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Internal conflicts were at the core of the birth of psychoanalysis (and still present in many psychodynamic comptemporary approaches), but they are also central for Gestalt and experiential approaches (being the two-chair dialogue a nice way to work with those splits). Many other approaches such as cognitive-analytic therapy, motivational interview, coherence therapy, etc. have recognized the importance of these internal conflcits or dilemmas. We have especialized in studying one type of these internal conflicts which in Personal Construct Theory are called implicative dilemmas. The advantatge with those is that they can be operationilized using the Repertory Grid Technique and used for case conceptualization. Also of relevance is that having a way to "measure" internal conflicts research can be implemented. Actually, we have conducted several studies with depressive, eating disorders, fibromyalgic and irritable bowel patients and also with women victims of interpersonal violence. We belief cognitive conflicts are a transdiagnostic issue.
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USING PERSONAL DILEMMAS FOR
CASE CONCEPTUALIZATION
Guillem Feixas
(with some help from Gloria Dada)
SEPI XXIXth ANNUAL MEETING, Barcelona
Plenary session, June 8th, 2013
Contemporary approaches to case formulations: A dialogue between approaches
CONSTRUCTIVIST ASSESSMENT
� “Person-centred approach“: it involves the study of a person's own theories (the "lay" perspective), which consists of personal constructs.
� It does not intend to classify the subject within theoretically derived categories but aims to explore the person's idiosyncratic construction processes.
� Less concerned with the subjects' "real world" than with the way in which they construe that world: “subjective method”
ANNIE
� 45-year-old woman with Major Depression
� Nurse
� Therapy lasted for16 sessions, in 5 months.
� 5-6 months before therapy: First symptoms
� 2 months before therapy: Crisis
1995
2001
4 years (10 years living together)
Ramona
Husband
60
Mar
54
Father
45
Mother
45
Brother
50
Annie
45
Sister
41
Richard
Richard
17
Charles
11
Isabella
Veronica Manu
Cristine
28 29
GOALS AND COMPLAINTS
� “I want to understand where does this malaise
came from, what is wrong with my head?”
� “I just want to feel better. I don’t like to feel this low,
this blue. I want to recover my will and the energy to
do things I like to do, and enjoy them!”
� She feels very sad, tired, and presents diminished
interest and pleasure.
SOME STRESSORS
�Her mother-in-law died recently
� Trouble at her husband’s company (one
of the employees had a terrible
accident at work)
�A friend’s son was terminally ill, and she
took care of him until he died
�She had been trying to get pregnant
unsuccessfully, and now she is in
treatment
�She was pursuing postgraduate studies
(back to school after several years)
DSM-IV
Axis I: Major Depression, Single Episode, Moderate
Severity [F32.1]
� Axis II: No Diagnosis [Z03.2]
� Axis III: Hormonal problems
� Axis IV: Work dissatisfaction; problems at herhusband’s workplace; Mother-in-law died recently.
� Axis V: 70
RESULTS: SCL-90R
0
1
2
3
4
Post-Therapy
Pre-Therapy
RESULTS: BDI-II
30
13
0
10
20
30
40
50
60
Pre-therapy Post-therapy
THE REPERTORY GRID
�Designed by George Kelly to capture
the dimensions and structure of personal
meanings.
� In its many forms, it is a method used to
explore the structure and content of a
person’s implicit theories about self and
others.
� It is not so much a “test” in the
conventional sense of the word as a
structured interview designed to make
those constructs with which a person
organises her world more explicit.
SELF-IDEAL
SELF-OTHERS
IDEAL-OTHERS
(r: 0.006)
(r: 0.208)
(r: 0.130)
Poor self-esteem
Moderate
perceived social
isolation
Poor perceived
adequacy of others
Measures of Self-Construing: Targets for Therapy?
