An Empirically Validated Hierarchy
of Defense Mechanisms
George E. Vaillant, MD; Michael Bond, MD; Caroline O. Vaillant, MSSW
\s=b\ We empirically examined the validity of ego mechanisms
of defense as an explanatory concept for psychological health
in 307 middle-aged men who were prospectively followed up
for 40 years. Assessed on the basis of a two-hour interview
when the men were 47 years old, the maturity (health) of the
men's defenses correlated highly with independently as-
sessed outcome measures. Evidence is offered that defensive
style provides an independent dimension of mental health.
First, childhood variables significantly predicted midlife men-
tal health but not midlife maturity of defenses. Second, the
bleaker the childhood the stronger the association of maturity
of defenses with adult mental health. Third, the Bond Defense
Style Questionnaire, administered to 131 of the 307 men six to
eight years after the interview, identified the same styles of
defense that were identified earlier by clinical assessment.
(Arch Gen Psychiatry 1986;43:786-794)
of ego mechanisms of defense has long
Theappealed
concept
With theirhigh
to clinicians and disappointed researchers.
tolerance for subjective judgment, clini¬
cians have found defenses to be a useful means of decipher¬
ing real-life mysteries. Researchers, on the other hand,
have found assessment of defenses to be unreliable and
unacceptably subjective.
Indeed, experimental psychology has been stymied for
almost a century by the task of empirically validating
defenses. In 1972, Kline1 concluded his review of the experi¬
mental literature on defenses with this statement: "Meth¬
odological difficulties, not unexpectedly, have proved too
much for most investigators." Two years later, Moos2 re¬
viewed 250 articles and concluded that existing means of
Accepted for publication Sept 11, 1985.
From the Department of Psychiatry, Dartmouth Medical School,
Hanover, NH (Dr and Mrs Vaillant); Harvard University Health Services,
Cambridge, Mass (Dr Vaillant); and the Department of Psychiatry, Sir
Mortimer B. Davis\p=m-\JewishGeneral Hospital, Montreal (Dr Bond).
Reprint requests to Department of Psychiatry, Dartmouth Medical
School, Hanover, NH 03756 (Dr Vaillant).
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Manitoba User on 06/05/2015
assessing defense mechanisms were inadequate. In gen¬
eral, experimental reliability could be achieved only at the
expense of clinical validity.
In the past 20 years, on the basis of empirical—usually
longitudinal—research,3"7 investigators have made prog¬
ress in areas of rater reliability and clinical validity. These
investigators have arranged defense mechanisms along a
hierarchy of psychopathology. They have shown that people
who deploy so-called mature8 or coping4 mechanisms are
happier and enjoy better mental health and more gratifying
personal relationships than do individuals who use imma¬
ture or defending mechanisms. Battista9 and Bond et al10
have provided independent empirical confirmation that
defenses can be arranged along such a hierarchy of maturity
and psychopathology. Recently, some textbooks have tenta¬
tively accepted the model proposed by Semrad and
Vaillant,1113 thus facilitating a uniform nomenclature.
However, two methodological problems remain unsolved.
First, clinical assessment of defenses is subjective and rater
reliability for individual defenses is unsatisfactory. To ad¬
dress this first problem, one of us (G.E.V.) and co-work¬
ers14,15 pooled individual defense choice into the three clus¬
ters suggested by the hierarchy (mature, intermediate, and
immature). This clustering provided good rater reliability
and confirmed that hierarchical arrangement of defensive
styles correlated highly with independent and objective
measures of mental health. This work, however, suffered
from the second methodological problem. Namely, reliable
clinical identification of defenses could only be achieved by
the rater knowing as much as possible about the subject's
inner and outer reality. Thus, the possibility exists that
rater knowledge of mental health may bias estimates of
overall maturity of defensive style and thus account for the
high correlations observed.
To overcome this second problem, we used the self-
administered questionnaire of Bond and colleagues10 that
taps possible conscious derivatives of defenses. By using
factor analysis, they demonstrated that statements se¬
lected to reflect relatively mature (adaptive) defenses were
positively and immature (pathological) defenses were nega-
 tively correlated with maturity of ego development (as
measured by the Loevinger16 sentence-completion test) and
with mental health. The instrument developed by Bond
et al10 had the obvious advantages of being free from
subjective clinical judgment and free from halo and context
effects.
In this article, we will marshall three lines of indirect
evidence to support the thesis that defenses reflect actual
homeostatic processes and not just epiphenomena of psy¬
chopathology. First, to argue that the evidence for defense
choice is qualitatively different than evidence for objective
mental health, we will illustrate the actual clinical evidence
on which such judgments were based. Second, to argue that
perceived defensive style is not a halo effect of the subject's
mental health, we will present evidence to illustrate that
the antecedents of psychopathology can be distinguished
from the antecedents of adult defensive style. Third, the
self-report instrument of Bond et al10 was administered to
our inner-city subjects six to eight years after the interview
on which clinical judgment of individual defenses was
based. The significant correlation of the individual items on
the Bond et al10 instrument with prior clinical assessment of
defensive style lends support both to the validity of our
original clinical raters' judgment and to the assertion that
defensive style reflects an enduring and important dimen¬
sion of personality.
SUBJECTS AND METHODS
Subjects
The sample consisted of 307 inner-city boys chosen by the
Gluecks17,18 as control subjects for their prospective study of
juvenile delinquents. Between 1940 and 1945, these subjects were
among the 456 boys selected in junior high school for nondelin-
quency and matched with severely delinquent youths in terms of
intelligence, ethnicity, and residence in high-crime neighborhoods.
All subjects were white and male; 50% had not graduated from high
school; their mean (±SD) IQ was 95 ±12; 31% of the subjects'
fathers met the criteria for social class V established by Hol-
lingshead and Redlich19 (eg, an unskilled worker with nine or fewer
grades of education who lived in derelict housing).
When the subjects were in junior high school the Gluecks had
interviewed them, their parents, and their teachers. The present
study contrasts the data obtained in childhood with the fourth
wave of face-to-face interviews obtained at the age of 47 years
(circa 1977). Six to eight years after this last interview, 131 subjects
at a mean age ( ± SD) of 54 ± 2 years completed the Bond et al10 self-
report questionnaire. The sample, the interview schedule, and the
rating scales below have been described in detail elsewhere.8,14,17,20
JuniorHigh School Ratings
Each rating was based on the family's social service records and
on interviews with the boy, his parents, and his teacher. Three
research assistants with college degrees in social work or psychol¬
ogy who were blind to all postadolescent information rated each
