Working with  Front Door and Cellar Door Defenses: Identification and Obedience to Introjected Dictates of Former Caretakers

Presented by: Josette ten Have-de Labije, PsyD and Robert J. Neborsky, MD

No psychotherapy will be successful when patient and therapist have no working alliance and when the patient has no observing, or no attentive ego. As most of our patients present themselves with high superego pathology and low ego adaptive capacity, their observing ego is low or even absent and their defenses are all more or less syntonic. The higher a patient’s superego pathology, the more the patient is identified with his superego part, the more a patient’s ego is paralyzed, the more the patient’s observing ego is totally absent, asleep or in coma. Often, these patients have been in interaction with former caregivers that were partners in crime.

For example, one caregiver by his behavior (e.g., controlling, devaluing) being ignoring/neglectful of the child’s needs/longings and the other one being submissive, passive, helpless. Instead of setting limits to the partner’s ignoring/neglectful abuse (and therefore conveying the message to the child that it is at least important enough to be cared for) the latter becomes a partner in crime. With this passivity, submissiveness and helplessness the devaluing, ignoring, neglectful abuse of the other caregiver is maintained.

Therapists should not forget that when a patient is identified with eg the neglectful eyes of caretaker number one, he is at the same time obeying the maintaining dictate of caregiver number 2, who didn’t set limits to the behavior of number one. A patient with an attentive ego is curious to learn from his therapist; curious and eager to investigate the conscious/unconscious processes he puts into operation that form and maintain his problems; curious and eager to investigate his own unlocked feelings, impulses, longings, norms, values; curious and eager to learn how to deal with these in a constructive way. Such a patient, once he understood what the therapist taught him, will take the initiative to do his part in the common undertaking of a therapy sessionTo establish a conscious working alliance; a therapist needs the patient´s observing ego as a partner: To establish a conscious and an unconscious working alliance the therapist needs the patient’s attentive ego as a partner In order to establish a working alliance with the patient, one of the first tasks of the therapist will be to assess the defensive pattern of the patient. The more a patient’s defenses are automatic, chronic, and the more there is satisfaction with them, the more they are considered as syntonic and maladaptive. In these cases the patient’s reactions are the patient’s habitual and representative reactions to everybody. As these reactions are so habitual and so non-specific to what  the other person(s) does, says or doesn’t do or say in the interaction, they have become rigid reactions to the world at large. Characteristics of former (aggressor)-caretakers are constantly, chronically projected onto all persons in the present, the ego’s discriminating function is absent  and reality testing is poor. In assessing the defensive pattern of the patient, the therapist should examine

It isn’t always easy  to assess the precise identity of a patient’s superego pathology, the extent to which a patient is identified  with and obedient to the abusive faces and voices of his introjected caregivers, the degree to which the patient’s observing ego is in operation, the degree to which the patient’s attentive ego is in operation and the degree and quality of a patient’s ego adaptive capacity. Mistakes that  therapists can make, are for example:

In this workshop the focus will be on assessing front door and cellar door defenses, understanding the dictates of former introjected aggressors, the importance of the maintaining factor, helping a patient to separate ego from his superego part, to have his observing ego awakened, strengthened and changed into an attentive ego. There will be much role play. Participants are encouraged to keep their own patients in mind.

Looking Forward to seeing you there,

Robert and Josette