ARTICLES
This article addresses the Core Competency of Patient Care and Procedural Skills
Defense Mechanisms of Pregnant Mothers Predict
Attachment Security, Social-Emotional Competence,
and Behavior Problems in Their Toddlers
John H. Porcerelli, Ph.D., Alissa Huth-Bocks, Ph.D., Steven K. Huprich, Ph.D., Laura Richardson, Ph.D.
Objective: For at-risk (single parent, low income, low support) mothers, healthy adaptation and the ability to manage
stress have clear implications for parenting and the socialemotional well-being of their young offspring. The purpose
of this longitudinal study was to examine associations between defense mechanisms in pregnant women and their
toddlers’ attachment security, social-emotional, and behavioral adjustment.
Method: Participants were 84 pregnant women during their
last trimester of pregnancy, recruited from community agencies primarily serving low-income families. Women were followed prospectively from pregnancy through 2 years after
birth and completed several multimethod assessments during that period. Observations of mother-child interactions
were also coded after the postnatal visits.
Results: Multiple regression analyses revealed that mothers’
defense mechanisms were significantly associated with
several toddler outcomes. Mature, healthy defenses were
Pregnancy can be a significant stressor for mothers (1), especially for low-income women (2). The ability to adaptively
cope with stress before, during, and after pregnancy—both
consciously and unconsciously—may affect a mother’s ability
to optimally support her child’s psychological development.
Coping mechanisms fall into three broad categories: seeking
social support, cognitive strategies, and involuntary defense
mechanisms (3). This study focused on defense mechanisms—
automatic psychological processes that mediate reactions to
emotional conflicts and internal or external stressors. Special
attention was given to the adaptive defenses (e.g., altruism) because they promote optimal adaptation by keeping individuals
aware of their thoughts and feelings and the consequences of
their actions. This differs from pathological defenses, in which
both thought and feeling are ignored (4). Thus, healthy defenses
should allow mothers to cope with stressors and remain attuned
to their child’s thoughts, feelings, behaviors, and needs.
significantly associated with greater toddler attachment security and social-emotional competence and fewer behavior
problems, and less mature defenses (disavowal in particular)
were associated with lower levels of attachment security and
social-emotional competence. Associations remained significant, or were only slightly attenuated, after controlling for
demographic variables and partner abuse during pregnancy.
Conclusions: The study findings suggest that defensive
functioning in parents preparing for and parenting toddlers
influences the parent-child attachment relationship and
social-emotional adjustment in the earliest years of life.
Possible mechanisms for these associations may include
parental attunement and mentalization, as well as specific
caregiving behavior toward the child. Defensive functioning
during times of increased stress (such as the prenatal to
postnatal period) may be especially important for understanding parental influences on the child.
Am J Psychiatry 2016; 173:138–146; doi: 10.1176/appi.ajp.2015.15020173
Infants are born into a complex social world with an innate
capacity for social relatedness. A major developmental task in
the first year of life is to develop at least one attachment
relationship, which is characterized by a preference for
a specific caregiver (or more than one), who is expected to
care for the infant and with whom the infant shares a close,
emotional bond (5, 6). According to attachment theory, the
capacity for social relatedness ensures the child’s survival.
Attachment behaviors, such as crying and smiling, are present
at birth to facilitate this process; these behaviors increase the
likelihood that a caregiver will respond to, care for, and
protect the child. Caregivers also assist considerably with the
infant’s emotional and behavioral regulation through their
responses to infant cues (7, 8). By the end of the first year,
infants’ cognitions about the self, others, and the world
(i.e., internal working models) are also beginning to develop
as the result of experiences with the people most important to
See related features: Editorial by Dr. Perry (p. 99), Clinical Guidance (Table of Contents), CME course (p. 201), and AJP Audio (online)
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Am J Psychiatry 173:2, February 2016
PORCERELLI ET AL.
them (5), and these cognitions subsequently guide the child’s
behaviors and future interactions. Thus, the infant’s emotional, behavioral, and social capacities are organized and
firmly rooted in the relational context with primary attachment figures during the first several years of life (6, 9).