boyhood on the first four variables.
i. Familial Strengths.—This seven-point scale is a subset of a
20-point Childhood Environmental Strengths scale described in
detail elsewhere.20,21 The scale reflected the sum of three one- to
three-point scales. One scale reflected judgments that maternal
and one that paternal relationships were "warm, nurturing, en¬
couraging of autonomy, helping boy develop self esteem." The third
subscale reflected a warm, cohesive home atmosphere or "special
harmony in spite of difficulties." A low score reflected a "warm"
family environment; a high score a "bleak" environment. Rater
reliabilities are Pearson's product-moment correlation coefficients
and express the range of correlations between three raters.
Interrater reliabilities for each subscale ranged from .50 to .74.
While the familial-strengths scale was less reliable than the
composite childhood environmental-strengths scale used else¬
where, it excluded subscales that could be construed as reflecting
nature and not nurture.
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Manitoba User on 06/05/2015
2. Childhood Emotional Problems.—This one- to three-point
scale20 (few, average, and many), also a subset of the Childhood
Environmental Strengths scale, reflected the relative presence or
absence of phobias, shyness, feeding and disciplinary problems,
and interpersonal difficulties. Interrater reliability ranged from
.53 to .57.
3. Childhood Environmental Weaknesses.—The scale14
summed 25 concrete weaknesses (eg, family known to nine or more
social agencies or mother either delinquent or alcoholic). The point
was to contrast concrete environmental liabilities and childhood
weaknesses with the less tangible environmental assets cited
above. Sixty-two of the men met the definitions of "multiproblem
family membership," which meant that they experienced ten or
more of the 25 liabilities that made up the scale. Another 105 men
experienced two or fewer of these liabilities. Interrater reliability
ranged from .91 to .94.
4. Boyhood Competence.—This eight-point scale22 assessed
the extent to which the subjects, at entrance into the study, had
mastered Erikson's23 (1950) fourth stage of industry: "doing things
beside and with others." Interrater reliability ranged from .70 to
.91.
5. Hartmann Indicators of Vulnerability to Schizophrenia.—
Two blinded raters, different from those above, assessed the men
on this scale,24 again using data gathered when the men were in
junior high school. This scale consisted of 11 items (unusual anxiety,
neophobia, lack of historicity, inappropriate aggression, inap¬
propriate anger, flat affect/anhedonia, lack of object constancy,
poor relationships, permeable boundaries, lack of competence, and
neurologic abnormalities). Rater reliability was .76.
6. 'Emotional Maturity'.—This was a highly subjective,
dichotomous variable, originally labeled "feels adequate," that was
rated by the psychiatrist who evaluated each youth for the
Gluecks.17 It was intended to reflect the "relationship of emotional
dynamics to social efficacy" and each boy's "ability to conduct
himself or express himself with fair efficiency." Out of more than 50
psychosociobiological variables assessed by the Gluecks in junior
high school, emotional maturity correlated most highly with
maturity of defenses.
7. Restlessness.—Each boy's home-room teacher was asked to
check several personality traits present or absent. One of these,
"restlessness," provided the only recorded estimate in 1940 to 1945
of the modern concept of "hyperactivity" or "attention-deficit
disorder." As was the case with emotional maturity, for statistical
analysis restlessness was scored 0 or 1.
8. Parental Social Class.—This five-point classification,
devised by Hollingshead and Redlich,19 was applied to the men's
parents on the basis of the 1940 to 1945 data. (The same scale was
applied by the judges of adult ratings to the men when they were 47
years old.)
9. IQ.—On entrance into the study, each boy was given the
Wechsler-Bellevue intelligence test.
Ratings at the Age of 47 Years
Blinded to all information collected before subjects reached the
age of 30 years, research social workers rated the men at the age of
47 years, primarily on the basis of a recent, semistructured, two-
hour interview. Raters who judged defenses were blind to the first
three adult ratings listed below, and vice versa.
1. Health Sickness Rating Scale (HSRS).— This scale25 of
global mental health has been widely validated.26 Interrater re¬
liability was .89.
2. Social Competence.—This was a 25-point scale20 reflecting
each individual's relative success in accomplishing eight different
tasks of adult interpersonal relations excluding marriage. One
task each reflected enjoyment of children, family of origin, and
workmates; three tasks reflected friendship network; and two
tasks reflected participation in group activities. (Marriage was
treated as a separate variable.) Rater reliability was not obtained.
3. Psychosocial Maturity.—This rating14 was made on a five-
point scale based on a modified Eriksonian model,23 as follows: 1,
failed to live independently of family of origin or institution; 2,
stage 5 (identity); 3, stage 6 (intimacy); 4, an interpolated stage 6A
between stages 6 and 7 that reflected career consolidation; and 5,
stage 7 (generativity). Ratings were obtained from two raters;
 differences were resolved by discussion. Rater reliability was not
obtained. Validity, however, was demonstrated by establishing
that objective tasks characteristic of a higher stage were not
achieved unless objective tasks characteristic of earlier stages had
been mastered.14
4. Maturity (Health) of Defenses (Adaptive Style).—The defi¬
nitions of the individual defenses are provided elsewhere,8,27 as is
the empirical rationale for equating "maturity" of defensive style
with both developmental maturity and freedom from psycho¬
pathology.7 "Healthy" may be a more accurate term than "mature,"
but the latter term captures the fact that as young adults grow
older or recover from mental illness, their choice of defenses
evolves along the hierarchy outlined in the following paragraph.
Raters of defenses were blinded both to childhood records and to
the independent adult ratings cited above. They were given
uniform definitions of 15 defenses27 and trained on interview
protocols that had been rated by many others. The 15 defenses
were divided into three clusters determined on the basis of prior
empirical study7: (a) mature (sublimation, suppression, anticipa¬
tion, altruism, and humor); (ft) intermediate/neurotic (displace¬
ment, repression, isolation [intellectualization], and reaction for¬
mation); and (c) immature (projection, schizoid fantasy, passive
aggression [turning against the self], acting out, hypochondriasis,
and dissociation [neurotic denial]). Raters were given a 20- to 30-
page summary of the men's two-hour semistructured interview at
the age of 47 years. These interviews had been designed to focus on
difficulties in the individual's relationships, physical health, and
work. In writing the interview summary, the interviewer was
instructed to elucidate but not to label the behaviors by which the
individuals had coped with these difficulties. Interview protocols
were prepared by the interviewer from verbatim notes taken
during the interview. Numerous direct quotes were included in the
interview protocols, but the methodology embodied both the
