Defense mechanisms in substance abuse counselors and therapy outcomes

Defense Mechanisms

Psychologists, particularly psychodynamically-oriented psychologists, view defense mechanisms as allowing people to distance themselves from unpleasant feelings, thoughts, or behaviors. Defense mechanisms are typically categorized on how primitive they are; the more primitive defense mechanisms are typically more ineffective and less "mature." Defense mechanisms are typically unconscious in nature; that is they are activated immediately and without awareness when an individual feels threatened (Wijk-Herbrink, Andrea, & Verheul, 2011). The Thematic Apperception Test (TAT; Murray, 1943) is a projective test that has been used to identify three levels of defense mechanisms in individuals: denial, projection, and identification (Cramer, 1991). The TAT has been validated with respect to its use for this task and is a widely used projective test to understand how people view others, their motivations, and other aspects of their personality (Cramer, 1991; Hibbard et al. 1994*).

Individuals that suffer from substance abuse and addiction have been identified as a group that often uses defense mechanisms to justify their behavior (Twerski, 1997). The most prevalent of these defense mechanisms in addicts and substance abusers is denial (Eliason, Arndt, & Schut, 2005; Stein et al., 2006; Twerski, 1997). Other defense mechanisms commonly encountered in substance abusers and addicts include repression (which is a more mature form of denial), rationalization, intellectualization, projection, identification, and displacement (Eliason et al., 2005; Twerski, 1997). Often the treatment of addicts or substance abusers is difficult due to the "expertise" with which these individuals can apply their defense mechanisms to their disorder and justify or ignore their issues. In substance abuse counseling the defense mechanisms of the counselee (the substance abuser) are often addressed by the counselor in order to assist the client with understanding and overcoming their substance-abuse problem or addiction (White & Miller, 2007). In fact, the whole premise of the popular motivational interviewing technique is applying a tactful manner to overcoming resistance and defense mechanisms in substance abusers (Eliason et al., 2005; White & Miller, 2007).

A significant number of substance abuse and addiction counselors were former substance abusers or addicts in the past (Eliason et al., 2005). Since the use of defense mechanisms is quite prevalent in addicts and substance abusers it can be surmised that a good number of these counselors relied upon them during their abuse or addiction. Moreover, since defense mechanisms by definition are automatic and unconscious it would not be unrealistic to believe that individuals who relied on them to explain past behaviors, even if the behavior is no longer present, might rely on them to deal with other current unpleasant events or feelings (Kramer, 2010). Moreover, relapse rates are high in both former substance abusers counselors and others with substance abuse problems (Stein et al., 2006; White & Miller, 2007). Defense mechanisms are also used to justify these relapses or other coping behaviors (Kramer, 2010; Twerski, 1997).

There has been very little research on the coping methods that substance abuse counselors use, how a substance abuse counselor's defense mechanisms impact therapy outcome, and virtually no research that has identified defense mechanisms used by substance abuse counselors that were former addicts were abusers themselves. Such a study would be useful in determining how these individuals address the challenges of a vocation that has multiple levels of influence and meaning to them and also perhaps identify how their approach and strategy to treating others is impacted by their own views and their responses to them.

Methods

Participants

Thirty substance abuse counselors will be recruited for the study. Fifteen will be former substance abusers were addicts and 15 will not have any abuse or addiction issues in their background. One current client from each counselor will also be selected (n = 30).

For the purposes of this study abuse and substance dependence in counselors will be defined by the DSM -- IV -- TR diagnostic criteria (American Psychiatric Association [APA], 2000) via the use of a clinically validated instrument.

Materials and Resources

Assessment and statistical analysis materials. The following assessment measures will be used:

The Addiction Severity Index 6(ASI6; McCellen et al., 2006) The ASI6 is a semi-structured interview designed to address seven potential problem areas in substance-abusing patients. The ASI6 has been demonstrated to have adequate psychometric properties and provides an overview of problems related to the particular substance of abuse.

The Beck Depression Inventory -- II (BDI-II; Beck, Steer, & Brown, 1996). In order to screen participants for depression which may interfere with the aim of the study participants will be screened with the BDI-II. The BDI-II consists of 21 items read by the subject (or alternatively they can be read to the subject by the administrator). Each item is followed by four options (statements) that the respondent is required to endorse as they are related to their feelings over the prior two weeks including the day of the assessment. It can be used over multiple assessments and remains one of the most used measures of depression for both research and clinical uses. Participants scoring in the depressed range will not be utilized for the study.