When the attachment relationship goes well, caregivers
consistently respond to the child’s needs in an accurate and
attuned way, and the parent-child relationship is said to be
“secure” because the child can count on and expect the attachment figure to provide appropriate care in times of need
(5). Secure attachment relationships are associated with
better social-emotional and behavioral functioning for the
child both concurrently and in their future (10). In contrast,
when parents are not able to provide consistent, sensitive care
(for a variety of reasons, such as their own mental health
difficulties and problematic defensive processes), the parentchild relationship suffers and is considered “insecure” because the young child is forced to develop a less adaptive
relationship strategy in order to maintain proximity with the
parent. Attachment insecurity is in turn associated with less
adaptive developmental outcomes and greater social-emotional
problems for the child (9).
We hypothesized that mothers who frequently utilize mature defenses are more attuned to their child’s needs and respond more appropriately to meet those needs, helping the
child to develop adequate behavioral and emotional regulatory
capacities early in life. Mature defense mechanisms may be
especially important during times of stress and major relational changes, as is the case during the prenatal and postpartum periods. Therefore, a greater capacity to cope with the
physical and emotional demands of preparing for and parenting a new infant, particularly in the context of other psychosocial adversity, is likely to facilitate a healthy parent-child
relationship and optimal child development. Thus, we hypothesized that the maturity of defense mechanisms in at-risk
pregnant mothers would predict their toddlers’ attachment
security, social-emotional competence, and behavior problems.
METHOD
Participants
Participants were 84 pregnant women recruited for a larger
longitudinal study (11) of the role of psychosocial risk in
women and their young children. Data were collected during
the third trimester of pregnancy, at 3 months postpartum, and
when children were 1 and 2 years old. For the present study,
data from the prenatal and 2-year waves were chosen, since
we believed that the strengths and challenges of the children
would be more clearly observable at age 2, especially socialemotional competence and potential behavior problems.
Participants were recruited through fliers posted at public
locations and agencies serving mostly low-income families.
Procedures
Pregnant women interested in participating in the study were
screened by telephone. Inclusion criteria were age $18 years
Am J Psychiatry 173:2, February 2016
and English fluency. The majority of assessments were
conducted in the family home by two or three research
assistants who had received intensive training from the
second author. At each wave of data collection, self-report
questionnaires were read aloud to enhance participant understanding of each question and limit random responding.
Each protocol was recorded in order for the research assistant to assess for participant literacy difficulties. Financial
compensation was provided in the form of gift cards.
Interviews were conducted in the third trimester and
lasted approximately 2.5–3 hours. The assessments, which
were administered in a standardized order, included a demographic measure, a semistructured clinical interview
assessing mothers’ representations of their infant in utero,
and self-report measures. Mothers were contacted approximately 2 weeks after the baby’s due date to gather birth
information, and a brief telephone interview was administered when infants were approximately 3 months old.
Postnatal assessments were conducted around the child’s
first and second birthdays, each lasting approximately 3–3.5
hours. Demographic and self-report data were collected, and
observations of parent-child interactions were made.
Because of factors associated with poverty status and other
psychosocial risks, participants were relatively transient with
their living arrangements. To reduce attrition, participants
were contacted every 3 months to update contact information
as well as that of friends and relatives who would know their
location if they could not be reached. Study staff conducted
home visits in person to update information if participants
could not be reached by telephone or mail. At the 2-year
point, 84 of 120 mother-child pairs had completed all study
measures.
The study was approved by the institutional review board
of Eastern Michigan University. Informed consent was obtained
from each participant at every wave of data collection.
