USING PERSONAL DILEMMAS FOR

CASE CONCEPTUALIZATION

Guillem Feixas

(with some help from Gloria Dada)

gfeixas@ub.edu

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

THANKS FOR YOUR ATTENTION!!

Comments are welcome….

gfeixas@ub.edu