Cognitive-Behavioral Therapy & Learning Theory Lecture 3 PDF

Cognitive-Behavioral Therapy&Learning Theory&Psychodynamic Psychotherapy Natia Badridze Clinical Psychologist,MD  Aaron Beck is generally considered as a pioneer of CBT.  He was a professor of Psychiatry at the University of Pennsylvania.  He developed Cog...

Cognitive-Behavioral Therapy&Learning Theory&Psychodynamic Psychotherapy Natia Badridze Clinical Psychologist,MD  Aaron Beck is generally considered as a pioneer of CBT.  He was a professor of Psychiatry at the University of Pennsylvania.  He developed Cognitive therapy for treating depression in 1960s  It was subsequently expended to include behavioral components and became CBT.  CBT is a type of Psychotherapy (“Talk Therapy”)  CBT stands for Cognitive Behavior Therapy  Cognition refers to thoughts  Behavior refers to actions  How a person thinks (cognition) and acts (behavior) can affect how a person feels (mood).  Negative cognition and maladaptive behaviors can cause a person to feel depressed.  By identifying and correcting negative thoughts and maladaptive behaviors, mood can be improved.  CBT THE CONCEPT OF ACCESSIBILITY The content & Thoughts are not process of our "unconscious" thinking is "subconscious" accessible inaccessible to consciousness Cognitive-behavioral therapy confirms the point that with proper training and attention, people can understand their own thought process.  CBT-THE CONCEPT OF MEDIATION Thoughts determine our emotional What we think or response to what we conclude different situations about an event is directly related to our feelings Our thoughts have a serious impact on our behavioral patterns (patterns) in various life situations.  CB T T OF C EP C ON GE H E H AN T C Is the result of the previous two concepts. As long as cognitive processes are recognizable and connects different situations and reactions — we can consciously change the reaction to the events around us.  CBT Structured Time-limited (12-16 sessions. once a week for 50 minutes) Real time oriented- focus on “here and now”  Short-term  Long-term  Mainly for depression  Mainly for and anxiety disorders personality disorders  Main focus on “here and  Main focus on how now” problems that are early-life experiences obvious currently have contributed to  Therapist is current problems active,advising patient and giving homework  Therapist is passive, tasks the patient is active  Negative cognitions and  Unconscious behaviors are identified processes are hypothesised  Fundamental to the cognitive model is the way in which cognition (the way we think about things and the content of these thoughts) is conceptualised.  Beck (1976) outlined three levels of cognition:  Core beliefs  Dysfunctional assumptions  Negative automatic thoughts  Core beliefs, or schemas, are deeply held beliefs about self, others and the world.  Core beliefs are generally learned early in life and are influenced by childhood experiences and seen as absolute.  The cognitive triad of negative core beliefs, captures how they relate to:  The self, e.g. ‘I’m useless’  The world/others, e.g. ‘the world is unfair’  The future, e.g. ‘things will never work out for me’  Dysfunctional assumptions are rigid, conditional ‘rules for living’ that people adopt.  These may be unrealistic and therefore maladaptive.  For example, one may live by the rule that ‘It’s better not to try than to risk failing’.  Negative automatic thoughts (NATs) are thoughts that are involuntarily activated in certain situations.  In depression, NATs typically centre on themes of negativity, low self-esteem and uselessness.  For example, when facing a task, a NAT may be ‘I’m going to fail’.  In anxiety disorders, automatic thoughts often include overestimations of risk and underestimations of ability to cope.  They are always negative – “I just missed that turn on the motorway, therefore I am useless, I will never get there on time, I am always messing up, I never do anything right, They will think I am an idiot. She didn’t call me back. I’m not worth bothering about. No-one likes me anyway. And so on.  They make you feel bad about yourself – “I’m such a failure, I am useless, I never do anything right, no-one likes me, I’m too fat, too old, too unfit etc”. And they make you feel bad about your life in general. “My life is useless, hopeless”  They are uninvited – Like a rude gatecrasher who thinks you need to be told what a loser you are, and they can be harshly critical ‘You’ll never amount to anything’ ‘You are so selfish’ ‘You are a show off’  They are believable – It seems to be more plausible to think negatively of yourself than positively. To tell yourself that ‘You are really not that great, you’re just not that clever’ or ‘You are always making mistakes, therefore you are the clumsiest most useless impractical person” – seems acceptable and fair enough to accept these admonishments as truths.   