scientific limitations and advantages of journalism. The purpose
was to use the interviewer's summary as the first step in data
reduction and to retain interview emphasis that is often lost in
transcripts of tape recordings.
For each of the interview protocols, raters were asked to note all
possible instances of each of the 15 defensive styles. Attention was
paid to concrete past behaviors, to the style of adaptation to past
difficulties, and to specific vicissitudes of the interview interac¬
tion.
To control for marked variation across subjects in the frequency
of identified defensive vignettes, the following quantitative strat¬
egy was adopted to force clinical judgment of the global maturity
(health) of defenses into a nine-point scale. The relative proportion
of defense vignettes in each of the three general categories
(mature, intermediate, and immature) was determined. This ratio
was used to distribute a total of eight points. Of the eight points,
one to five points were assigned to each of the three general
categories, but the total had to be eight. The score for overall
defensive style for each man was then estimated by subtracting the
rating (1 to 5) for immature defenses from the rating (1 to 5) for
mature defenses. This procedure provided a nine-point range, a
normal distribution of scores, and a rater reliability of .84. Global
ratings by the two raters differed by more than two points for only
23 subjects (7%). (In calculating global maturity of defenses, the
intermediate category was ignored; the rationale for ignoring this
category is its insignificant correlation with outcome variables.)
5. Individual Defenses.—For each interview, ten to 30 in¬
stances of defensive behavior were noted, reflecting three to seven
different defenses. Weighing of the salience of each individual
defense was achieved through redundancy, ie, through frequency
rather than certainty of identification. Each rater scored each
defense as follows: 0 if absent, 1 if noted once or twice, and 2 if it was
the most frequently used defense or it was noted three times or
more. Reliability was only modest. The raters had more difficulty
agreeing on individual defense ratings and, depending on the
defense, one rater could score a given defense 2 (major) and the
other could score it 0 (absent) in 4% to 20% of cases. The two raters'
ratings were summed, providing an individual rating for each
defense that ranged from 0 (both agreed it was absent) to 4 (both
agreed it was major).
6. Bond Defense Style Questionnaire.—The questionnaire10 is
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Manitoba User on 06/05/2015
designed to elicit manifestations of a subject's characteristic style
of dealing with conflict, whether conscious or unconscious, at the
age of 54 ±2 years. It is based on the assumption that persons can
accurately comment on their unconscious adaptive style. Subjects
were asked to indicate their degree of agreement or disagreement
with 67 statements on a five-point scale (1, strongly agree; 5,
strongly disagree). In addition to the 15 defenses cited by us, Bond
et al10 designed their statements to reflect behavior suggestive of
the mechanisms of pseudoaltruism, "as-if" behavior, clinging,
regression, somatization, withdrawal, omnipotence-devaluation,
inhibition, identification, primitive idealization, and splitting.
These statements had been subjected to an initial test of face
validity by asking three psychodynamically oriented raters (in¬
cluding two psychoanalysts) independently to match each state¬
ment with a given defense mechanism.
Because the current project was designed to correlate the
hierarchy of defenses proposed by one of us (G.E.V.)15 with the
Bond et al10 questionnaire, each of the 67 statements on the Bond
et al10 questionnaire were relabeled to reflect one of our 15 defense
mechanisms. Labels reflected the consensus of three experienced
defense raters (a clinical psychologist, a psychoanalyst, and a
social worker). For 44 items, including ten "lie" items, the labels
were the same as those on the Bond et al10 questionnaire. For 23
items, many of which had been originally selected to reflect terms
favored by Kernberg,28 the labels were translated into those used
by us (usually passive aggression, fantasy, or projection). The final
labels for the statements by Bond et al10 included 42 statements
reflecting immature defenses (11 projection, ten passive aggres¬
sion, seven fantasy, five dissociation, four acting out, two hypo-
chondriasis, one splitting, and two unclassified). Nine statements
reflected neurotic or intermediate defenses (seven reaction forma¬
tion, one displacement, and one isolation), and six reflected mature
mechanisms (two suppression, two humor, one sublimation, and
one altruism).
RESULTS
Attrition
Of the original 456 boys selected by the Gluecks,17,18 no subject
was completely unavailable for follow-up. However, due to death
(33 men), unavailability (ten men), withdrawal from the study (29
men), and interviews obtained by phone or from relatives (17 men),
only 367 men were interviewed face to face at the age of 47 years.
For raters to identify defenses, only the most complete interview
protocols could be used. In a few cases, raters were not sufficiently
blind to other data. These two restrictions further reduced the
sample used in this report to 307.
When these 307 men were compared with the 149 excluded
subjects (Table 1), the latter subjects contained significantly more
men with less than ten grades of education and men who came from
multiproblem families and from families in social class V. The two
groups of men did not differ significantly in terms of IQ, ethnicity,
childhood emotional problems, boyhood competence, or childhood
environmental strengths. In outcome the two groups differed in
mortality and sociopathic traits but not with regard to alcoholism.
When the 131 men who returned the Bond questionnaire were
contrasted with 325 subjects who did not return it, the differences
exaggerated those already described in Table 1. In addition, those
subjects who did not return the questionnaire spent an average of
twice as many years (three) unemployed, were three times as likely
(11%) to have been in jail, were twice as likely to be alcohol-
dependent (21%), and were twice as likely to have IQs under 85
(21%).
Among men rated for defenses, those who returned the Bond
et al10 questionnaire did not differ significantly from those who
ignored it in terms of maturity of defenses or in terms of personality
disorder. However, consistent with our hypothesis that defenses
reflect an enduring facet of personality, the two groups of men
differed dramatically in defense style and in personality subtype.
Men who had been rated as using reaction formation and suppres¬
sion as a dominant defense were significantly more likely to return
the Bond et al10 questionnaire. Men who used projection and
passive aggression were significantly less likely to return it. Men
who met axis II criteria for paranoid, dependent, or passive-
aggressive disorders were twice as likely not to return their
 questionnaires; those men who met the criteria for avoidant,
schizoid, or narcissistic disorders were twice as likely to return Table 1.—Attrition
them. This selection bias may also have been affected by the fact
that subjects were told that if they returned the questionnaire, $10 Included Excluded
would be contributed to a charity of their choosing. Subjects, % Subjects, %
Variables (n 307)
=
(n l49)
=

