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Unread December 8th, 2007, 04:11 PM
James Pretzer James Pretzer is offline
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Default CBT and Defense Mechanisms

There has been a request for more on how CBT can deal with the concept of "defense mechanisms." Here are some ideas taken from my "Beck Meets Freud" which I presented at several locations a couple of years ago:

The job of figuring out how CBT can deal with the concept of defense mechanisms is complicated by the fact that psychodynamic authors don’t necessarily agree on what they mean by “defense mechanism” or agree on a list of defense mechanisms. A typical definition might be: “Defense mechanisms are a set of unconscious ways to protect ourselves from being consciously aware of thoughts or feelings that we cannot tolerate. Although defense mechanisms serve a useful protective function, they usually involve some measure of self-deception and reality distortion, and may seriously interfere with the effective resolution of the actual problem.”

How can CBT deal with the concept of defense mechanisms? Well, the idea that individuals may engage in various cognitive maneuvers in order to avoid facing memories, thoughts, or feelings that they are unwilling to tolerate has received considerable attention in CBT circles in recent years. It is not hard to conceptualize defense mechanisms in CBT terms. Does that mean that a CBT approach to defense mechanisms will resemble a psychodynamic approach? Probably not.

First, there is an important difference in the therapist’s stance in therapy. One could argue that in psychodynamic therapy there is a tendency to presume that the therapist’s interpretations are accurate, whether or not they can be confirmed. If the client disagrees, they are engaging in denial. In cognitive behavioral therapy, the therapist’s interpretations are treated as hypotheses to be tested against the data. Sometimes the therapist is right, sometimes the therapist is wrong. If the client disagrees, the therapist may be wrong or the client may not yet see the data that shows that the therapist is right. Consider the following two case examples:

Psychodynamic example - A client has recently recovered from a psychotic depression that occurred when she learned that she is infertile. The therapist discloses that she is pregnant. The client speaks of admiration and joy for the therapist. Despite therapist’s attempts to invite a range of feelings, the client only expresses positive feelings over the course of the therapist’s pregnancy. The psychodynamic author discussing this case proposes that therapist may have been “unconsciously fearful of client’s anger” and “may have colluded with the patient in denying her angry and murderous feelings” (even though therapist invited client to express any negative feelings). The author clearly assumes that these assertions are correct rather than presenting them as possibilities to consider.

Cognitive behavioral example – A severely disturbed client has been unable to have a stable relationship, let alone a marriage and a baby. The therapist discloses that she is pregnant. The client speaks of admiration and joy for the therapist. Despite therapist’s attempts to invite a range of feelings, the client only expresses positive feelings. Therapist accepts this at face value but periodically elicits the client’s feelings in subsequent sessions. After several sessions during which client only expresses positive feelings, the client becomes angry and throws her cane at the therapist. Therapist and client now discuss the client's anger over the unfairness of the situation and her fears of abandonment.

Possible cognitive conceptualizations of defense mechanisms

• “Experiential Avoidance”
• “a straightforward, if perhaps dysfunctional, attempt at problem-solving.”
• safety behaviors
• schema avoidance/schema compensation
• self-protective mechanisms
• cognitive biases rooted in schemas

Suppose I grow up in a family where talking about feelings isn’t done…

• I don’t have good examples to learn from

• I may assume (or be taught) that it’s not OK to talk about feelings

• I don’t have a chance to get practice at verbalizing feelings

• It’s harder to deal with feelings if I can’t verbalize them

• Feelings may seem overwhelming

• I may have an assortment of assumptions and fears about feelings

• Many of the ways of avoiding feelings are dysfunctional

• The more I avoid, the more I fear

Useful interventions

• Pinpoint and discuss feelings in session

• Label avoidance as avoidance, discuss pros and cons

• Identify and Address fears

• Exposure to affect (staying with the feelings)

• monitor mild feelings in real life

• Identify options for dealing with emotions

• Work on necessary skills

Dealing with defense mechanisms in CT

• Stay close to the data. Treat the therapist’s interpretations as hypotheses to be tested.

• Work with the client to understand their thoughts and feelings.

• Note apparent contradictions, incongruities, etc. and consider a range of possible interpretations.

• Remember that the client may react differently than the therapist expects. (The therapist’s projections may be no more accurate than the client’s)

Addressing dysfunctional attempts at coping

• Identify drawbacks of current strategy (list pros and cons)

• Identify possible alternatives

• Examine pros and cons of promising alternatives

• Address fears and inhibitions that block promising alternatives

• Systematically put alternatives into practice and learn from the results
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