Thematic Apperception Test (TAT; Murray, 1943). The TAT consists of 32 picture cards of which normally 10 are chosen when utilizing them for psychological assessment. Some of the cards are gender specific (characters are either male of female) and are designated as either BM (males) or GF (females), whereas others have both genders in the picture (MF) or are gender neutral and have no designating letters following their number. Cards typically are chosen by gender (e.g., males get cards with either male or both genders and vice versa). For this study only six TAT cards will be used as these are the cards that were validated for the identification of defense mechanisms (Hibbard et al., 1994; Porcerelli, Cogan, Kamoo, & Miller 2010). The TAT cards utilizing the study will be card 1, 3GF or 3BM, 6 GFor 6BM, 8GF or 8BM, 10, and 13MF. Subjects are instructed to tell a story about the scene in the card and their responses are recorded verbatim and later coded.

Other materials needed. A Lab top computer, video-recording equipment, SPSS statistical program software, notebooks, ASI6 record sheets, TAT record sheets.

Design and Analyses

The first analysis of the study will compare the differences in the frequency of defense mechanism use between counselors who have no history of substance abuse or addiction and those who do. This portion of the analysis will determine whether or not former abusers and addicts appear to use more defense mechanisms using an independent T test with group (addiction or abuse history vs. no history) as the independent variable and the total number of defense mechanisms produced on the TAT as the dependent variable. An additional analysis could involve looking at differences in the type of defense mechanism used by the two groups with defense mechanism coded as a series of three dependent variables and group as the lone independent variable. Further analysis could determine which defense mechanism each group was more likely to use.

The second set of analyses of the study will compare ASI6 outcome data from one randomly chosen patient of each counselor. This study will utilize the drug/alcohol use scales from theASI6 with the dependent variable being the sum of any instances of use of drugs or alcohol within the past 30 days of the interview. This comparison will be a 2 (groups) X 3 (defense mechanism) ANOVA with numbers of relapses of the client as the dependent variable. This analysis will determine if counselors who use defense mechanisms as coping strategies display differences in their patient outcomes.

The use of SPSS procedures descriptive statistics, measures of reliability for the outcome measures (alpha), correlations, Independent T test, ANOVA, MANOVA and appropriate post hoc tests will be implemented. Alpha level will be set at .05 for the analyses.

Conclusion

Individuals that suffer from substance abuse or addiction have been observed to rely on defense mechanisms as a method for substituting the behavior (Eliason et al., 2005). Because substance abuse and addiction are such difficult problems to resolve or because many substance abusers are forced into treatment due to the ramifications of their behavior many of these individuals end up in counseling for their issues. Likewise, because of the difficulty in resolving abuse or addiction problem and many former addicts and substance abusers become counselors themselves as an effort to help other suffering individuals. These former addicts/abusers most likely relied on psychological defense mechanisms at one time or another to explain their behaviors and since these behaviors are unconscious and automatic it is quite probable that even abstinent or sober former abusers and addicts still rely on them. It would be helpful to know if former addicts/abusers were no counselors use defense mechanisms more often when treating clients in order to understand how this affects relapse in both client and counselor, the quality of the counseling session, the outcome of clients who have counselors with former abuse issues, and to alert counselors to potentially nonproductive behaviors that can occur in therapy sessions.

The current study proposes to determine if indeed counselors who are former addicts or abusers use more defense mechanisms for coping both personally and professionally than do counselors without these histories, if these defense mechanisms surface in counseling sessions, how the counselor views their use of defense mechanisms, and if use of defense mechanisms is associated with therapeutic outcomes. The study will also attempt to ascertain if a specific type of defense mechanism (e.g., denial) is used more often by counselors was substance-abuse histories and if the above relationships regarding defense mechanisms in counseling are mediated by the type of defense mechanism the counselor uses.

The current proposal is not without limitations: for example, causation cannot be implied in such a study as it is correlational nature, the TAT can only reliably detect a small portion of the defense mechanisms that are defined and therefore certain defense mechanisms and the relationships in counseling may be overlooked, and due to practical concerns the sample size does not allow for generalization. Nonetheless, these issues do not appear to have been investigated before it may offer insight and valuable suggestions on how counselors with histories of substance abuse (and those without such histories) can learn to be more aware of their own issues and how they relate to the treatment of abuse/addiction.