They are biaised – And, although they seem to be acceptable, they are likely to be distorted or wrong. Just because you didn’t do well at one thing, doesn’t mean that you never do well at anything. All or nothing/ black or white thinking If I don’t do it perfectly, then I’m rubbish If I am not a perfect mother/father/daughter/son – then I’m useless If I don’t do well at every area of my job, I am hopeless If I don’t get on with everyone, no one likes me If my partner is annoyed with me, they must hate me If I don’t win the game, I must be a loser Overcontrol and perfectionism Unless I do everything perfectly life is intolerable If my house is not perfectly clean, it is a pigsty If I don’t take care over my appearance, then I am a mess and I can’t go out If I allow paperwork to pile up, I will be out of control Magical thinking or fortune telling My thoughts are so powerful, just by thinking it, something bad will happen I know exactly what she is thinking…. I predict that if I say something about this to her, she will find me unacceptable If I don’t please everyone, they will hate me/ be disappointed in me Catastrophising If I don’t do well in my next exam, I am going to fail everything, get kicked out of university and be a failure for the rest of my life If I don’t get my act together soon, I never will If i don’t get this job, I will never get another one, and will be on the scrapheap If I get sick, I will never recover, and never be able to be happy again If I split up with my partner, I will never meet anyone again, and will be alone Pessimistic or negative bias If something bad is going to happen, it is much more likely to happen to me This proves what I suspected all along You can’t trust anyone these days Everyone is out to rip you off I will never get out of this mess Bad things are always happening to me, or someone I care about Personalisation, over responsibility You assume responsibility for bad things, even though you probably were not responsible A mother feels responsible for her daughters’ poor grades at school and concludes ‘I am a lousy mother’ You complete a tender at work and your company is not awarded the work – ‘ I failed, I don’t deserve the trust and respect people give me’ Activatin Thought Emotion Behavior g event  Using the cognitive model, you will learn to identify the patterns of thoughts, emotions, and behaviors.  You’ll come to understand how the thoughts shape feelings, and how they impact the life in significant ways.  Once you become aware of irrational thoughts, you will learn to change them. The thoughts that once led to depression, anxiety, and anger will be replaced with new, healthy alternatives.  Psychophysiology – focuses on how emotion, thoughts etc. modify the physiological response to a stimulus  Selye noted that the stress response is dependent on the nature, the intensity and the individual’s previous experience with that stimulus  Stimulus → Interpretation → Emotional response → Biological response.  Our physiological reaction to an event is dependent on our perception and interpretation of it.  Stimuli are recognized and processed in the neocortex (thinking brain)  The limbic system interprets and perceives these stimuli as stressful or not (emotional response)  Results in a physiological response through the endocrine system  Hypothalamic-pituitary-adrenal (HPA) axis part of neuroendocrine system, controls reactions to stress and regulates various body processes  Amygdala, hippocampus and hypothalamus (lower circuit of limbic system) facilitate activation of HPA axis, which leads to the release of cortisol  Prolonged high levels of cortisol have been associated with suppressed immune function, depression and may facilitate central adiposity, a risk factor for coronary heart disease and diabetes.  Sympathetic-adrenal-medulla (SAM) axis part of the sympathetic nervous system, responsible for initiating fight or flight response.  Stress stimulates nerves that directly innervate the adrenal medulla, releasing norephinephrine and epinephrine.  Results in increased heart rate, increased blood flow to muscles and diverted blood flow from digestive system, inhibited salivary flow, dilated pupils etc.  Chronic stress → chronic HPA & SAM activation:  May increase other risk factors (abdominal obesity, immune disfunctioning, insulin resistance).  May disrupt normal homeostatic processes resulting in abnormal physiological functioning.  May have long-term effects on the immune and cardiovascular systems, increasing risk of disease and leading to more rapid progression once established. 1. Cognitive restructuring or reframing 2. Mindfulness-based ‘third wave’ technique 3. Exposure therapy 4. Journaling and thought records 5. Behavior activation 6. Behavioral experiments 7. Relaxation and stress reduction techniques 8. Role playing 9. Socratic questioning  Cognitive restructuring, or cognitive reframing, is a therapeutic process that helps the client discover, challenge, and modify or replace their negative, irrational thoughts (or cognitive distortions;).  Situation: Some friends are going out to dinner this weekend and I wasn't invited.  Thoughts: My friends don't like me. They think I am boring. I will end up having no friends.  Feelings: Sad. Disliked. Alone. Stressed.  Evidence that supports the thought: I do get moody every now and then.  Evidence that doesn't support the thought: My friends have told me several times that they think I am fun and that I make them laugh. Other friends have not been invited to other activities. I do get invited to most things.  Alternative/balanced thought: My friends like me but that doesn't mean that they have to invite me to everything.  Outcome: I feel happier. I no longer feel stressed about this.  What is meant by “Third Wave?”  The “first wave” of behavioral therapies were characterized by behaviorism (i.e., operant conditioning, classical conditioning). Albert Ellis and Aaron Beck pioneered the “second wave” of behavioral therapies with cognitive behavioral therapy (CBT), which integrated a person’s thoughts and beliefs in understanding and changing behavior and emotional experiences such as depression.  