Measures
Maternal defense mechanisms. The DSM-IV Defensive
Functioning Scale was developed as a proposed axis for DSM
to provide researchers and clinicians with a standard list of
defense mechanisms and definitions for diagnostic and research purposes (12, 13). The scale includes 31 defenses organized into seven hierarchical levels of functioning: high
adaptive, mental inhibitions, minor image-distorting, disavowal, major image-distorting, action, and defensive dysregulation. Defenses are rated each time they emerge during
a clinical interview. Total scores for each level of defense and
an overall defensive functioning score (a measure of maturity
of defense) were calculated. The overall defensive functioning score is calculated by multiplying the score for each
level (ranging from 7, “high adaptive,” to 1, “defensive dysregulation”) by the total number of defenses at each level
and dividing that score by the total number of defenses.
Defensive dysregulation (i.e., psychotic) defenses were not
observed in this study. Interrater agreement of the scales has
ranged from fair to excellent, and their validity has been
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DEFENSE MECHANISMS OF PREGNANT MOTHERS AND TODDLER OUTCOMES
TABLE 1. Demographic Characteristics of Mothers in a Study of
Maternal Defense Mechanisms During Pregnancy and Subsequent
Toddler Outcomes (N=84)
Characteristic
Age (years)
Mean
SD
26.87
5.81
N
%
Ethnicity
Caucasian
African American
Biracial
Other
32
39
9
4
38
46
11
5
Marital status
Married or living with partner
Single
Separated or divorced
27
53
4
32
63
5
Education
Less than high school
High school graduate
College graduate
4
56
24
5
67
28
Yearly income
Less than 20,000
20,000–39,999
40,000–59,999
60,000 or more
43
20
9
12
51
24
11
14
Partner abuse during pregnancy
Psychological
Physical
62
18
74
21
TABLE 2. Descriptive Statistics for Child Outcome Variables and
Maternal Defense Levels
Variable
Criterion variables/toddler outcomes
Attachment security
Social-emotional competence
Behavior problems
Predictor variables/defenses
Overall defensive functioning
High adaptive level
Mental inhibition level
Minor image-distorting level
Disavowal level
Major image-distorting
Action level
Mean
SD
0.30
18.36
11.37
0.27
2.42
6.80
5.51
2.57
3.92
1.83
3.23
0.23
0.17
0.66
2.53
2.59
2.06
2.64
0.61
0.51
supported through studies of defenses and symptoms or
disorders, personality disorder, social or occupational functioning, immature defenses, childhood or adult abuse, relatedness, improvement in depressive episodes, and therapists’
use of psychodynamic-interpersonal interventions (14–23).
Interviews of mothers were coded by a psychologistpsychoanalyst (J.H.P.) with 24 years of experience rating
defense mechanisms. Interrater agreement for the defenses
was calculated from 25 randomly selected interviews rated
by a doctoral candidate in clinical psychology (L.R.) who
underwent extensive training. Raters were blind to all
participant information. Interrater agreement (intraclass
correlation) (24) for this study was as follows: overall
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defensive functioning, 0.81 (excellent); high adaptive,
0.76 (excellent); mental inhibition, 0.66 (good); minor
image-distorting, 0.70 (good); disavowal, 0.79 (excellent);
major image-distorting, 0.59 (fair); action level, 0.49 (fair).
The Defensive Functioning Scale was used to code maternal narratives resulting from the Working Model of the
Child Interview (25), which was administered during the
pregnancy interview. The Working Model of the Child Interview is a 1-hour (audio-recorded) semistructured interview that assesses a caregiver’s representations of the
infant, the self as a caregiver, and the mother-infant relationship. The original coding system (26) includes qualitative scales (e.g., acceptance, coherence, and involvement)
and categorical classifications (balanced, disengaged, and
distorted); the present study utilized the narratives to evaluate mothers’ level of defenses.
Child attachment security. The Attachment Q-Set (27) was
used to measure toddler attachment security at the 2-year
visit. It includes 90 items of infant behavior indicative of
attachment security and insecurity, along a continuum; these
items are later sorted by the researchers into nine equal piles
of 10 statements ranging from “least characteristic of the
child” to “most characteristic of the child” and are based on
naturalistic observations of infant behavior toward the
caregiver/mother during the 3-hour home visit. Research
assistants were extensively trained for 6 months prior to
attending home visits and sorting. Training included extensive readings and discussions about attachment theory,
infant attachment behaviors, and attachment assessments.
