on current somatic or psychic pain that cannot be relieved, the hypochondriac attempts to manage past unbearable
grief or abuse. This point is more fully elaborated elsewhere
(Vaillant, I992a).
Table 3 puts the defenses underlying Axis II disorders in the
perspective of both the psychodynamic and the genetic and temperamental domains. When conceptualized in terms of reversible defenses, rather than as the result of a largely irreversible,
genetically ordained temperament, personality disorders can be
viewed as potentially more plastic and more dynamic. Such
plasticity is supported by prolonged follow-up studies (Perry,
1993; Stone, 1990; Thomas & Chess, 1984; Vaillant, 1993).

Table 3
Congruence of Different Domains of Classification
of the Personality Disorders
Classification domain
DSM-IIIandlCD-9
diagnostic domain
Paranoid, schizoid,
schizotypal
Antisocial, narcissistic,
borderline,
histrionic, explosive
Avoidant, dependent,
compulsive,
passive-aggressive,
affective, anankastic

Genetic or
temperament

Psychodynamic or
adaptive

Schizophrenic
spectrum,
psychoticism
Psychopathic
spectrum,
extra version

Projection, schizoid
fantasy

Introversion,
neuroticism

Acting out,
splitting,
devaluation,
dissociation
Passive aggression,
hypochondriasis

Note. DSM-Iff = third edition of the Diagnostic and Statistical Manual of Mental Disorders; ICD-9 = ninth revision of the International
Classification of Diseases.

Empirical Evidence
Too often, different frames of reference or different nosologies are contrasted by studying them in different groups of individuals. This technique makes real comparison of vantage
points impossible. For this reason, I discuss a single sample
studied from multiple vantage points. A cohort of relatively unselected junior high school boys (Glueck & Glueck, 1950) were
followed for 35 years (Vaillant, 1983). The sample originally included 456 boys studied by the Gluecks between 1940 and 1963
as a control group for their well-known investigations of juvenile delinquency (Glueck & Glueck, 1968). The boys had been
carefully matched with a sample of Boston youths remanded to
reform school for age, IQ, ethnicity, and high crime neighborhood. Their mean age was 14 years (SD = 2), and their average
IQ was 95 (SD = 12). They attended inner-city schools. None of
the boys was African American, but 278 (61%) had at least one
parent who was foreign born.
Approximately 80% of the surviving subjects received semistructured interviews at age 25 (n = 360), age 31 ( = 349), and
age 47 (SD = 2,n= 369). Questions regarding alcohol use and
social and occupational functioning were specifically included
in these interviews. In addition to interview data, psychiatric,
medical, and arrest records were obtained over the 33-year follow-up period. In addition, estimates of both childhood social
class (Hollingshead & Redlich, 1958) and ratings of multiproblem family membership were made by raters unaware of adult
adjustment (Vaillant, 1983).
The entire sample of men was assessed by independent sets of
raters along three contrasting diagnostic axes. The first axis was
each man's global psychiatric impairment as measured by the
Health Sickness Rating Scale of Luborsky (1962), the prototype
of Axis V of the DSM-III-R. The second axis was the DSMHPs Axis II: Which diagnoses, if any, did each man meet? The
third axis was the maturity and nature of each man's predominant defense mechanisms as outlined in Tables 1-3. The assessors of each axis were kept unaware of both the men's ratings
on the other two axes and their childhoods (Drake & Vaillant,
1985; Vaillant & Drake, 1985).
Over the 33-year follow-up period, attrition was modest. Of
the original 456 subjects, 33 (7%) had died, 29 (6%) had withdrawn from the study, and 25(5%) were not interviewed directly

47

DEFENSE AND PERSONALITY

Table 4
Association of Individual Defenses With Axis H Personality Disorders

Category

Immature
defenses
predominate

No personality disorder
Personality disorder
Cluster A
Schizoid
Paranoid
Cluster B
Narcissistic
Antisocial
Cluster C
Avoidant
Passive-aggressive
Dependent