What is meant by “Third Wave?”  “Third wave” cognitive behavioral therapies are a group of emerging approaches to psychotherapy that represent an evolution and extension of traditional cognitive behavioral treatment approaches.  Third wave therapies prioritize the holistic promotion of psychological and behavioral processes associated with health and well-being over the reduction or elimination of psychological and emotional symptoms, although that typically is a “side-benefit.  Concepts such as metacognition, acceptance, mindfulness, personal values, and spirituality are frequently incorporated into what might otherwise be considered traditional behavioral interventions.  Rather than focusing on the content of a person’s thoughts and internal experiences, third wave behavioral therapists are instead more focused on the context, processes, and functions of how a person relates to internal experiences (i.e., thoughts, urges, sensations).  Mindfulness is a state of open, flexible attention on the present moment. When you’re in a state of mindfulness, you are in a state of observation of your internal experiences.  You observe your thoughts and feelings from a distance, without judgment, and without intervening or controlling them.  Mindfulness has many synonyms. You could call it awareness, attention, focus, or presence. The opposite, then, is not just mindlessness, but also distractedness, inattention, and disengagement.  Mindfulness can be thought of as both a state of mind and a state of being (or acting).  For example, when you practice mindfulness meditation, you’re sharpening your focus and training your brain to be more mindful long after you’re done meditating.  When you’re acting mindfully, you are acting with intention and awareness of the entirety of your present-moment experience, both internal (i.e., your mind and body) and external (i.e., your environment).  Exposure therapy is a psychological treatment that was developed to help people confront their fears. When people are fearful of something, they tend to avoid the feared objects, activities or situations.  In this form of therapy, psychologists create a safe environment in which to “expose” individuals to the things they fear and avoid.  The exposure to the feared objects, activities or situations in a safe environment helps reduce fear and decrease avoidance.  Thought records are a tool used to help the person recognize and change unhelpful thoughts.  The purpose of a thought record is to get a person into the habit of paying attention to it’s thoughts and working to change them.  In behavioral activation, a person identifies specific goals for the week and work toward meeting those goals.  These goals take the form of pleasurable activities that are consistent with the life the person wants to live.  Behavioral experiments are typically used for anxiety disorders that involve catastrophic thinking.  Before embarking on a task that normally makes you anxious, you will be asked to predict what will happen. Later, you’ll talk about whether the prediction came true.  Over time, you may start to see that the predicted catastrophe is actually not very likely to happen. You’ll likely start with lower-anxiety tasks and build up from there.  In CBT, you may be taught some progressive relaxation techniques, such as:  Deep breathing exercises  Muscle relaxation  Imagery You’ll learn practical skills to help lower stress and increase your sense of control. This can be helpful in dealing with phobias, social anxieties, and other stressors  Role playing can help you work through different behaviors in potentially difficult situations. Playing out possible scenarios can lessen fear and can be used for:  Improving problem solving skills  Gaining familiarity and confidence in certain situations  Practicing social skills  Assertiveness training  Improving communication skills  The Socratic method, often described as the cornerstone of Cognitive Behavioral Therapy (CBT), solves this inadequacy by asking a series of focused, open-ended questions that encourage reflection.  By surfacing knowledge that was previously outside of our awareness, the technique produces insightful perspectives and helps identify positive actions.  Socratic questioning involves a disciplined and thoughtful dialogue between two or more people. It is widely used in teaching and counseling to expose and unravel deeply held values and beliefs that frame and support what we think and say.  By using a series of focused yet open questions, we can unpack our beliefs and those of others.  Socratic questioning is critical to successful Cognitive Behavioral Therapy.  Indeed, in CBT, where the focus is on modifying thinking to facilitate emotional and behavioral change, the technique is recognized as helping clients define problems, identify the impact of their beliefs and thoughts, and examine the meaning of events. Refers to a psychological approach which emphasizes scientific and objective methods of investigation. The approach is only concerned with observable stimulus-response behaviors, and states all behaviors are learned through interaction with the environment.  Ivan Pavlov was Russian physiologist known primarily for his work in classical conditioning.  