Clinical Evidence for Validity of the Model Childhood

Not emotionally mature 69 65 NS
The findings of this study are congruent with those of previous
investigators. The right-hand column of Table 2 presents the Many emotional problems 30 31 NS
correlation of the individual defenses that make up the hierarchy Worst boyhood competence 14 21 NS
used in this article with the independent assessment of the IQ<90 29 35 NS
subjects' global mental health measured by the Health Sickness Few environmental strengths 26 30 NS
Rating Scale (HSRS). Many different facets of the men's mental
health were also correlated with this hierarchical arrangement of Multiproblem family 11 19 <.05
defensive style in Table 2, and these findings are reported else¬ 9 grades or less of school 31 43 <.05
where.16 Parental social class V 26 43 <.05
Table 2 also contrasts these correlations with those from three
Adult*
previous studies. Haan3,29,30 obtained empirical support for her Dead 0 27 <.05
hierarchy by studying subjects at the Berkeley (Calif) Institute of
Human Development. She demonstrated that mechanisms that she 5+ sociopathic traits 7 11 NS
called coping were significantly correlated with upward social Problem drinker 26 29 NS
mobility, adult increases in IQ, and with three other measures of *Most adult variables, of course, were themselves so compromised by
positive midlife outcome. Mechanisms that she called defending attrition that their inclusion in this table would be without meaning.
were negatively correlated with such outcomes. In a sample of 95
college men also followed up for several decades, one of us (G.E. V.)7
used a 32-item scale reflecting objective success in working and drive a car and did not require driving lessons. He did not entertain
loving to validate the theoretical hierarchy in Table 2. Battista9 but relaxed in his spare time by listening to the radio or to records
assessed the defensive style of 78 psychiatric inpatients by means by himself.
of an ego-function inventory rated on a five-point Likert scale. He Case B, Schizoid Fantasy.—This man had nine grades of
rated his patients' mental health by means of the Global Assess¬ school, a childhood environment that was only fair, and parents in
ment Scale.31 social class IV. He worked as a night security guard. He entered
into it for "no special reason" but because he was "fascinated by it."
Clinical Examples When asked of any difficulty in the job he remarked that alertness
As our first argument that maturity of defenses is not synony¬ is the top priority. He said he gets along with people and illustrated
mous with adult adjustment, we will illustrate that the evidence for this with a story of striking up a conversation with people on a park
identifying defenses and that for assigning the HSRS scores are bench during vacation in California. Mostly he worked alone. If he
conceptually very different. Evidence for assessing defenses de¬ could live his life over, he had thought of being a physical therapist
pended on inferred intrapsychic distortions of reality, while evi¬ or a lawyer because he wanted to help people. He was interested in
dence for assigning HSRS scores depended on assessing objective journalism and he occasionally thought of writing a book. He took
behaviors. Four clinical examples will be offered. an electronics course but nothing came of it. He said that his family
The evidence for rating two men high on schizoid fantasy (an was very close-knit. In actual fact, his parents were divorced 25
immature defense) is contrasted with evidence for rating two men years ago; recently they had remarried each other but lived 2000
high on suppression (a mature defense). These particular defenses miles away. He said he was not particularly close to any one
were chosen both because they were the most highly correlated relative. "They are all the same—cousins, aunts, and everybody."
with outcome and because they were among the most conceptually He had no children. Then he said if he had had children he imagined
difficult of the defenses. The examples illustrate both the inferred that he might have had a son killed in Vietnam or a "daughter to
intrapsychic mechanisms and the external evidence of defense worry me sick." Instead, he and his wife had a dog and a cat. He said
utilization that the blind raters excerpted from the interview of his dog, "You could swear that he was human." He said of his cat,
protocols to make their judgments. "He has a mind of his own." He and his wife got along although they
The subjects' social class of origin, their education, and their should not have, he said, because he was a Scorpio and she was a
assessed childhood environment were not significantly associated Leo. When troubled or angry, he would run up to the attic to listen
with their relative maturity of defenses. to his citizen's band radio, which had a police scanner. After five to
In brief, schizoid fantasy was defined as creating gratifying ten minutes, his anger would pass. He never did have a special
interpersonal relationships inside one's mind that had little coun¬ friend. He said that he was not a loner, but that he just did not
terpart in reality; suppression was defined as stoicism, minimizing happen to see anyone. There was no one outside his family to whom
distress but maintaining it in consciousness, and postponing he would go for help because he said he "never needs people." He
gratification without repressing ideation or isolating affect. said he and his wife mostly "keep to ourselves" and "don't need
Case A, Schizoid Fantasy.—This man had 11 grades of school, a anyone." His hobbies included citizen's band radio, photography,
good childhood environment, and parents in social class V. He shooting targets (not animals), and fishing. He also liked war
worked as a library clerk. He enjoyed a vicarious sense of pres- movies.
tigiousness from the slight association that he had with professors Case C, Suppression.—This man had 11 grades of school, a
and doctors. "I just like the academic atmosphere," he said. "I just childhood environment that was only fair, and parents in social
sort of feel a part of it." When asked about his future: "I will still be class IV. His main job was "keeping the peace between customers
at the library, maybe something on the academic level. I'm still and the boss" and he found that he often had to "bite his tongue" in
interested in photography . . I've had so many cameras." He
. his role as diplomat.
assumed a tinge of grandiosity as he began to talk about certain He had been married for 26 years and said "nothing really
cousins in the "old country" who were all "8 feet tall." When asked bothers him" about his wife. "She's my whole life. I get to love her
about relationships with women, he recalled a girl at school 35 more every day... The family just doesn't disagree about much...
years ago, in 1942, on whom he had had a crush and of whom he had nothing major." He and his wife both agreed that they had worked
thoughts of marrying. He thought that she had married someone hard on their marriage but "after 26 years it's beautiful." He and his
else. There had been no one since. He blamed religious prejudice, wife remembered that they had thought of separating in the first
and he said he had had little to do with non-Jewish girls. He did not year of their marriage. (In contrast with the man who imagined he
drive or have a driver's license, but he said he might be interested in could "intuitively" drive a car, this man held it in mind that long
getting a license in the future. He said he knew "intuitively" how to marriages require work.)

Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Manitoba User on 06/05/2015

 When he felt bad, he tried to "think positive" and then he tried to
"take care of whatever the problem is." For instance, when he was
overwhelmed with bills, he just started to pay them one at a time.
When he feared he was losing control of his drinking, he stopped
using alcohol 19 years ago and was abstinent after that.
He said he had not been sick a day in his life. Hearing this, his
wife groaned and said, "He would go to work even if he was
bleeding. When he gets a cold, he doesn't believe in staying home,
as he always says have to work.'"
Case D, Suppression.—This patient had nine grades of school,
a childhood environment that was only fair, and parents in social
class V This man reported no serious problems with other men in
his shop. When he became troubled, he tried not to show it and "to
take things in stride." In this way, he maintained an even tempera¬
ment, "at least on the outside." At work he was known as the man
with "no emotions" because he never looked rattled. "I want to
make sure I know what I am hollering about before I start
hollering." "I guess I just don't want to make a fool of myself—if

Table 2.—Correlations of Adaptive Styles With Global Measures of Mental Health

Selected Measure of Mental Health, r

Health Sickness
Shift in Rating Scale,
IQ and Social Adult Adjustment Global Assessment Present Study
Defenses* Mobility (n 99)3 =
Scale (n 50)7= Scale (n = 78)9t (n 307)
=

Mature
Anticipation (objectivity) Coping .34* .50 •40§
Suppression
(suppression, concentration) Coping 57§ .25 .55§
Altruism Coping .10 .19 46§
Sublimation
(substitution, sublimation) Coping .04 .26 45§
Humor (playfulness) Coping Not rated Not rated .33§
Intermediate
Isolation (isolation) Defending .14 .29 .06
Repression (repression) Defending .04 .04 .04
Reaction formation
(reaction formation) Defending .13 Not rated .00
Displacement (displacement) Defending .16 .16 .12*
Immature
Passive aggression or
masochism (regression) Defending .19 .07 47§
Hypochondriasis Not rated .23 .04 52§
Acting out Not rated 37* .22 27§
Dissociation (denia Defending .24 .40 39§
Projection (projection) Defending .41* .22 46§
Schizoid fantasy Not rated .28* .60 55§
*Terms in parentheses are Haan's3 terms for equivalent mental processes.
fSignificance not given.
*P<.05.
§P<,001 (Pearson's product-moment correlation).