233
74

10
66

2
17

2
15

12
6

39
100

17
33

21

18
8

78
75

12
14
23

58
71
78

Acting
out

Projection

Passive
aggression

32

12
27

7
27

12
34

17

17
33

6
75

17
100

11
33

11
0

17
0

3.
63

61

25

39
39

33
25

17
0
26

8
7
17

25
43
56

17
21
30

17
14
26

25
61
30

Hypochondriasis

Fantasy

Dissociation
7

Note. Values presented are percentages. Numbers of Axis II diagnoses add up to 99, not 74, because in 25 cases men met criteria for two diagnoses.
Underlined cells highlight the association of Axis II categories with an individual's dominant use of the defense considered characteristic of that
category. Defense choice and Axis II diagnosis were determined by independent raters.
for a variety of reasons. The other 369 (87% of the survivors)
were evaluated for personality disorder. Blind estimates of maturity of defenses were available for 307 of the 369 interviewed
subjects.
Relative immaturity of defenses was assessed with a 9-point
scale (1 indicating mature and 9 immature). Examples of adaptive behavior at times of crisis and conflict were excerpted as
vignettes. On the basis of a glossary (Vaillant, 1977), each vignette was labeled as one.of 15 different defenses. These 15 defense headings were grouped into immature (schizoid fantasy,
projection, passive aggression, hypochondriasis, acting out, and
dissociation); intermediate (intellectualization or isolation, repression, displacement, and reaction formation); and mature
(sublimation, suppression, anticipation, altruism, and humor)
categories. Interrater reliability for scaling of the maturity of
the three groupings of defenses has ranged from .72 to .84.
Methods for identifying individual defenses, rationale, and reliability are described in detail elsewhere (Perry & Cooper, 1989;
Skodol & Perry, 1993; Vaillant, 1992b).
Although mature defenses are arguably more conscious and
certainly more successful as coping strategies than immature
defenses, to dichotomize defenses as either coping or defending
has proven both arbitrary and unhelpful. Both functions are
encompassed by each defense. The defense most highly associated with mental health is suppression, by which individuals
deal with emotional conflict or internal or external stressors
through stoicism, by postponing but not ignoring wishes, and
by subjectively minimizing but not ignoring disturbing problems, feelings, and experiences.
The ratings of personality disorder were made on the basis of
a 2-hr interview by two research psychiatrists when subjects
were 47 years old. Criteria from Axis II of the DSM-HI were
used exclusively. Interrater reliability for the presence or absence of personality disorder resulted in a kappa of .77, but for
individual diagnoses the average kappa was .41.
Table 4 shows the distribution of Axis II diagnoses. Seventyfour (24%) of the 307 men with available ratings for maturity of
defenses met DSM-HI criteria for personality disorder. Raters

attempted to select a most likely diagnosis among the 11 specific

Axis II diagnoses and to specify all of the specific diagnoses
present rather than use the categories atypical and mixed.
Twenty-five of these men met criteria for more than one Axis
II diagnosis. Diagnoses were skewed toward the interpersonally
withdrawn disorders, such as schizoid, avoidant, and dependent, and away from the acting-out disorders, such as antisocial.
This distribution reflects the original sample-selection criterion
of nondelinquency in early adolescence. Compulsive traits were
not a predominant response mode in this sample of men from
lower class, less oversocialized backgrounds (Snarey & Vaillant,
1985); thus, no subjects met criteria for diagnosis of compulsive
personality disorder.
Table 4 also depicts the relation of individual Axis II personality disorder diagnoses to the use of individual defenses as a
major style. (If one rater scored a given defense as major and the
other scored it as either major or present, men were considered
to use that defense as a major style.) As might be expected, all
men meeting the criteria for paranoid character used projection
as a major defense. Both the narcissistic and antisocial characters seemed to use projection, acting out, and dissociation.
However, narcissistic personalities did receive far lower scores
on Robins's (1966) scale of deviant behaviors than did those
who met Axis II criteria for antisocial personalities. Two thirds
of the men meeting the criteria for passive-aggressive personalities tended to turn anger provocatively against themselves. A
third of the men who met Axis II criteria for schizoid personality used fantasythe least frequently identified defenseas a
dominant style. Avoidant personalities did not appear to specialize in any one defense. These data lend support to the theoretical outline presented in Table 3.
Any scheme that classifies a community sample in terms of
relative mental health will note that individuals with personality
disorders are concentrated among the least healthy and that
such individuals have difficulty in working and loving. Table 5
shows the relationship of selected immature and mature defensive styles to global mental health as measured by the Health
Sciences Rating Scale. Studies from a companion cohort of col-

48

GEORGE E. VAILLANT

Table 5
Percentage of Individuals at Different Levels of Global Mental
Health Using Selected Defenses
HSRS score
Major defense

0-65
(n = 53)

66-70
(n = 36)

71-84
(n=143)

85-99
(n = 74)

Projection
Fantasy
Hypochondriasis
Passive aggression
Dissociation

30
19
21
32
55

17
11
11

36
36

7
1
1
15
15

0
0
0
1
1

0
2

3
14

6
27

35
59

Altruism
Suppression

Note. Low scores on the HSRS indicate impaired mental health, and
high scores indicate good mental health. HSRS = Health Sickness Rating Scale.

lege-educated men has confirmed that maturity of defenses is

as robust an indicator of adult mental health as any of the other
adult outcome variables (Vaillant & Schnurr, 1988) and as good
a predictor of future mental health as any other single variable
(Vaillant & Vaillant, 1990).
It is tempting to view mature defenses as a by-product of middle-class socialization or at the very least of loving parents.
However, there was not a strong association between the maturity of defenses and the quality of the men's childhoods. Table 6
illustrates that the correlation of maturity of defenses with
global mental health, with the absence of sociopathic traits, with
regular unemployment, and with adult social class were highly
significant (p < .001) but that the correlations with childhood
socioeconomic status and other childhood problems could have