Two to three research assistants from the team (advanced
undergraduates and clinical psychology graduate students)
attended every home visit. After each visit, all research
assistants who attended the home visit completed the Q-sort
together, using consensus methodology, usually within 24–48
hours. Because home observations were made while research
assistants were attending to all that was occurring in the
home (e.g., the lead interviewer was focused on appropriate
administration of measures, others were focused on monitoring the baby’s activities, etc.), the decision was made early
on to have all assistants complete the Q-sort together, rather
than independently, so that all observations were taken into
account in the final Q-sort. Research assistants discussed
every item together, consulted their interview notes, shared
their observations, and decided on card placement. Every
home visit was also discussed with the study’s principal investigator (A.H.B.) during weekly lab meetings with all research assistants present. Disagreements (which were rare)
were conferenced. Each participant’s sort was then correlated with a criterion sort developed by experts in the field
that represents the “ideal secure” infant. The resulting correlations were then used as the variable in analyses, with
higher scores representing greater attachment security.
Child social-emotional competence and behavior problems.
The Brief Infant-Toddler Social and Emotional Assessment
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TABLE 3. Correlations Between Maternal Demographic and Partner Abuse Characteristics, Maternal Defenses, and Toddler
Outcomes (N=84)
Maternal Demographic Variables
Partner Abuse
Age
Marital Statusa
Education
Ethnicitya
Income
Psychological
Physical
Mother’s defenses
Overall defensive functioning
High adaptive
Mental inhibition
Minor image-distorting
Disavowal
Major image-distorting
Action
0.30**
0.28*
0.01
–0.24*
–0.20
–0.05
–0.07
–0.08
–0.12
0.01
0.02
0.03
–0.03
–0.07
0.37***
0.20
0.01
–0.14
–0.29**
–0.01
–0.14
–0.08
–0.11
0.08
–0.21
0.18
0.09
0.11
0.34**
0.21
0.05
–0.01
–0.34**
–0.01
–0.02
–0.24*
–0.27*
–0.09
–0.04
–0.22*
–0.05
–0.08
–0.08
–0.11
0.03
0.27*
0.17
–0.05
–0.08
Toddler outcomes
Attachment security
Social-emotional competence
Behavior problems
0.22*
0.17
–0.19
–0.21
–0.01
–0.09
0.41***
0.10
–0.14
–0.26*
–0.15
0.14
0.35***
0.07
–0.15
–0.20
0.03
0.16
–0.26*
0.01
0.04
Measure
a
Dummy variables were created for marital status (single=1, other=0) and ethnicity (African American=1, other=0).
*p,0.05. **p,0.01. ***p,0.001.
(28) was administered to evaluate the toddler’s social,
emotional, and behavioral problems, as well as competencies,
according to maternal report. The 42-item scale assesses
child difficulties and competencies within the past month on
a 3-point scale from 0 (not true/rarely) to 2 (very true/often).
Items are summed to form the problem scale (31 items) and
the competence scale (11 items). The measure has been
demonstrated to have strong psychometric properties (28). In
the present study, Cronbach’s alpha was 0.83 for the problem
scale and 0.85 for the competence scale.
Demographic characteristics. A questionnaire was administered to mothers to gather data on characteristics such as age,
education, income, marital status, and ethnicity (Table 1). The
Conflict Tactics Scale (29) was used to assess partner abuse
during pregnancy with items covering minor and severe
forms of abuse. Participants rated items on the subscales for
physical abuse (12 items), sexual coercion (seven items), and
psychological abuse (eight items) in reference to their
partner’s behavior during pregnancy. Physical and sexual
abuse items were combined into a total score, and the final
physical and psychological abuse scores were dichotomized
(absent or present). In this study, Cronbach’s alpha was 0.63
for the physical abuse scale and 0.79 for the psychological
abuse scale.