Table 3.—Childhood Traits Are More Importance Predictors of Maturity of Adult Defenses Than Are Environmental Variables
Outcome Variables at 47 Years of Age, r

Adult Social Health Sickness Psychosocial Maturity of

Junior High School Variables Class (n = 306) Rating Scale (n 307)=
Maturity (n 307)
=
Defenses (n 307) =

Traits
IQ .35* .17* 18* 16*
"Emotional maturity" 13* 17* 13* .18*
.11* -.15* 13*
•

Restlessness .09
Trait-environment interactions
Boyhood competence .29* .23* .25* 16*
Childhood emotional problems .22* .21* .21* .14*
Hartmann Schizophrenia scale§ .01 18* .29* .03
Environment
Familial strengths 15+ .14* .17* .07
Environmental weaknesses .07 .09 -.02
•

10*
Parental social class .08 .06 .00 .00
*P<.001 by Pearson's product-moment coefficient.
*P<.01 by Pearson's product-moment coefficient.
*P<,05 by Pearson's product-moment coefficient.
§This score was only calculated for 123 subjects.

Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Manitoba User on 06/05/2015

 you get mad first and then find out you're wrong, well, then it's too
late." He did speculate at first that his style might have been the
reason for his ulcer problem. When he was especially troubled, he
talked things over with his wife and they tried to settle it together.
When he got very angry, he became quiet. He never raised his voice
and tried to avoid blowing his top. Sometimes he sat and played
music on his record player until he cooled off. He generally tried to
avoid fights. On the other hand, he said that he never backed down
from a fight if it got to a point where it could not be avoided without
losing face.
There are three points to be made by these vignettes. First,
suppression seems so reasonable that it is hard to imagine that it is
not voluntary until one reflects that if volitional coping with stress
were that easy, more people would use suppression. Second, the
evidence used to identify defense mechanisms is based on psycho¬
logical behaviors that do not just reflect success at living. The
evidence has more to do with cognitive and affective styles than
with the objective success at working and loving on which the
mental health outcome ratings were based. Third, when asked to
explain their defensive behavior, all subjects could be said to use
rationalization. What determines defense identification is the
actual behavior, not the subject's explanation of that behavior.
Evidence That Childhood Predictors of Adult Defensive
Style and of Global Mental Health Differ
The second argument that the correlation of defensive maturity
with mental health is not just a halo effect derives from an
observation that was first made by Weinstock32 and again by one of
us (G.E.V.) and Drake7,15: namely, defensive style in midlife was
surprisingly independent of childhood influences that predicted
other facets of adult outcome. Table 3 illustrates that defenses
were significantly associated with variables reflecting traits (ie,
Table 4.—Correlations of Maturity of Defense
With Other Adult Outcome
Measures Controlling for Familial Strengths
Bleak Intermediate Warm
Childhoods Childhoods Childhoods
(n 87)
=
(n 140)
=
(P) (n=78)*
IQ, restlessness, emotional maturity, and boyhood competence).
However, in contrast with other facets of mental health outcome,
maturity of defenses seemed to be relatively independent of
environmental antecedents (ie, familial strengths and environmen¬
tal weaknesses). If the effect of the three "traits"—IQ, restless¬
ness, and emotional maturity—on defenses were controlled by
multiple regression, then the remaining six at least partly environ¬
mental variables explained only 0.6% of additional variance in the
maturity of defenses.
The finding that a favorable childhood environment predicts
adult mental health better than such an environment predicts
mature defenses offered a chance to demonstrate that maturity of
defenses might be causal of rather than synonymous with mental
health. In paradigms where trait/environment (ie, nature/nurture)
interactions are inevitable, by controlling nurture one can demon¬
strate the independent effects of nature. For example, individuals
who grow up with rich parents are likely to enjoy high adult
socioeconomic status and above-average intelligence. Does high
intelligence "cause" high socioeconomic status in these individuals
or is it only a by-product? One way to demonstrate a causal role is to
demonstrate that individuals who grow up with poor parents are
unlikely to attain a high socioeconomic status without above-
average intelligence. Thus, to prove that mature defenses are not
just a by-product of good mental health, we needed to demonstrate
that men from warm childhoods might be able to attain good mental
health without the benefit of mature defenses, but that men from
bleak childhoods achieved good adult mental health only by
deploying mature defenses. The data in Table 4 confirm this test.
Maturity of defenses correlated with mental health most strongly
when the individual had experienced a bleak childhood, a fact not
known to the raters of the adult-outcome variables. The differences
in correlation were statistically significant. Such a finding is
consistent with the hypothesis that maturity of defenses and adult
adjustment are not identical. Thus, their high correlation may
reflect mutual causation and not just halo effect.
Additional evidence that raters' assessment of choice of defenses
was not wholly influenced by knowledge of the men's mental health
came from another antecedent variable, the Hartmann et al24 scale.
This scale significantly predicted who among the Gluecks' original
sample of 1000 delinquents and nondelinquents would develop
schizophrenia. Although the Hartmann et al24 scale did not signifi¬
cantly predict the general use of immature defenses per se (Table
3), the scale significantly predicted (r=.20; .013) men who 30
=

Psychosocial maturity .77 .66 .46 (P<.01)

years later would be rated as using schizoid fantasy as a dominant
Health Sickness Rating mode of defense.
Scale .82 .78 .70 (P<.06)
Social competence .68 .51 .38 (P<,01) Independent Assessment of Defensive Style
*Statistical significance of differences between Pearson's correlation
coefficients for men with bleak and those with warm childhoods was The third line of evidence comes from contrasting two modes of
calculated according to method of Bruning and Kints.33 assessing defensive style—valid but subjective clinical judgment

Table 5.—Relative Number of Statements by Bond et al'0 Significantly (P .05)

=

Correlated With Each Clinically Assessed Style of Defense

Clinically Assessed Defense Style (1975-1977), %

Passive Others
Prelabeled Bond et al10 Statements Projection Fantasy Aggression Hypochondria Dissociation Sublimation Suppression Styles*
Projection (N 11 )=
73 64 36 64 27
Fantasy (N 7) =
43 71 28 14
Passive aggression (N 10) =
10 60 40 40 20 10
Hypochondriasis (N 2) =
50 50 100
Acting out/dissociation (N 10) =
30 30 30 30 50
Humor/sublimation (N 3) =
100 33
Suppression (N 2) =
50 100 12
Lie (N 10)
=
10 10 40 10
Other (N 12)
=
15 25
*The percentages in this column reflect the total number of significant positive correlations divided by eight to give the average percentage of agreement
between Bond et al10 statements and the clinically assessed defensive styles of displacement, repression, isolation, reaction formation, humor, acting out,
altruism, and anticipation.

Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Manitoba User on 06/05/2015

 with less valid but more independent pencil-and-paper self-re¬
port—on the same sample of subjects. To achieve this, we adminis¬
tered the Bond Defense Style Questionnaire, by itself too crude to
identify robustly individual defenses, to our subjects whose de¬
fenses had been clinically assessed six to ten years previously.
Table 5 shows that our ability to predict in advance which Bond
questionnaire statements would correlate positively with which
clinically assessed defense was not perfect. For example, all four of
the items selected by both us and Bond et al10 to predict acting out
instead identified men who, on clinical grounds, were judged to use
passive aggression or dissociation. Nevertheless, 50% or more of
the prelabeled Bond et al10 statements were significantly corre¬
lated with the clinically identified defensive style it was supposed
to reflect. This was despite of the fact that the Bond et al10
instrument was administered an average of seven years later. On
the one hand, it was demonstrated that the Bond et al10 instrument
was able to identify defensive styles, albeit crudely, through self-
report; on the other hand, the labels assigned by our clinical raters
were demonstrated to be not just a function of context and halo
effects.
Bond et al10 identified five statements (their factor IV) that they
predicted would identify mature defense mechanisms. All were
correlated with mature mechanisms at a of less than .01, and
three of the statements correlated significantly and positively with
global mental health. Bond et al10 identified 42 items intended to
reflect immature defenses. Twenty-four of these 42 statements
were significantly and negatively correlated with maturity of
defenses, and 23 of the 42 statements were significantly correlated
with clinical assessment of the individual defense that the state¬
ment was predicted to identify. Only three of these 42 Bond
questionnaire statements correlated positively with maturity of
defense; none of these correlations were significant.
A scale of global maturity of defenses was constructed by adding
the ratings for all Bond questionnaire statements prelabeled as
mature and subtracting the ratings for all Bond questionnaire
statements prelabeled projection and fantasy. This composite
scale correlated with the HSRS score estimated seven years earlier
with an r of. 48 (P<. 001), and with maturity of defenses with an r of
.35 (P<.001). Since pencil-and-paper personality tests usually
correlate with personality and outcome measures with an r of .3 or
less,34 and since seven years separated the two assessments, such
agreement seems acceptable.
Table 6 illustrates the specificity of agreement between a few of
the Bond questionnaire prelabeled statements and clinical assess¬
ment of individual defensive styles. Statements identified as
mature correlated positively with mature mechanisms, but did not
correlate negatively with immature mechanisms. However, state¬
ments reflecting immature defensive styles consistently correlated
negatively with suppression. (Suppression was the defensive style
most consistently correlated with all measures of positive mental
health.7,15) Statements that correlated highly with projection were
often significantly correlated with other immature defenses, espe¬
cially fantasy. Perhaps because of the selective exclusion of anti¬
social personalities both by the Gluecks'17,18 original design and by
attrition, statements selected to identify acting out (eg, number
27) were in fact never completed by the very individuals that the
statement was trying to identify.
The ten lie statements of Bond et al10 were also validated.
Designed to identify factitious disagreements, these ten lie state¬
ments included six of the eight statements with which all respon¬
dents most strongly agreed. In sharp contrast to the statements
designed to assess defenses, no lie statement was significantly
correlated with any major outcome variables, with a single predict¬
able exception. Four of the ten lie statements were significantly
correlated with dissociation (neurotic denial) that had been
clinically identified seven years earlier. Once again we had evi¬
dence both that clinicians were not just influenced by mental health
in labeling defensive style and that defensive style was stable over
time.
The correlations between the Hartmann et al24 schizophrenia
scale and the individual Bond questionnaire statements were very
interesting. Among all variables gathered when the subjects were
in junior high school, no variable, other than the Hartmann scale,
was associated at much better than chance levels with responses to
the Bond questionnaire statements. In contrast, the Hartmann
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Manitoba User on 06/05/2015
Bond et al10 Statement (Defense Label)
1. I get satisfaction from helping others and if this were
taken away from me I would get depressed, (altruism)
3. I'm able to keep a problem out of my mind until
I have time to deal with it. (suppression)
5. I work out my anxiety through doing something constructive
and creative like painting or woodwork, (sublimation)
18. I often feel superior to people I work with, (fantasy)
sex. (isolation)
50. I'm shy about
7. I keep getting into the same type of frustrating
situations and I don't know why. (passive aggression)
34. My friends see me as a clown. ( .12 with humor) (passive
aggression) -
27. I often act impulsively when something is bothering me. (acting out)
66. I am sure I get a raw deal from life, (projection)
25. People tell me I have a persecution complex, (projection)
53. As far as I am concerned, people are either good
or bad. (-17* with humor) (projection/splitting)
scale was significantly correlated with 17 Bond questionnaire
statements answered 40 years later (r=.25 to .46). Of these 17
Bond questionnaire statements, 14 were significantly correlated
with schizoid fantasy assessed seven years earlier. These 14
statements included all five Bond questionnaire statements with
the highest correlation with schizoid fantasy. Of equal interest,
just as the Hartmann scale was not specifically correlated with
clinical assessment of other immature defenses, so it was not
correlated with Bond questionnaire assessment of other immature
defenses. Only three Bond questionnaire statements correlated
significantly with the Hartmann scale but not with schizoid
fantasy. Two statements (43 and 64) were designed by Bond et al10
to identify splitting, and the third significant correlation was
disagreement r=-.33; P<.01) with the statement "I fear
nothing."
COMMENT
This article is an effort to move from undisciplined
inference to empirical, systematized, if inevitably con-
textually based, observation.
In an earlier effort to validate this hierarchy of defenses
among college graduates, one of us (G.E.V.)7 cited the
following four serious methodological limitations: (1) an
intellectually and socially privileged, ethnically homoge¬
neous sample; (2) inadequately controlled halo effects; (3)
circular reasoning, ie, failure to separate defense defini¬
tions completely from definitions of psychopathology and
adjustment; and (4) failure to employ "pencil and paper
tests, controlled laboratory paradigms and standardized
rating scales." In the present article, we have tried to
address these limitations. We have confirmed the hierarchy
in an ethnically diverse and socially and intellectually
underprivileged sample. Halo effects and circular reason¬
ing have been addressed and attenuated, if not abolished.
Finally, standard measures of social class, IQ, and mental
health were substituted for more idiosyncratic measures;
both the Hartmann et al24 and the Bond et al10 measures
allowed modest experimental manipulation of what from
necessity is a naturalistic study.
 Table 6.—Specificity of Individual Bond et al10 Questionnaire Statements
Strength of Correlation With Clinical Assessment of Defense 8 y Earlier, r
Passive Maturity of
Projection Fantasy Hypochondria Aggression Dissociation Repression Altruism Suppression Sublimation Ego Defenses
NS NS NS NS NS NS .21* NS ß* NS