occurred by chance. Because all of the men had been raised in

inner city neighborhoods and because parental social class did
not affect defensive style, the association of low adult social class
with immature defense deployment seemed a result, not a
cause, of immaturity of defensive style. Although cross-cultural
studies are sorely needed, the absence of socioeconomic status
as a predictor of maturity of adult defensive style has been confirmed by contrasting these inner city men with a sample of
Harvard graduates and with Lewis Terman's gifted women
(Vaillant, 1992b). In other words, ego defenses, like the immune
system, may represent an innate means by which humans protect themselves.
Admittedly, pathophysiology is more difficult to study empirically than is phenomenology. Defenses are, after all, metaphors;
they are a shorthand way of describing different cognitive styles
and mental modes of altering inner and outer realities. Like creativity and intelligence, defense mechanisms reflect integrated
mental processes and cannot be broken into component parts,
reliably measured, and uniformly labeled. Thus, like creativity,
defenses have not yielded easily to rating scales (Bond, Gardiner, Christian, & Sigal, 1983; Gleser & Ihilevich, 1969), to experimental analysis (Kline, 1972; Moos, 1974), to projective
tests (Blum, 1956), or even to precise description (Siegel, 1968).
In addition, the validity of defense assessment goes down as the
ease of administration (e.g., multiple-choice questionnaire) and
reliability (e.g., Q-sort techniques) go up (Vaillant, 1992b; Vaillant, Bond, & Vaillant, 1986).
Defenses, however, can be consensually validated on the basis
of multiple observations or multiple observers or both. Thus,
the clinical techniques used by Haan (1977), Vaillant (1977),
and especially Perry and Cooper (1989) appear most helpful in
identifying defenses. These techniques use the long view and
the strategies that Runyan (1982) outlined for qualitative, as

Table 6
Percentage of Individuals in Each Category ofMidlife-Defensive
Selected Childhood and Midi ife Psychosocial Criteria

Maturity Manifesting

Maturity of defensive style

Criterion

Immature
(n = 73)

Neurotic or
intermediate
(n = 164)

Mature
(n = 70)

Midlife"
HSRS score
Healthy (85- 100)
Impaired (0-65)
5+ on Sociopathic Traits Scale (Robins, 1966)
4+ years unemployed
Social Class V

71

21

14
9
2

44
21

10
4

4
1

26
14
36
42

24

32

10
29
26

26
30

1
54

0
3

Childhood"
Social Class V
Multiproblem family membership
Emotional problems
Less than 10 grades of school
Note. HSRS = Health Sickness Rating Scale.
"Age 47. b Age 14.

12

DEFENSE AND PERSONALITY

opposed to quantitative, research in personality. Intrapsychic

distortions (defenses) can also be inferred (triangulated) with
some reliability by contrasting self-report (autobiography) with
objective report (biographical record) with symptoms (creative
product). With the use of such biographical methods, the subjectivity of clinical intuition is avoided, as is the artificiality of
the psychological laboratory and pencil-and-paper instruments.

Conclusions
Despite problems in reliability, the validity of defenses makes
them a valuable diagnostic axis for understanding psychopathology. There are several reasons why. First, clinicians now appreciate that the symptomatology of infectious disease is often
caused not so much by the bacteria as it is by the idiosyncratic
adaptive response of the host to the infectious agent. These same
pathophysiological principles hold true in psychology. It is often
not just life stress but also the patient's idiosyncratic response
to life stress that leads to psychopathology. By deciphering defenses, we can begin to understand the underlying pathophysiology of our patient's disorder. In contrast, by thoughtlessly
challenging irritating, but partly adaptive, immature defenses,
a clinician can evoke enormous anxiety and depression in a patient and rupture the alliance.
Second, sometimes phobia is a primary illness to be treated
with drugs or behavior therapy; sometimes it reflects a displacement of affect. Clinical medicine appreciates that almost half of
all visits to general physicians are made by patients with functional disordersin other words, by patients with psychological
illness or problems in living who have displaced, projected, repressed, or transformed these problems into serviceable medical complaints (Vaillant, Shapiro, & Schmitt, 1970; Von Korff
et al, 1987). Similarly, complaints of Axis I disorders should
often be treated as clues to lead the clinician to the primary
cause and not be mindlessly eradicated.
Third, attempts to mitigate the immature defenses of individuals with personality disorders are facilitated by strong social
supports. But empathic social support of such difficult individuals requires a clear understanding of the dynamics of their defenses (Vaillant, 1992a). We all display more mature defenses
when we feel understood.
A final reason for paying attention to defenses can be illustrated by the internist's understanding of referred pain. A pain
in the right shoulder may reflect an inflamed gall bladder; a pain
in the left shoulder may reflect coronary thrombosis. Proper diagnosis depends on the internist's seeing behind the symptom.
By understanding that a function of much psychopathology is
to distort and deny conflict, we learn not to take psychological
symptoms too literally. In short, defenses provide a diagnostic
template for understanding distress and for guiding the clinical
management of psychology's most baffling and frustrating clients.

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Received April 15, 1993
Revision received July 27, 1993
Accepted July 28, 1993

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