Data Analysis
Means, standard deviations, and ranges were computed for
each variable (Table 2). Pearson correlations (two-tailed) are
reported in Table 3. Significant correlations between predictor (mothers’ defenses) and criterion variables (toddler
variables) determined inclusion in regression analyses. Hierarchical multiple regression analyses were performed with
demographic and partner abuse variables entered into the
first block and defense levels entered into the second block in
order to determine whether defenses predict attachment
security, social-emotional competence, and behavior problems beyond what is accounted for by the demographic and
Am J Psychiatry 173:2, February 2016
partner abuse variables. To avoid the issue of collinearity, the
overall defensive functioning scores were run in separate
analyses from defense levels.
RESULTS
Correlations Between Mothers’ Defenses, Demographic
Variables, and Abuse During Pregnancy
Correlations between demographic or partner abuse variables and defense mechanisms are reported in Table 3. Only
marital status failed to correlate significantly with any defense or toddler outcome variables, and it was not included in
any subsequent analyses.
Correlations Between Maternal Defenses and
Toddler Outcomes
Mothers’ overall defensive functioning and high adaptive
level defense scores were significantly and positively correlated with child attachment security and social-emotional
competence (Table 4). Mothers’ overall defensive functioning and high adaptive level defense scores were also
significantly and negatively correlated with child behavior
problems. The correlation between disavowal and behavior
problems approached but fell short of significance (p=0.07).
Disavowal was the only other defense level that significantly
correlated with toddler outcomes. Therefore, high adaptive
and disavowal level defenses were included in the regression
analyses predicting attachment security and social-emotional
competence. Separate regressions were run with overall
defensive functioning predicting toddler outcomes.
Predicting Toddler Outcomes With Overall Defensive
Functioning and Defense Levels
For regression analyses, demographic and partner abuse
variables were entered into the first block and overall defensive functioning, high adaptive, and disavowal defense
variables were entered as the second block. Results of the six
analyses are reported in Table 5.
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DEFENSE MECHANISMS OF PREGNANT MOTHERS AND TODDLER OUTCOMES
TABLE 4. Correlations Between Maternal Defense Characteristics and Toddler Outcomes (N=84)
Maternal Defense Variables
Toddler Outcomes
Attachment security
Social-emotional
competence
Behavior problems
Overall
Defensive
Functioning
0.40***
0.23*
–0.26*
High
Adaptive
0.47***
0.24*
–0.29**
Mental
Inhibition
Minor
ImageDistorting
–0.03
–0.07
–0.19
–0.07
–0.07
0.14
Toddler Outcomes
Disavowal
Major
ImageDistorting
Action
–0.22*
–0.30**
0.05
0.06
–0.09
0.03
0.20
0.12
0.05
SocialEmotional
Competence
0.32**
Behavior
Problems
–0.19
–0.21
*p,0.05. **p,0.01. ***p,0.001.
Mothers’ Defense Mechanisms Predict Attachment
Security, Social-Emotional Competence, and Behavior
Problems in Toddlers
Demographic and partner abuse variables significantly predicted attachment security (p=0.001), and together they
explained 25% of the variance in attachment security. Overall
defensive functioning significantly predicted attachment
security after variance from the first block was accounted
for (p=0.015), explaining an additional 6% of the variance.
In a separate analysis, high adaptive and disavowal level
defenses, entered as the second block, significantly predicted
attachment security (p=0.001), explaining an additional 13%
of the variance.
Demographic and partner abuse variables in the first block
failed to predict toddler social-emotional competence. Overall
defensive functioning, entered as the second block, approached
significance (p=0.06) in predicting social-emotional competence
after variance from the first block was accounted for (p=0.015),
explaining an additional 5% of the variance. In a separate
analysis, high adaptive and disavowal level defenses significantly predicted social-emotional competence after variance
from the first block was accounted for (p=0.007), explaining an
additional 12% of the variance.
Finally, demographic and partner abuse variables in the
first block failed to predict toddler behavior problems.
