Psychosomatics 2014:55:210–211 & 2014 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved

Book Reviews

Jason P. Caplan, M.D.Book Review Editor

Psychological AdaptiveMechanisms: Ego DefenseRecognition in Practiceand ResearchBy Thomas P. BeresfordNew York, NY, OxfordUniversity Press, Inc., 2012319 pagesISBN: 978-0-19-979449-2Hardcover, $59.99

Reviewed by John B. Taylor, M.D.,M.B.A.

As psychiatrists, we stumbleupon psychological adaptive

mechanisms—formerly known asego defense mechanisms—in everypatient encounter. How a patientresponds to stress, and thereforewhich mechanisms are displayed,can be enormously useful informa-tion for a clinician, helping to createa differential diagnosis and giving asense of how a patient responds tostress in other situations. ThomasBeresford acknowledges GeorgeVaillant as a seminal influence andwrote a book that attempts to makeadaptive mechanisms, for whichVaillant is well known, more acces-sible for the beginning clinician.

This book develops a straight-forward manner for identifyingthese adaptive mechanisms. Theauthor has developed an algorithmthat allows the physician to categor-ize the behavior being witnessedinto 1 of 4 domains: primitive,

210 www.psychosomaticsjournal.org

immature, neurotic, or mature. Toarrive at a domain, the physician isto consider 3 questions, in order:Does the patient perceive a pro-blem? Does the patient identify theproblem as his own and recognizethat he is responsible for its solu-tion? Does the patient integrate thecognition and affect content of theproblem? Each successive answer of“yes” brings the patient closer to themature domain, whereas a “no”asks the physician to consider a lessmature set of adaptive mechanisms.

Through this algorithm a spe-cific adaptive mechanism, and ageneral idea of the patient's rangeof functioning, can be surmised.Eighteen mechanisms, each receiv-ing a chapter, are defined andexplained in the text. The chapterspresent each mechanism in a similarformat. The mechanism is brieflydefined. The author then choosesseveral examples from literaturedemonstrating the mechanism atwork. Finally, a fictional intern isplaced in numerous situations wherehe must adapt to whatever situa-tions befall him. When using imma-ture mechanisms, he is often askedto leave the hospital or placed onprobation; when using maturemechanisms, he meets success andis recognized as a potential leaderamong residents.

The various examples illustrat-ing the mechanisms, and howone arrives at eachmechanism using

the algorithm, are clearly writtenand entertaining. Most literaryexamples make use of classic texts.For example, a passage from Dos-toevsky's Crime and Punishment, inwhich Rodion experiences numer-ous constitutional symptoms, isused to illustrate hypochondriasis,and the use of Beresford's algorithmin arriving at that conclusion.Others include Miss Havisham inCharles Dickens's Great Expecta-tions to demonstrate schizoid fan-tasy and Shakespeare's Love'sLabour's Lost for displacement.

Its use of examples from litera-ture and an imagined intern's worklife, coupled with its rigorous use ofBeresford's algorithm in demon-strating how adaptive mechanismscan be identified, makes this texteasily accessible for any clinicianwho would require facility withpsychotherapeutic principles. Inparticular, junior residents who aregetting their first exposure to psy-chodynamic psychotherapy wouldfind this book particularly useful.The novice psychotherapist residentoften finds the process of psy-chotherapy to be too loose, particu-larly in comparison to howregimented the rest of his workdayand their responsibilities are. Withhis algorithmic approach, Beresfordbrings some semblance of order andstructure to psychotherapy whilealso explaining how to identifyadaptive mechanisms and how their

Psychosomatics 55:2, March/April 2014

Book Reviews

identification directs the patient-physician encounter.

For an in-depth look at adaptivemechanisms, this book is an excellentchoice for clinicians in training.Rather than confining its examplesto anoutpatient office,many vignettescenter on patients who have been

Psychosomatics 55:2, March/April 2014

medically hospitalized, which is nota common finding in a text targeted toa more general demographic. In par-ticular, second- and third-year psy-chiatry residents would find this auseful reference, as would psychia-trists who would be working withthe medically ill. Beresford provides

w

structure to psychodynamic psy-chotherapy,which trainees of all typeswould find beneficial.

Dr. JohnB.Taylor,M.D.,M.B.A.is a Fellow in Psychosomatic Medicineat Massachusetts General Hospital,Boston, MA.

ww.psychosomaticsjournal.org 211