Using Personal Dilemmas for Case Conceptualization_Guillem Feixas

7/28/2019 Using Personal Dilemmas for Case Conceptualization_Guillem Feixas

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USING PERSONAL DILEMMAS FOR

CASE CONCEPTUALIZATIONGuillem Feixas

(with some help from Gloria Dada)

[email protected]

SEPI XXIXth ANNUAL MEETING, Barcelona

Plenary session, June 8th, 2013Contemporary approaches to case formulations:

A dialogue between approaches


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CONSTRUCTIVIST ASSESSMENT

Person-centred approach: it involves thestudy of a person's own theories (the "lay"perspective), which consists of personalconstructs.

It does not intend to classify the subjectwithin theoretically derived categories butaims to explore the person's idiosyncratic

construction processes. Less concerned with the subjects' "real

world" than with the way in which theyconstrue that world: subjective method


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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


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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


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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 dont like to feel this low,

this blue. I want to recover my will and the energy todo things I like to do, and enjoy them!

She feels very sad, tired, and presents diminishedinterest and pleasure.


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SOME STRESSORS

Her mother-in-law died recently

Trouble at her husbands company (one

of the employees had a terribleaccident at work)

A friends son was terminally ill, and she

took care of him until he diedShe had been trying to get pregnant

unsuccessfully, and now she is in

treatmentShe was pursuing postgraduate studies

(back to school after several years)


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DSM-IVAxis 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 her

husbands workplace; Mother-in-law died recently.

Axis V: 70


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RESULTS: SCL-90R

0

1

2

3

4

Post-Therapy

Pre-Therapy


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RESULTS: BDI-II

30

13

0

10

20

30

40

50

60

Pre-therapy Post-therapy


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THE REPERTORY GRID

Designed by George Kelly to capturethe dimensions and structure of personal

meanings. In its many forms, it is a method used to

explore the structure and content of a

persons implicit theories about self andothers.

It is not so much a test in the

conventional sense of the word as astructured interview designed to makethose constructs with which a person

organises her world more explicit.


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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?


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GETTING TO KNOW ANNIE:

SELF-DEFINITION

Very Quite

sentimental vs. cold responsible vs. irresponsiblefamilial 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


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DISCREPANT CONSTRUCTS

Present Self Ideal Self

Demanding vs. Tolerant

Mother Teresa vs. looks after her selfPresent Self Ideal Self

Scores difference: 4


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CONGRUENT CONSTRUCTS

Affectionate vs. Sour

Fool vs. Smart

Well-mannered vs. Rude

protective vs. Not-protective

Present Self Ideal Self

Scores difference: 1


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IMPLICATIVE DILEMMAS

FoolProtective

SmartNon protective

Mother Teresa Looks after

herself

Self/ideal self

Self Ideal Self


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MOTHER TERESA SINCE WHEN?

When she was a little girl, her mother wasvery sick

She took care of her little sister, took care ofthe house, the cooking and cleaning...

She had to leave school for a year


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Mother Teresa Look for herselfAdvantages You dont 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

Dont take care of myself

Dont have time

Dont evaluate important

aspects of my own life.

Face facets of my life thatIm avoiding to.

Have to make my own

decisions

Working with implicative dilemmas


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INTERNAL CONFLICT/PERSONAL DILEMMA

NEED FOR

CHANGE

ANTI-SYMPTOMPOSITION

NEED FORCONTINUITY

PRO-SYMPTOMPOSITION


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PERSONAL CONSTRUCT THEORY

Kelly (1955) sees the human being ascientist 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 invalidationour core constructs (resistance?)

If invalidation occurs our system cannot

predict events (great distress)


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COINCIDENTAL APPROACHES

Cognitive Analytic Therapy

Coherence TherapyEmotion Focused Therapy

Motivational Interviewing

Psychodynamic approaches

Concepts like approach/avoidance

HOWEVER, little has been done in terms ofdefining internal conflicts in an

operational way, and thus, little researchhas been done


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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


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IMPLICATIVE DILEMMAS IN DEPRESSION

161 patients with MDD (SCID-I)

compared with 110 community controls

68%35%

2 = 28.73; p < .01; = .33

t = -5.79; p < .001; eta2

= 0.5


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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 theneed 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 theclient may enhance existing approaches (CBT,psychodynamic, etc.) and allow more direct andfocused work


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THANKS FOR YOUR ATTENTION!!

Comments are welcome.

[email protected]

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