Overall defensive functioning, entered as the second block,
also failed to predict behavior problems. In a separate
analysis, high adaptive level defenses, entered as the second
block, significantly predicted behavior problems, explaining
an additional 6% of the variance.
DISCUSSION
To our knowledge, this is the first prospective study evaluating maternal defense mechanisms as predictors of toddler
attachment security, social-emotional competence, and behavior problems. Our findings demonstrate that greater use of
healthy, adaptive defenses by pregnant mothers, assessed
through their representations of their child in utero, predicted greater attachment security, better social-emotional
competence, and fewer behavior problems in their toddlers
after accounting for the significant relationships between
demographic or partner abuse variables and child outcomes.
Similarly, the findings demonstrate that less frequent use of
maladaptive defenses (disavowal level defenses) predicted
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greater attachment security, better social-emotional competence, and fewer behavior problems. Thus, it appears that, as
predicted, a mother’s ability to use healthy defense mechanisms during stressful times allows her to support the child’s
psychological development and regulatory capacities in the
earliest years of life.
These findings raise questions regarding the mechanisms
by which certain maternal defenses contribute to toddlers’
social-emotional adjustment. We propose several such
mechanisms, including maternal caregiving behavior and
the mother’s capacity to mentalize about the child during
pregnancy and after birth. Mentalization is the process by
which an individual is able to consider and anticipate what is
in the mind of another and use mental states to understand
behavior (30–32). For a parent, mentalization, also known as
parental reflective functioning (33, 34), involves entering into
the inner world of the child and helping the child make sense
of and organize his or her experiences.
In our sample, the most frequently occurring high
adaptive defense mechanisms were humor, anticipation, altruism, suppression, and self-observation, all of which may
promote more sensitive caregiving and greater parental
mentalizing. For instance, the appropriate use of humor likely
increases shared positive affect and attentive playfulness
with the child and may help diffuse tension or negative affect
under stress. Anticipation promotes the mother’s ability to
store up and/or measure her own resources, considering
ahead of time when the child is likely to need her support;
planning and anticipation may also reduce the occurrence of
stressful experiences in general. Altruism allows the mother
to set her own needs aside to care for the child, placing the
child’s attachment needs at the forefront, while also continuing to gain gratification from doing so. The use of suppression in response to daily stress, anger, and fatigue while
parenting a toddler diminishes the chances of any direct
aggression or hostility toward the child and instead allows
for a “cooling down” period before responding. Finally, selfobservation refers to the mother examining her feelings,
wishes, fears, and maladaptive ways of potentially responding
to the child. Through the use of self-observation, the mother
can choose not to follow her immediate impulses in responding
to a difficult situation with the toddler (e.g., blaming [projection or devaluation] or hitting the child [acting out]). Selfobservation most overlaps with mentalizing, although all
of the healthy defenses probably overlap somewhat with
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PORCERELLI ET AL.
TABLE 5. Multiple Regression Analyses Predicting Toddler Outcomes With Overall Maternal Defensive Functioning Score and
Defense Levels
Measure
B
R2
Adjusted R2
R2 Change
F Change
df
p for F Change
0.25
0.19
0.25
4.27
6, 77
0.001
0.31
0.24
0.06
6.21
1, 76
0.015
0.38
0.31
0.13
7.76
2, 75
0.001
0.04
0.03
0.04
0.58
6, 77
0.74
0.09
0.004
0.05
3.75
1, 76
0.06
0.16
0.07
0.12
5.30
2, 75
0.007
0.07
–0.004
0.07
0.95
6, 77
0.47
Predicting attachment security
Block 1
Age
Ethnicity
Education
Income
Partner psychological abuse
Partner physical abuse
Block 2
Overall defensive functioning score
Block 2
High adaptive
Disavowal
0.27
0.39
–0.04
Predicting social-emotional competence
Block 1
Age
Ethnicity
Education
Income
Partner psychological abuse
Partner physical abuse
Block 2
Overall defensive functioning
Block 2
High adaptive
Disavowal
0.24
0.24
–0.31
Predicting behavior problems
Block 1
Age
Ethnicity
Education
Income
Partner psychological abuse
Partner physical abuse
Block 2
Overall defensive functioning score
–0.20
0.10
0.02
0.03
2.46
1, 76
0.12
Block 2
High adaptive
–0.23
0.11
0.03
0.06
3.88
1, 76
0.05
a mother’s capacity for reflective functioning. Therefore,
overall, the findings in our study are consistent with past
research demonstrating that higher levels of maternal reflective functioning are associated with more sensitive caregiving behavior, as well as greater infant attachment security
(35, 36).
