Douglas Berger, M.D., Ph.D, has been working in Japan for many years as a counselor, psychotherapist, and psychiatric researcher. His therapy approach features the The Core Issue-Defense Paradigm:

A central theme in therapy is that everyone has certain core issues like feeling inadequate or unloved that threaten psychological stability. Psychological defenses attempt to mitigate the negative effects of these core issues but sometimes these defenses are maladaptive (i.e. trying too hard to get noticed by others or getting into unhealthy romantic relations) and lead to psychosocial troubles for the individual. This paradigm is closely related to the Ego-Psychological Psychodynamic model described above.

Understanding and reworking these defenses and how they lead to trouble, as well as minimizing the effects of one's core issues is a very powerful tool in therapy. The model is clearly described to the patient, and the therapist and the patient work together to make a clear picture of how these factors fit together for the patient's individual situation. It is often helpful for patients to write their own "case description" in the third person in order to help with an objective understanding of oneself (see the case examples below). This understanding can then help one to develop more adaptive life strategies (defenses), thus leading to fewer troubles, as well as minimizing the negative influences that specific core issues may have over one's daily life.

Core Issues

Core issues are mental schemas that one has about oneself and the world. They are often unconscious, coming to the surface only under specific psychosocial stress. Some examples of core issues are that of feeling: unloved, unwanted, unvalidated, inadequate, threatened, controlled, belittled, that one always to blame or is at fault (guilt), etc. While everyone has more or less of all of these issues to negotiate as a child, the intensity of these issues that remains as an adult differs from person to person, probably determined by a mixture of early life experiences and relationships as well as family genetics. Core issues that remain unresolved serve as major drivers in one's personality structure as an adult.

Defenses and Psychosocial Troubles

Core issues threaten one's sense of psychological stability and one needs to have defense mechanisms against them. For descriptive purposes, defenses can be divided into adaptive (mature) defenses that lead to contentment and smooth psychosocial functioning, or maladaptive (immature) defenses that lead to psychosocial troubles. Adaptive defenses include things like logic, making jokes, praising and helping others, as well as sublimating one's feelings into work and play (ie. a person who has aggressive impulses and who becomes a boxing announcer is using a relatively adaptive defense against his aggression). Defenses are largely unconscious; one is not usually aware they are using a psychological defense in everyday behavior, although insight into one's defenses can be obtained in psychotherapy. Resistance is also an important feature of defenses as one does not want to easily give up the way they have become used to dealing with the world.

The more maladaptive the defenses one uses, the more likely one will have troubles in life that result from them. Maladaptive defenses include things like bragging, devaluing oneself and others, projecting one's feelings about oneself into others (i.e. misogynists and bigots project their own internal devaluation onto others), exploiting others, externalizing one's aggression (like getting into fights easily etc.), avoidance, over-control of others or of one's own environment and activities, passive-aggression, frantic attempts to avoid break-up of a relationship, constantly trying to punish oneself or to make up for one's guilt, and many others. You can see that the maladaptive defenses are more child-like, more unrefined, and can easily lead to trouble. When one's first-line defenses fail, one tends to resort to more and more maladaptive defenses, leading to more trouble, and sometimes to a catastrophic reaction (e.g. a suicide attempt to get a lover back after all other attempts have failed).

Troubles can be divided into active or acute troubles that greatly bother the individual, and inactive or chronic troubles that the individual may or may not be aware of (see the case descriptions below for examples). The troubles are usually the complaints clients bring to the sessions, they do not often come to talk about their defenses or core issues.

The basic mechanism then is:

Early life experiences and family genetics leading to a particular set of Core Issues that threaten psychological stability. The Core Issues are protected by Defenses: Adaptive (leads to smooth psychosocial functioning) or Maladaptive (leads to psychosocial Troubles). Troubles can be divided into active or acute troubles, and inactive or chronic troubles. http://www.japanpsychiatrist.com/ryouhou.html#Template

In an article entitled, Defenses Can Sabotage the Therapy, Dr. Berger prefaces concrete examples of the sabotage with these remarks:

Psychotherapy has an interesting paradoxical twist to it in the therapist's attempt to provide help. When one goes to a surgeon, for example, to remove a lump, he patient recognizes they have a lump and agrees to have the surgeon remove it. With a psychological problem, however, patients may recognize that they have some problem, but they often do not see it as a result of their own life strategies (defenses or personality styles), and in trying to protect themselves with these defenses, patients may actually sabotage their own therapy.

Even if they do have some insight into their maladaptive use of defenses, patients often show resistance to changing their life strategies. They would prefer that things go smoother in the world using the same life strategies they have been using up to now. In fact, patients may seek validation on their style from the therapist or even advice on how to make their maladaptive defenses work better. Can you imagine a patient with a lump telling the surgeon to remove the lump but at the same time trying to convince the surgeon why it is better to live with the lump?

This is where the unconscious nature of defenses, and the resistance to changing one's defenses, comes into play. Resistance is often unconscious in patients as they may provide many rationalizations on why their maladaptive life strategies are valid.This resistance may occur even in the face of significant psychosocial troubles arising from these defenses as seen from the outside. The work of the therapy needs to overcome these barriers.

These maladaptive life strategies have been used by the patient both in past and present relationships, so it is no surprise that these personality styles will also manifest in the relationship with their therapist. It is the therapist's challenge to find the common thread that runs through the patient's interpersonal style and then guide the patient to use new and more adaptive life strategies. The therapist attempts to remain neutral in attitude and does not disclose personal material to the patient. In this way therapists try to keep their countertransference issues out of the session. Thus, the therapist and patient can begin to create a picture of the patient's personality style without undue influence of the therapist's style. If the patient's insight is poor and/or their defenses are of a certain quality that leads to dissatisfaction in the therapy, the defenses themselves can sabotage the help the patient needs to fix their defenses. http://www.psychiatrictimes.com/binary_content_servlet

I saw myself to a degree in the concrete examples. I am more convinced that ever just how critical the therapy alliance is in achieving a good result from treatment. The challenge indeed is great.