GETTING TO KNOW ANNIE: SELF-DEFINITION
Very Quite
sentimental vs. cold responsible vs. irresponsible
familial vs. distant demanding vs. tolerant
not jealous vs. jealous active vs. calm
Mother Teresa vs. looks after herself emotive vs. rational
fool vs. smart affectionated Vs. sour
expressive vs. inexpressive well-mannered Vs. rude
protective vs. non protective
fighter vs. lazy
unpractical vs. practical
critical vs. critical
far-sighted vs. materialist
SELF-CONGRUENCY AND
SELF-DISCREPANCY IN THE RGT
To study the construction of the self, the RGT includes these two elements:
�SELF NOW (How I see myself now?)
� IDEAL SELF (How I would like to be?)
Constructs in which SN and IS are close are termed “congruent” and those in which they are set apart “discrepant”
DISCREPANT CONSTRUCTS
Present Self Ideal Self
Demanding vs. Tolerant
Mother Teresa vs. looks after her selfPresent Self – Ideal Self
Scores difference: ≥4
CONGRUENT CONSTRUCTS
Affectionate vs. Sour
Fool vs. Smart
Well-mannered vs. Rude
protective vs. Not-protective
Present Self – Ideal Self
Scores difference: ≤1
IMPLICATIVE DILEMMAS
Fool
Protective
Smart
Non protective
Mother Teresa Looks after
herself
Self/ideal self
Self Ideal Self
“MOTHER TERESA” SINCE WHEN?
�When she was a little girl, her mother was
very “sick”
�She took care of her little sister, took care of
the house, the cooking and cleaning...
�She had to leave school for a year
Mother Teresa Look for herself
Advantages
You don’t have to decide
No risk of making mistakes
People “pat your back”
Serenity
Balance
To be aware of what you
want and what you think
Disadvantages I feel “on a cloud”
Everything is superficial
Don’t take care of myself
Don’t have time
Don’t evaluate important
aspects of my own life.
Face facets of my life that
I’m avoiding to.
Have to make my own
decisions
Working with implicative dilemmas
INTERNAL CONFLICT/PERSONAL DILEMMA
NEED FOR
CHANGE
ANTI-SYMPTOM POSITION
NEED FOR CONTINUITY
PRO-SYMPTOM POSITION
PERSONAL CONSTRUCT THEORY
�Kelly (1955) sees the human being a
scientist who creates hypotheses in order to
interpret and make sense of events.
� These hypotheses are personal constructs.
�Constructs are the grasping of differences,
discriminations we make in our experience.
� They form a hierarchical system in which
the core constructs define the identity
�We function to protect from invalidation
our core constructs (resistance?)
� If invalidation occurs our system cannot
predict events (great distress)
COINCIDENTAL APPROACHES
�Cognitive Analytic Therapy
�Coherence Therapy
�Emotion Focused Therapy
�Motivational Interviewing
�Psychodynamic approaches
�Concepts like approach/avoidance
HOWEVER, little has been done in terms of
defining internal conflicts in an
operational way, and thus, little research
has been done
DILEMMAS AND MENTAL HEALTHFeixas, Saul & Avila-Espada(2009) J Constructivist Psych
Sample
Clinical Non-clinical
Presence of implicative dilemmas
NOn = 136 213
% 47,9 % 66,1 %
YESn = 148 109
% 52,1 % 33,9 %
TOTAL (n = 606) n = 284 322
•Differences are significant using a chi-squared test
•A logistic regression analysis including sex and age
yields presence of implicative dilemmas as the first
variable to enter into the equation
IMPLICATIVE DILEMMAS IN DEPRESSION
161 patients with MDD (SCID-I)
compared with 110 community controls
68%35%
χ2 = 28.73; p < .01; φ = .33
t = -5.79; p < .001; eta2 = 0.5
CONCLUSIONS
� Implicative dilemmas a measurable type of
internal conflict
� They may help to explain some difficulties and set-
backs in the change processes
� These dilemmas reflect the tension between the
need to change and the need for continuity (to
protect core constructs from invalidation)
� Detecting implicative dilemmas with the Repertory
Grid a key ingredient of case conceptualization
� Focusing therapy on the specific dilemma(s) of the
client may enhance existing approaches (CBT,
psychodynamic, etc.) and allow more direct and
focused work