In contrast, the use of disavowal level defenses (denial,
projection, rationalization) may distort perceptions of a
child’s mental states and behavior. For example, denying
a toddler’s need for emotional refueling after separations may
interfere with the child’s sense of security because the mother
may not offer support or soothing at such times. Anecdotally,
Am J Psychiatry 173:2, February 2016
we have also heard mothers in our sample describing the
toddler as “not needing me” because of the child’s (pseudo)
independence or because of the child serving in some rolereversed way in order to meet the needs of the mother
(another form of denial of the child’s needs). Additionally,
projecting malevolent intentions to a child’s behaviors (e.g.,
“He won’t go to bed because he wants me to be miserable,” or
as seen in the first of the two vignettes presented in the shaded
box) is likely to result in negative maternal responses that do
not match the child’s internal experience. As a result, repeated experiences with a mother who displays such projections likely results in the toddler developing an incoherent
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DEFENSE MECHANISMS OF PREGNANT MOTHERS AND TODDLER OUTCOMES
Vignettes From the Working Model of the Child Interview
A Mother With an Immature Level of Defensive
Functioning (4.5 on a Scale of 1 to 7)
Interviewer: How have you felt physically and emotionally throughout your pregnancy?
Mother: Umm … Probably in between, I think. In
between, ’cause she’s [fetus] been pushing me around!
[Level 4: projection] I don’t know the words to describe it.
Interviewer: What have you been doing during your
pregnancy?
Mother: Resting because they … they somehow rest on
you … I basically been resting. Trying to stay off of my
feet.
Interviewer: What have been your impressions about
the baby while you’re pregnant? What do you sense the
baby might be like?
Mother: Hoping he ain’t nothing like his daddy! [Level
5: devaluation] I don’t know. I hope he come out alright
and healthy.
Interviewer: How do you think you’ll react to labor and
delivery?
Mother: I don’t have no feelings because I’m having
a C-section! [Level 4: denial/rationalization] Just ready to
be over with it all.
Toddler’s profile: During the home visit, the child was
observed to display a number of signs of attachment insecurity. For example, researchers coded the child on the
Q-sort as often showing feelings of ambivalence toward
the mother. The child seemed to need to stay in close
contact with her (beyond simply keeping track of her
whereabouts) and indicated wanting contact, but also
fussing and wanting to be put back down again at the same
time. The child also showed wariness, along with disinterest, in the research assistants who came along to
provide care, and avoided them throughout the visit.
Furthermore, the toddler was observed to fall to the floor
several times, face down, whimpering and crying, in an
apparent helpless state. Reports from the mother also
indicated that the child exhibited low levels of socialemotional competence and a high number of behavior
problems.
sense of self, having difficulty understanding and organizing
interpersonal experiences, and exhibiting poor emotion
regulation and insecure, if not disorganized, attachment
behavior. Indeed, a few reports (37, 38) indicate that maternal
negative projections toward their infant or toddler are associated with problematic caregiving behavior, as well as
child internalizing and externalizing problems and disorganized attachment. It is important to note, however, that no
existing studies to our knowledge have measured projection
per se by trained coders. Furthermore, the importance of
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A Mother With a Mature Level of Defensive
Functioning (6.3 on a Scale of 1 to 7)
Interviewer: How have you felt physically and emotionally throughout your pregnancy?
Mother: I’ve actually felt really good, physically and
emotionally. I’ve just been excited because I’m getting so
close. I feel tired because it’s a lot to carry.