Classical conditioning-a learning process that occurs when two stimuli are repeatedly paired: a response which is at first elicited by the second stimulus is eventually elicited by the first stimulus alone.  Pavlov won the Nobel Prize for Physiology and Medicine in 1904 John B. Watson was an American psychologist who established the psychological school of behaviorism. The behaviorist movement began in 1913 when John Watson wrote an article entitled 'Psychology as the behaviorist views it', which set out a number of underlying assumptions regarding methodology and behavioral analysis. Basic Assumptions All behavior is learned from the environment. Behaviorism emphasizes the role of environmental factors in influencing behavior, to the near exclusion of innate or inherited factors. This amounts essentially to a focus on learning. We learn new behavior through classical or operant conditioning (collectively known as 'learning theory'). Therefore, when born our mind is 'tabula rasa' (a blank slate). Frederic Skinner commonly known as B. F. Skinner, was an American psychologist, behaviorist, author, inventor, and social philosopher. Learning is the acquisition of new behavior patterns. Methods of learning include simple forms, such as habituation and sensitization, and more complex types, including classical conditioning and operant conditioning. Learning methods are the basis of behavioral treatment techniques, such as systematic desensitization, aversive conditioning, flooding, biofeedback, token economy, and cognitive therapy. Habituation (also called desensitization), repeated stimulation results in a decreased response (e.g., a child who receives weekly allergy injections cries less and less with each injection).  The best-known of Pavlov’s experiments involves the study of the salivation of dogs.  Pavlov was originally studying the saliva of dogs as it related to digestion, but as he conducted his research, he noticed that the dogs would begin to salivate every time he entered the room—even if he had no food.  The dogs were associating his entrance into the room with being fed.  This led Pavlov to design a series of experiments in which he used various sound objects, such as a buzzer, to condition the salivation response in dogs.  Classical Conditioning Unconditioned Unconditioned Stimulus Response Unconditioned Neutral Neutral Unconditioned Unconditioned Stimulus Stimulus Stimulus Response Response Repeat Repeatpairing pairingUS USwith withNS NS Conditioned Conditioned Conditioned Conditioned Stimulus Stimulus Response Response  Classical conditioning is a form of learning whereby a conditioned stimulus (CS) becomes associated with an unrelated unconditioned stimulus (US) in order to produce a behavioral response known as a conditioned response (CR).  The conditioned response is the learned response to the previously neutral stimulus.  The unconditioned stimulus is usually a biologically significant stimulus such as food or pain that elicits an unconditioned response (UR) from the start.  The conditioned stimulus is usually neutral and produces no particular response at first, but after conditioning it elicits the conditioned response. 1.Inacquisition, the conditioned response (e.g., salivation in response to the lunch bell) is learned. 2.In extinction, the conditioned response decreases if the conditioned stimulus (e.g., the sound of the lunch bell) is never again paired with the unconditioned stimulus (e.g., the odor of food). 3.Instimulus generalization, a new stimulus (e.g., a church bell) that resembles a conditioned stimulus (e.g., the lunch bell) causes a conditioned response (e.g., salivation).  An unwanted behavior (e.g., setting fires) is paired with a painful or aversive stimulus (e.g., a painful electric shock).  An association is created between the unwanted behavior (fire-setting) and the aversive stimulus (pain) and the fire-setting ceases.  An animal receives a series of painful electric shocks from which it is unable to escape.  By classical conditioning, the animal learns that there is an association between an aversive stimulus (e.g., painful electric shock) and the inability to escape.  Subsequently, the animal makes no attempt to escape when shocked or when faced with any new aversive stimulus; instead, the animal becomes hopeless and apathetic.  Learned helplessness in animals may be a model system for depression (often characterized by hopelessness and apathy) in humans.  Antidepressant treatment increases escape attempts in animal models.  Behavior is determined by its consequences for the individual.  The consequence (reinforcement or punishment) occurs immediately following a behavior.  In operant conditioning, a behavior that is not part of the individual’s natural repertoire can be learned through reinforcement.  Reinforcement is used to help increase the probability that a specific behavior will occur in the future by delivering or removing a stimulus immediately after a behavior.  Another way to put it is that reinforcement, if done correctly, results in a behavior occurring more frequently in the future.  Positive The following are some examples of positive reinforcement works reinforcement: by presenting a motivating/reinforci A mother gives her son praise ng stimulus to the (reinforcing stimulus) for doing homework (behavior). person after the The little boy receives $5.00 desired behavior is (reinforcing stimulus) for every exhibited, making A he earns on his report card (behavior). the behavior more A father gives his daughter likely to happen in candy (reinforcing stimulus) the future. for cleaning up toys (behavior).  