NS NS NS NS NS .24* NS .26* NS NS

NS NS NS NS NS NS NS NS .26* .16*

NS_.24*_NS_NS_NS_NS_NS_NS_NS_NS
NS_.25*_NS_NS_NS_NS_NS_NS_NS_NS
.18* NS .15* .20* NS NS -.16* NS -.23* -.25*

NS .18* .31* .15* NS NS NS -.22* NS -.16+

NS_.18*_.16*_126*_.20*_NS_NS_-.21*_NS_-.26*
.20* .26* .31* .21* NS NS NS -.26* -.21* -.28*

.29*_.24*_124*_NS_.16*_NS_NS_-.31*_-.22*_-.24*
.25* .22* NS NS NS NS -.21* -.25* -.18* -.24*

*P<.01 by Pearson's product-moment correlation coefficient.

*P<.05 by Pearson's product-moment correlation coefficient.
*P<.001 by Pearson's product-moment correlation coefficient.

By administering the Bond questionnaire to our subjects,
the inherent limitations of the context-free but often irrele¬
vant pencil-and-paper test and the context-laden but highly
relevant estimates of functioning in the real world cancelled
each other out. On the one hand, the theoretically derived
individual statements of Bond et al10 were validated. On the
other hand, the correlations of the Bond et al10 items with
clinical assessment of that defense suggest that our raters'
judgments of mature and immature defenses were not made
solely on the basis of context.
One conclusion is that defenses can be better appreciated
from a distance than by close scrutiny. Using life-span
observation, one of us (G.E.V.)4 and Haan7 have enjoyed
more reliable results than either psychoanalysts (eg,
A. Freud35) or psychiatric research workers (eg, Wolff
et al36) using cross-sectional clinical methods. As with
distant mountains, the objective salience of a given defense
can best be measured by triangulation. By triangulation we
mean the contrast of symptom with both autobiographical
statement and with objective biographical data. In cross-
sectional studies, clinical observation (biography), self-
report (autobiography), or projective test results (symptom
or creative product) are inadequate by themselves to iden¬
tify inferred unconscious processes. Longitudinal observa¬
tion, however, allows the clinician and the biographer to use
all three methods together to validate such inferences.
Admittedly, rater reliability of individual defenses is still
very primitive. It will be improved by investigators devel¬
oping more precise definitions (in the model of DSM-III) to
replace the impressionistic definitions offered by Meissner
and Mack37 and one of us (G.E.V.).27
The second broad conclusion that can be drawn from
these findings is that defensive style is an enduring facet of
personality. We administered the Bond et al10 questionnaire
belief that defenses represent traitlike facets of personality.
The Hartmann scale linked fearfulness in junior high school
with the schizophrenic diathesis in young adulthood and
with the tendency to use schizoid fantasy but not other
immature defenses at the ages of 47 and 54 years. Such
evidence directly contradicts the following undocumented
assertion by Brenner38: "No one's repertory of defense is
limited or repetitive."
A third (rather tentative) conclusion is that the recently
devised categories of narcissistic and borderline personal¬
ity may merely reflect relabeling of schizoid, paranoid,
hypochondriacal, and sociopathic personality disorders. In
modern American psychiatry there have been two parallel
systems for classifying personality disorders. Psychiatrists
following the tradition of descriptive European psychiatry
have been able to classify most personality disorders in
terms of the eight subtypes in The International Classifica¬
tion of Diseases, ninth revision. The immature defenses
proposed by one of us (G.E.V.)8 are congruent with this first
model. In contrast, psychiatrists following the tradition of
Melanie Klein, Kernberg, and Kohut have been able to
classify most personality disorders as narcissistic or bor¬
derline. The defenses that Kernberg28 has suggested are
specific to persons with borderline disorders and defenses
that compose factor II of Bond et al10—splitting, omnipo¬
tence, devaluation, and primitive idealization—are con¬
gruent with this second model. It was significant that the
three statements that Bond et al10 devised to reflect split¬
ting correlated positively with clinical assessment of projec¬
tion and negatively with altruism (empathy). For example,
the statement "As far as I am concerned, people are either
good or bad" correlated .25 with projection, .22 with
fantasy, and .21 with altruism. The six items that Bond
et al10 group devised to reflect omnipotence-devaluation and
-

in 1983, six to eight years after the interview on which the primitive idealization proved to be highly correlated with
clinical assessment of defense was based. The significant clinical assessment by our raters of projection or fantasy.
correlations observed between defensive style at two points However, it is also noteworthy that by using factor
in time provide empirical support for the long-established analysis, Bond et al10 found that statements designed to

Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Manitoba User on 06/05/2015

 reflect splitting, omnipotence/devaluation, and primitive
idealization loaded on a separate factor from statements
designed by us to reflect immature defenses. This finding
supports the assertion by Bond and co-workers10 that their
factor II, or "image-distorting" defense style,39 is distinct
from what we term immature defenses. If confirmed, the
work of Bond et al10 supports retaining "borderline" and
"narcissistic" as separate and useful axis II categories.
Finally, the question "Where do mature defenses come
from?" remains unanswered, but we have some clues.
Biology, not unexpectedly, plays a role in defense choice. In
the passage from adolescence to adulthood defensive styles
seem to mature,7 and we know that fatigue, alcohol, organic
brain disease, and certain hereditary mental illnesses all
shift an individual's defenses toward less mature styles.
In contrast, environment, most unexpectedly, seems less
important. The data in Table 2 militate against the obvious
competing explanatory concept of childhood environment.
Similarly, other environmental factors such as sex,29
culture,40 and social class (although Swanson41 disagreed) do
not seem to play a major role in maturity of defenses. For
example, the maturity of defenses of socioeconomically
favored college students7,14 did not differ from that of the
present inner-city sample when one takes selection bias into
account. Again, 61% of our inner-city subjects had parents
born in a foreign country, with the greatest number of
foreign-born parents being Irish, Canadian, and Italian. In
no case did ethnic origins correlate significantly with a
particular defensive style.
Yet environmental and context cannot be wholly irrele¬
vant. Social supports affect the maturity of individuals'
defenses and vice versa.78·42,43 For the present, the determi¬
nants of choice of defenses must be regarded as multifac-
torial. We would guess that the lion's share of variance
depends on person-situation interactions of the sort defined
by Mischel34 and Magnusson and Endler.44 Further research
in this area should be rewarding.
References
1. Kline P: Fact and Fantasy in Freudian Theory. London, Methuen & Co
Ltd, 1972.
2. Moos RH: Psychosocial techniques in the assessment of adaptive
behavior, in Coelho GV, Hamburg DA, Adams JE (eds): Coping and
Adaptation. New York, Basic Books Inc, 1974, pp 334-399.
3. Haan N: Proposed model of ego functioning: Coping and defense
mechanisms in relationship to IQ change. Psychol Monogr 1963;77:1-23.
4. Haan N: Coping and Defending. San Francisco, Jossey-Bass Inc, 1977.
5. Weinstock A: Longitudinal study of social class and defense prefer-
ences. J Consult Clin Psychol 1967;31:539-541.
6. Semrad EV, Grinspoon L, Feinberg SE: Development of an ego profile
scale. Arch Gen Psychiatry 1973;28:70-77.
7. Vaillant GE: Natural history of male psychological health: V. The
relation of choice of ego mechanisms of defense to adult adjustment. Arch
Gen Psychiatry 1976;33:535-545.
8. Vaillant GE: Adaptation to Life. Boston, Little Brown & Co, 1977.
9. Battista JR: Empirical test of Vaillant's hierarchy of ego functions. Am
J Psychiatry 1982;139:356-357.
10. Bond M, Gardiner ST, Christian J, Sigel JJ: An empirical examination
of defense mechanisms. Arch Gen Psychiatry 1983;40:333-338.
11. Kolb LC: Modern Clinical Psychiatry. Philadelphia, WB Saunders
Co, 1977.
12. Kaplan HI, Sadock BJ: Modern Synopsis of Comprehensive Textbook
of Psychiatry, III. Baltimore, Williams & Wilkins, 1981.
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Manitoba User on 06/05/2015
13. Rosenhan DL, Seligman MEP: Abnormal Psychology. New York,
WW Norton & Co Inc, 1984.
14. Vaillant GE, Milofsky ES: Natural history of male psychological
health: IX. Empirical evidence for Erikson's model of the life cycle. Am J
Psychiatry 1980;137:1348-1359.
15. Vaillant GE, Drake RE: Maturity of ego defenses in relation to DSM-
III, axis II personality disorder. Arch Gen Psychiatry 1985;42:597-601.
16. Loevinger J: Ego Development. San Francisco, Jossey-Bass Inc, 1976.
17. Glueck S, Glueck E: Unraveling Juvenile Delinquency. New York,
The Commonwealth Fund, 1950.
18. Glueck S, Glueck E: Delinquents and Nondelinquents in Perspective.
Cambridge, Mass, Harvard University Press, 1968.
19. Hollingshead AB, Redlich FC: Social Class and Mental Illness. New
York, John Wiley & Sons Inc, 1958.
20. Vaillant GE: The Natural History of Alcoholism. Cambridge, Mass,
Harvard University Press, 1983.
21. Vaillant GE: The natural history of male psychological health: II.
Some antecedents of healthy adult adjustment. Arch Gen Psychiatry 1974;
31:15-22.
22. Vaillant GE, Vaillant CO: Natural history of male psychological
health: X. Work as a predictor of positive mental health. Am J Psychiatry
1981;138:1433-1440.
23. Erikson E: Childhood and Society. New York, WW Norton & Co Inc,
1950.
24. Hartmann E, Milofsky E, Vaillant GE, Oldfield M, Falke R, Ducey C:
Vulnerability to schizophrenia: Prediction of adult schizophrenia using
childhood information. Arch Gen Psychiatry 1984;41:1050-1056.
25. Luborsky L: Clinicians' judgments of mental health. Arch Gen
Psychiatry 1962;7:407-417.
26. Luborsky L, Bachrach H: Factors influencing clinicians'judgments of
mental health: Eighteen experiences with the Health Sickness Rating
Scale. Arch Gen Psychiatry 1974;31:292-299.
27. Vaillant GE: Theoretical hierarchy of adaptive ego mechanisms: A 30-
year follow-up of 30 men selected for psychological health. Arch Gen
Psychiatry 1971;24:107-118.
28. Kernberg O: Borderline Conditions and Pathological Narcissism.
New York, Jason Aronson Inc, 1975.
29. Haan N: The relationship of ego functioning and intelligence to social
status and social mobility. J Abnorm Social Psychol 1964;69:594-605.
30. Haan N: Coping and defense mechanisms related to personality
inventories. J Consult Clin Psychol 1965;29:373-378.
31. Endicott J, Spitzer RL, Fleiss JL, Cohen J: The Global Assessment
Scale: A proecedure for measuring overall severity of psychiatric distur-
bance. Arch Gen Psychiatry 1976;33:766-770.
32. Weinstock A: Family environment and the development of defense
and coping mechanisms. J Personality Social Psychol 1967;5:67-75.
33. Bruning JL, Kintz BL: Computational Handbook of Statistics.
Glenview, Ill, Scott Foresman & Co, 1977.
34. Mischel W: On the interface of cognition and personality. Am Psychol
1979;34:740-754.
35. Freud A: NormalitInternationalgy of Childhood: Assessments of
Development. New York, international Universities Press, 1965.
36. Wolff CT, Friedman SB, Hofer MA, Mason JW: Relationship between
psychosocial defenses and mean urinary 17-hydroxycorticoid excretion
rates: I. A predictive study of parents of fatally ill children. Psychosom Med
1964;26:576-591.
37. Meissner WW, Mack JE: Theories of personality and psycho-
pathology: Classical psychoanalysis, in Freedman AM, Kaplan HI (eds):
Comprehensive Textbook of Psychiatry II. Baltimore, Williams & Wilkins
Co, 1975, pp 535-536.
38. Brenner C: Defense and defense mechanisms. Psychoanal Q 1981;50:
557-569.
39. Bond M, Vaillant JS: An empirical study of diagnoses and defense
styles. Arch Gen Psychiatry, in press.
40. Blum G: Defense preferences in four countries. J Projective Tech
1956;20:33-41.
41. Swanson GE: Determinants of the individual's defenses against inner
conflict: Review and reformulation, in Glidewell JC (ed): Parental Attitudes
and Child Behavior. Springfield, Ill, Charles C. Thomas Publisher, 1961.
42. Brown GW, Harris T: Social Origins of Depression. New York, Free
Press, 1980.
43. Nuckolls KB, Cassel J, Kaplan BH: Psychosocial assets, life crisis and
the prognosis of pregnancy. Am J Epidemiol 1972;95:431-441.
44. Magnusson D, Endler S (eds): Personality at the Crossroads.
Hillside, NJ, Lawrence Erlbaum Assoc Inc, 1977.