Studies on ego defense mechanisms (EDMs) have established them as observable phenomena and demonstrated their relation to measurable aspects of health and illness (1, 2). Among other things, empirical research on EDMs has found that adolescent defenses used in adolescence predict health in adulthood (3), that immature defenses such as hypochondriasis are associated not with specific forms of "psychosomatic" illness but with chronic illnesses of many types (4), and that flexible adaptations can be thwarted by conditions that affect brain function (5, 6).
Early psychoanalysis itself paid little attention to EDMs because they could be observed only when deployed and appeared to have little to do with the process of understanding the unconscious (7). The same characteristics in our day offer ways of recognizing changes in brain function (8), improvement or worsening in psychological health status (9), and healing in response to psychotherapy, or medication treatments, or both (10). For many, however, EDMs appear to be theoretical research constructs or psychodynamic theories more than clinically applicable tools. In part, this may be due to the lack of systematic teaching for residents and others in the techniques involved in EDM recognition and use.
This report focuses on a simple question: can EDM recognition be taught? It presents data from successive classes of psychiatric residents who participated in a course that presented a clinical method of recognition of EDMs. The working hypothesis for this project asserted that residents’ knowledge of EDM recognition would increase significantly after the formal learning experience.
In response to requests from previous classes of psychiatry residents exposed only to EDM theory, the author devised a course focusing on EDM recognition in the clinical setting. The course was conducted in eight weekly sessions: first were two sessions outlining the theory and nosology of EDMs as well as a clinical algorithm on recognizing them. The next six of the weekly sessions were dedicated to exercises in which class members were given teaching materials in which EDMs could be observed. Class discussions focused on which EDMs the residents recognized along with the justifications for their assessment based on the data presented.
The materials used for the class discussions took several forms including vignettes from works of literature (published short stories, novels, plays and poems), excerpts from public descriptions of crises reported by the news media (for example, the Columbine murders, the World Trade Center disaster), videotaped interviews of consenting subjects interviewed by the author for use in this course (focusing on specific problems such as the new onset of serious illness or reaction to medical procedures), and case presentations brought in by the residents themselves. The use of EDM recognition as a tool in psychiatric differential diagnosis, for example in relation to physical illness or social trauma, was presented as a theme throughout the course.
The data reported here were gathered prospectively as part of the quality control (teaching effectiveness) assessment for the course. Each participant was asked to answer a 10 item test on EDM recognition at the beginning of the first teaching session; an example is provided in Appendix 1. A similar 10-item test was given at the beginning of the eighth and final teaching session of the course. Both tests were devised by the instructor from the course material. Participation in both tests was voluntary, and course participants were informed that they could refuse the test without prejudice. Before the first exam, it was explained that test data were gathered to assess teaching effectiveness only and had no use whatsoever in any evaluation procedure of the residents’ performance. No grades were given in the course. The posttest correct answers were discussed in the final session as a teaching exercise. The test data were not conveyed to the residency director’s office or to any other forum where residents’ performance might be evaluated; the data were kept by the author in locked files.
All of the test items were written in a multiple-choice format that allowed for one correct answer per item from a choice of four possible answers. Each test was scored by the frequencies of correct answers out of 10 possible answers. Pre- and posttest scores were grouped according to the timing of the test. Scores from successive resident classes were pooled in pre- and posttest groups and were coded and then entered into a spreadsheet with no identifying information included. Based on the a priori hypothesis, one-tail Student’s t tests for mean comparison of paired data were used to assess total group mean differences between pre- and posttests. Since the tests were 7 weeks apart, no assessment of test/retest learning was undertaken. A statistical probability difference of <0.05 was considered significant.
A total of 28 psychiatric residents from two successive classes participated in the EDM course as part of the required training in the 11th and 12th months of their second residency year. All 28 took the pretest in the first session, but only 25 (89%) were available for the posttest at the last session owing to summer vacation schedules. The three pretest scores without paired posttest scores were dropped for the final sample (N=25). Stated as percent of items answered correctly, pretest mean scores were 54% (SD=15); mean scores in the posttest were 82% (SD=16). The difference in means was highly significant (p<0.0001) (F1).
Data from this teaching experience suggest that a systematic method of EDM recognition can be taught effectively to second-year residents. At the same time, their ease of learning what often may appear to be overly subtle clinical phenomena indicates the residents’ ability both to understand the theoretical underpinnings and to acquire the skills necessary for clinical recognition of EDMs.
The study is limited by its relatively small sample size and its confinement to only one instructor in one institution. Demonstration of the appropriateness of teaching this course in other institutions must await the development of a systematized curriculum that can be exported. At the same time, follow-up study that demonstrates the continued use of EDM recognition skills in clinical settings will be needed to establish the ongoing practicality of this tool in clinical assessment.
As an example of the kind of vignette used in the course, the author provides the following passage from Herodotus (484—425 B.C.), a contemporaneous historian of ancient Greece. The scene is the famous Battle of Thermopylae: a mountain pass at which a small unit of Greek warriors held off an overwhelming Persian invading force, for a time. Herodotus records an instance just prior to the fighting when he introduces us to one of the combatants, Dieneces:
Of all the Spartans and Thespians who fought so valiantly, the most signal proof of courage was given by the Spartan Dieneces. It is said that before the battle he was told by a native of Trachis that when the Persians shot their arrows, there were so many of them that they hid the sun. Dieneces, however, quite unmoved by the thought of the strength of the Persian army, merely remarked, ‘This is pleasant news that the stranger from Trachis brings us: if the Persians hide the sun, we shall have our battle in the shade.’ He is said to have left on record other sayings, too, of a similar kind, by which he will be remembered (11).
Dieneces uses the mature defense of humor—that is, the ability to laugh at one’s self and one’s circumstance even when the latter is most distressing. The effect, the terror of imminent violent death in this case, is nearby. As readers we perceive that terror as the emotional energy in Dieneces’s joke. As the joke engages our emotions, we perceive his bravery. We admire him as, according to Herodotus, did his contemporaries who recognized him for similar comments. Mature EDMs, such as humor, integrate cognition (incipient violent death) and emotion (terror) in a way that is creative and that connects with others in a positive, welcoming manner, whether on the battlefield of the time or when reading the account centuries later.
In the class, however, the nature of the various EDM domains—primitive, immature, neurotic, and mature (3)—is not apparent to most students at the beginning. The task of the instructor is first to provide repeated exposure to a series of vignettes that elicit EDMs in the main characters or in the videotaped interviews; these exemplify the different domains. The second and equally important task is to foster the informed discussion among the learners that leads to their experiencing recognition. This entails the residents’ stating which EDM domain or specific defense is in operation and how they can substantiate their view from the presented material. For this purpose, both printed and video recorded materials offer particular usefulness because they can be referred to or replayed to compare a recognition hypothesis against the actual data. While live interviews can elicit EDM productions as well, unless they are recorded, the learning device of review and comparison depends on the often varying memories of the conversation or may be lost altogether.
The enthusiasm with which the residents joined in the discussions as they learned about EDMs in a clinical context and began bringing their own clinical cases into the course offered a subjective indication of both the usefulness they found in the topic as well as the professional fun of acquiring new ways to see and consider human behavior. Many participated in animated discussions on differential diagnoses for their patients after each course session had concluded. The enthusiasm exhibited by the participants, along with the data presented above, suggest that EDM recognition can be taught to this willing and interested audience.