Interviewer: What have you been doing during your
pregnancy?
Mother: I’m pretty much doing everything the same …
cleaning, being social, and seeing friends. Now I’m just so
big. [Laughs] I’m too big to do yard work! [Level 7: humor]
Interviewer: What have been your impressions about
the baby while you’re pregnant? What do you sense the
baby might be like?
Mother: She’s been really active. She’s been great …
She seems to react a lot when I touch my stomach, and,
umm, and that’s kinda fun.
Interviewer: How do you think you’ll react to labor and
delivery?
Mother: Well, I’m nervous about it. It’s scary ’cause you
don’t know what to expect, it’s the unknown. I mean of
course I have in head all of the different ways that I want it
to be, and the ways it could be, and how I’m planning for
things. [Level 7: anticipation] But whether it will actually
be like that, it’s hard to say. I’m just trying to be realistic.
Toddler’s profile: In contrast to the previous example,
this toddler demonstrated a number of signs of attachment security during the home visit. Researchers observed the child to use the mother as a secure base from
which to explore and play, alternating between checking
in with her and exploring toys and others in the home.
When being picked up by the mother, the child readily
accepted her contact with comfort and ease. The toddler
also showed considerable positive affect, appearing
lighthearted, playful, happy, and friendly while still
showing a preference for the mother over the research
assistants. Reports from the mother indicated that child
exhibited high levels of social-emotional competence and
a low-moderate number of behavior problems.
negative maternal projections is highlighted by the fact that
they are the focus of some forms of infant-parent psychotherapy (39).
This study had several strengths. One was its prospective, multimethod design, following women and their
children from pregnancy through age 2. Another strength
was that the ratings of the mothers’ defenses were based on
a semistructured interview that elicited representations of
their unborn child; to our knowledge, defense mechanisms
have not previously been studied in pregnant parents to
Am J Psychiatry 173:2, February 2016
PORCERELLI ET AL.
predict later child outcomes. Furthermore, ratings of defense mechanisms were not based on mothers’ defense use
in general. The Defensive Functioning Scale allows for
a comprehensive assessment of defenses ranging from
normal to pathological functioning. A third strength was
the success in maintaining contact with 84 at-risk mothers
over a 2-year period. As for limitations, mentalization
capacities and observed maternal behavior among participants were not directly assessed. Consequently, statements
about causality cannot be made with certainty, and interpretations of the findings need to be examined in future
studies. Whether or not mothers’ defense mechanisms directly
influence attachment security and other aspects of child development, or are mediated in part by maternal mentalization
and maternal behavior, remains an empirical question.
In summary, findings from this study suggest that maternal
defense mechanisms are important in understanding the
nature of the earliest parent-child relationship and subsequent child adjustment in the early years of life. Examining
maternal defenses and other forms of coping may be particularly important during the prenatal and postnatal periods
because this is typically a physically and emotionally demanding time, especially for women experiencing adversity
and risk such as single parenthood, economic disadvantage,
and difficulties with partners and social support. The findings
underscore the importance of assessing defense mechanisms
as part of a comprehensive evaluation of pregnant mothers
and mothers with young children.
AUTHOR AND ARTICLE INFORMATION
From the Department of Family Medicine and Public Health Sciences,
Wayne State University School of Medicine, Detroit; the Department of
Psychology, Eastern Michigan University, Ypsilanti; the Department of
Psychology, Wichita State University, Wichita, Kan.; and the Department
of Psychology, University of Detroit Mercy, Detroit.
Address correspondence to Dr. Porcerelli ([email protected]).
Presented in part at the 2014 National Meeting of the American Psychoanalytic Association, New York, Jan. 14–19, 2014.
Supported by grants from the American Psychoanalytic Fund for Psychoanalytic Research and the International Psychoanalytic Association to
Dr. Huth-Bocks.
The authors report no financial relationships with commercial interests.
Received February 6, 2015; revisions received May 11 and June 9, 2015;
accepted June 15, 2015; published online September 11, 2015.
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