Negative reinforcement occurs when a certain The following are some stimulus (usually an aversive stimulus) is removed after a examples of negative particular behavior is reinforcement: exhibited.  The likelihood of the particular behavior occurring Bob does the dishes again in the future is increased because of (behavior) in order to removing/avoiding the negative consequence. stop his mother’s nagging (aversive  Negative reinforcement stimulus). should not be thought of as a punishment procedure. Joe presses a button (behavior) that turns off a With negative reinforcement, loud alarm (aversive  you are increasing a behavior, whereas with punishment, you stimulus) are decreasing a behavior.  When thinking about reinforcement, always remember that the end result is to try to increase the behavior, whereas punishment procedures are used to decrease behavior.  For positive reinforcement, think of it as adding something positive in order to increase a response. For negative reinforcement, think of it as taking something negative away in order to increase a response.  When people hear that punishment procedures are being used, they typically think of an aversive or harmful consequence.  Punishment is a process by which a consequence immediately follows a behavior which decreases the future frequency of that behavior.  Like reinforcement, a stimulus can be added (positive punishment) or removed (negative punishment).  There are two types of punishment: positive and negative, and it can be difficult to tell the difference between the two. Below are some examples to help clear up the confusion. Positive punishment works by presenting an aversive consequence after an undesired behavior is exhibited, making the behavior less likely to happen in the future. The following are some examples of positive punishment: A child picks his nose during class (behavior) and the teacher reprimands him (aversive stimulus) in front of his classmates. A child touches a hot stove (behavior) and feels pain (aversive stimulus). A person eats spoiled food (behavior) and gets a bad taste in his/her mouth (aversive stimulus). Negative punishment happens when a certain reinforcing stimulus is removed after a particular undesired behavior is exhibited, resulting in the behavior happening less often in the future. The following are some examples of negative punishment: A child kicks a peer (behavior), and is removed from his/her favorite activity (reinforcing stimulus removed) A child yells out in class (behavior), loses a token for good behavior on his/her token board (reinforcing stimulus removed) that could have later be cashed in for a prize. A child fights with her brother (behavior) and has her favorite toy taken away (reinforcing stimulus removed).  With punishment, always remember that the end result is to try to decrease the undesired behavior.  Positive punishment involves adding an aversive consequence after an undesired behavior is emitted to decrease future responses.  Negative punishment includes taking away a certain reinforcing item after the undesired behavior happens in order to decrease future responses. Example: A mother would like her 8-yr-old son to stop hitting his 6- yr-old brother. She can achieve this goal by using one of the following features of operant conditioning. Feature Effect on Example Comments Behavior Positive Behavior is Child increases his Reward or increased by kind behavior toward reinforcement reinforcement (praise)increases reward his younger brother to get praise from his desired behavior mother (kindness toward brother)A reward can be praise or attention as well as a tangible reward like money Negative Behavior is Child increases his kind Active avoidance of an reinforcement increased by behavior toward his aversive stimulus (being younger brother to scolded) increases avoidance or avoid desired behavior escape being scolded (kindness toward brother) Punishment Behavior is Child decreases his Delivery of an aversive decreased by hitting behavior after stimulus (scolding) his mother scolds him decreases unwanted suppression behavior (hitting brother) rapidly but not permanently Extinction Behavior is Child stops his hitting Extinction is more eliminated behavior when the effective than Features The likelihood that a behavior will occur is increased by positive or negative reinforcement and decreased by punishment or extinction The pattern, or schedule, of reinforcement affects how quickly a behavior is learned and how quickly a behavior becomes extinguished when it is not rewarded. Extinction in operant conditioning is the gradual disappearance of a learned behavior when reinforcement (reward) is withheld. Schedule Reinforcement Example Effect on Behavior Continuous Presented after A teenager receives a Behavior (putting in a candy bar each time she dollar to receive candy) every response puts a dollar into a is rapidly learned but vending disappears machine. One time she rapidly (has little puts a dollar in and resistance to extinction) nothing comes out. She when not reinforced (no never buys candy from candy comes out) the machine again Fixed ratio Presented after a A man is paid $10 for Fast response rate every five hats he (many hats are made designated makes. He makes as quickly) number of many hats as he can responses during his shift Fixed Presented after a A student has an The response rate anatomy quiz every (studying) increases interval designated Friday. He studies for toward the end of each amount of time 10 min on Wednesday interval (1 wk) nights, and for 2 h on When graphed, the Thursday nights response rate forms a scalloped curve Variable Presented after a After a slot machine The behavior (playing pays off $5 for a single the slot machine) ratio random and quarter, a woman plays continues (is highly unpredictable $50 in quarters despite resistant toextinction) number of the fact that she despite the fact that it receives no further is only reinforced responses payoffs (winning money) after a large but Resistance to extinction is the force that prevents the behavior from disappearing when a reward is withheld. Shaping and modeling 1. Shaping involves rewarding closer and closer approximations of the wanted behavior until the correct behavior is achieved (e.g., a child learning to write is praised when she makes a letter, even though it is not formed perfectly). 2. Modeling is a type of observational learning (e.g., an individual behaves in a manner similar to that of someone she admires).  Sigmund Freud was an Austrian neurologist and the founder of psychoanalysis a clinical method for treating psychopathology through which an analyst unpacks unconscious conflicts based on the free associations, dreams and fantasies of the patient. His theories on child sexuality, libido and the ego, among other topics, were some of the most influential academic concepts of the 20th century. Psychoanalytic theory is based on Freud’s concept that behavior is determined by forces derived from unconscious mental processes. Psychoanalysis and related therapies are psychotherapeutic treatments based on this concept. To explain his ideas, Freud developed, early in his career, the topographic theory of the mind and, later in his career, the structural theory. A.Topographic theory of the mind. B.In the topographic theory, the mind contains three levels: The unconscious, preconscious, and conscious. 1. The unconscious mind contains instinctive drives and wishes that are not available to the conscious mind, and uses primary process thinking. a. Primary process is a type of thinking associated with primitive drives, wish fulfillment and pleasure seeking, and has no logic or concept of time. Primary process thinking is seen in young children and psychotic adults. b. Dreams represent gratification of unconscious instinctive impulses and wish fulfillment. Structural Topographic Age at which it Characteristics Component Level of Develops Operation Contains instinctive sexual and aggressive drives Id Unconscious Present at birth Controlled by primary process thinking Not influenced by external reality Controls the expression of the id to adapt to the requirements of the external world primarily by the use of defense mechanisms Enables one to sustain Unconscious, Begins to develop satisfying interpersonal Ego preconscious, immediately relationships Through reality testing and conscious after birth (i.e., constantly evaluating what is valid and then adapting to that reality), enables one to maintain a sense of reality about the body and the external world Unconscious, Begins to develop Associated with moral values and conscience Superego preconscious, by about 6 yrs Controls the expression and conscious of age of the id The preconscious mind contains memories that, while not immediately available, can be accessed easily. The conscious mind contains thoughts that a person is currently aware of. It operates in close conjunction with the preconscious mind but does not have access to the unconscious mind. The conscious mind uses secondary process thinking (logical, mature, time-oriented) and can delay gratification. Structural theory of the mind. In the structural theory, the mind contains three parts: The id, the ego, and the superego. Defense mechanisms are unconscious mental techniques used by the Ego to keep conflicts out of the conscious mind, thus decreasing anxiety and maintaining a person’s sense of safety, equilibrium, and self-esteem. They can be useful in helping people deal with difficult life situations such as medical illness, but, when used to excess, can become a barrier to seeking care or adhering to treatment recommendations. Specific defense mechanisms 1. Some defense mechanisms are immature (i.e., they are manifestations of childlike or disturbed behavior). 2. Mature defense mechanisms (e.g., altruism, humor, sublimation, and suppression), when used in moderation, directly help the patient or others. 3. Repression, pushing unacceptable emotions. Transference and countertransference are unconscious mental attitudes based on important past personal relationships (e.g., with parents). These phenomena increase emotionality and may thus alter judgment and behavior in patients’ relationships with their doctors (transference) and doctors’ relationships with their patients (countertransference). Transference 1. In positive transference, the patient has confidence in the doctor. If intense, the patient may over-idealize the doctor or develop sexual feelings toward the doctor. 2. In negative transference, the patient may become resentful or angry toward the doctor if the patient’s desires and expectations are not realized. This may lead to poor adherence to medical advice. In countertransference, feelings about a patient who reminds the doctor of a close friend or relative can interfere with the doctor’s medical judgment. THANK YOU