SEPI XXIXth ANNUAL MEETING, Barcelona Pre-Conference Workshop, June 6th, 2013

A Flexible Therapy Manual for Working with Internal Conflicts

Dr. Guillem Feixas gfeixas@ub.edu

Abstract
Internal conflicts have been a common focus for psychotherapies of a variety of orientations. All of them share the idea that internal conflicts (or personal dilemmas) are at the heart of human functioning. However, their almost opaque nature makes it difficult to identify and gauge. The notion of internal conflict can be formulated within the context of a broader psychological theory capable of contributing in more specific terms, as well as instruments for measuring it. Based on Personal Construct Theory, a constructivist theory that regards the significance attributed to events as being the basis of human functioning, research has been conducted on several clinical problems. Results suggests that internal conflicts can become a target for interventions promoting change. These personal dilemmas are identified in people who associate self-identity characteristics in which change is desirable (e.g., timid) to other, more central core identity constructs (e.g., modest). By implication, achieving change (e.g., becoming social) is linked in the subjects cognitive system to characteristics which are unacceptable for the persons sense of identity (e.g., arrogant). This workshop is designed to: (1) provide the clinician methods to identify internal conflicts, (2) use them for case formulation, and (3) offer the clinician specific guidelines for a dilemma-focused intervention. The presenter will describe and illustrate a protocol for working with internal conflicts, a mechanism that may be blockading change in a variety of clinical problems.

The notion of internal conflict

Conflicts and personal dilemmas have been credited for their importance in psychology Psychoanalysis is founded on the notion of conflict, in terms of the internal dynamics of the psyche Piaget used the term cognitive conflict to refer to contradictions the child encounters when trying to explain events

Bernes Transactional Analysis Greenwalds Decission therapy Gestalt therapy

Social cognitive theorists (Festinger, Heider) where also focused on conflicts and efforts human do to balance them HOWEVER, little has been done in terms of defining conflicts in an operational way, and thus, little research has been done Even less is known about the role of conflicts for both physical and psychological health, development, and change (psychotherapy)

Cognitive Analytic Therapy

Coming from and object relations and personal construct backgraound, Ryle (1979) underlined the importance of dilemmas. They were one of the seeds for his cognitive analytic approach which was developed later:
"Dilemmas can be expressed in the form of "either/or" (false dichotomies that restrict the range of choice), or of "if/then" (false assumptions of association that similarly inhibit change). Two common dilemmas could be expressed as follows: 1) "in relationships I am either close to someone and feel smothered, or I am cut off and feel lonely"; () 2) "I feel that if I am masculine then I have to be insensitive" (italics in the original).

Personal Construct Theory

Kelly (1955) sees the human being very much as a scientist who creates hypotheses in order to make it easier to interpret and understand events. These hypotheses are personal constructs which are basically bipolar in nature. Constructs are the grasping of differences, discriminations we make in our experience.

A person is obviously not guided by one only construct but by an entire network of meanings. This system consists of hierarchically arranged personal constructs. The most central or "core" constructs are those that define the person's identity. In addition, there are more peripheral constructs that, although subordinate to these core constructs, are actively involved in construing events and further actions.

In the core of the construct system lies the sense of identity, represented by a set of core constructs whose invalidation produces great distress, and is strongly resisted. This portion of the system is mainly non-verbal or implicit but governs decisions taken at lower, more peripheral levels. It also might produce plans and personal goals that in certain situations become incompatible. IT IS NOT A LOGICAL SYSTEM The person is not aware of all its components, neither of the conflicts created by the fragmentation of the system.

Repertory Grid Technique (RGT)

The RGT is a structured procedure designed to elicit a repertoire of constructs and to explore their structure and interrelations. Its aim is to describe the ways in which people give meaning to their experience in their own terms. 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 persons organise their world more explicit.

A Repertory Grid consists of:

a series of elements that are representative of the content area under study, a set of personal constructs that the subject uses to compare and contrast these elements, a rating system (e.g., from 1 to 7) that evaluates the elements based on the bipolar arrangement of each construct.

Teresas grid

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

Implicative dilemma
SELF, IDEAL SELF
Constructo Congruent Construct Congruente
Polo Congruente Congruent Pole

Undesirable Polo Indeseable Pole

modest SELF
Constructo Discrepant r >20 Discrepante Construct
Polo Actual Present Pole

arrogant IDEAL SELF

Polo Desired Pole Deseado r >20

timid

social

Implicative dilemmas in a clinical sample

Feixas & Saul (2004) n= Presence of implicative dilemmas TOTAL (n = 606) NO % n= YES % n= 136 47,9 % 148 52,1 % 284 Sample Clinical Non-clinical 213 66,1 % 109 33,9 % 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%

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

t = -5.79; p < .01

Some Conclusions
The presence of dilemmas as captured by repertory grids is a usual, natural, situation in humans at least to some degree (34%). Subjects consulting for clinical problems are more likely (52%) to present implicative dilemmas than subjects who dont. Grids of subjects presenting with psychological symptoms yield a greater number of dilemmas (4,37 vs. 2,11 a significant difference).

Presence of implicative dilemmas before and after therapy

Presence

of implicative dilemmas
NO

After therapy

NO

YES

TOTAL

35 (92%) 34 (69%) 69

3 (8%) 15 (31%) 18

38 (45%) 49 (55%) 87

Before therapy
YES

TOTAL

Therapy results in a significant (p < .001; McNemars test) decrease in the number of subjects presenting with implicative dilemmas. (Feixas & Sal, 2004)

Conflict resolution and change

Data suggest that psychological therapy, even when it is not specifically addressed to resolve previously identified dilemmas, produces a statistically significant reduction in the number of patients presenting with implicative dilemmas . Looking at the outcome measures we found that resolution of dilemmas during the therapy process was consistently related to symptom improvement.

Implications for future research

More attention should be paid to cognitive conflicts as a key variable in the therapy process. More research is needed in order to explore whether cognitive conflicts are more relevant for some specific clinical populations than others, and to find out whether different therapy models are more effective in resolving conflict. Also, the design and study of clinical efficacy of a specific therapy manual with a focus on resolving cognitive conflicts is clearly justified. In terms of clinical practice, the identification of cognitive conflicts should lead to the use of clinical procedures to deal with them as a way of achieving good outcomes.

Dilemma Focused Therapy: A Manual

Guillem Feixas (UB) Joana Senra & Eugenia Fernandes (Universidade do Minho, Portugal)

Overview
Based on the proposal of Feixas & Sal (2000), a more general protocol, a set of guidelines Designed primarily for research protocols but also suitable for clinical practice and training Addressed to neurotic clients showing implicative dilemmas in their rep grids Limited to those cases in which the client agrees to work on his or her dilemma

Recommendations
Clinical training with a constructivist/TCP emphasis Training in the especific techniques included in the manual Supervision

Formal issues
Five phases:
1. 2. 3. 4. 5.

Initial (admittance & assessment) Dilemma formulation Working with the dilemma Dilemma resolution (Fixed role) Termination

A total of 15 sessions. Phase 4 might be skipped, then it would be 10 sessions.

Initial Phase

1st. Session
Goals: Establishing a good therapeutic alliance Defining the complain in psychological terms Setting therapy goals Assessing selfconstruction Means: Clinical interview, empathic attitude Analysis of the complain

Self-characterization

2nd. Session
Goals: Assessing the clients construct system Identifying implicatgive dilemmas Means: Repertory Grid Technique

2nd. Phase: Dilemma formulation

3rd. Session
Goals: Feedback on assessment Reframing the problem in terms of the dilemma Reaching an agreement for working with the dilemma Means: Presenting the dilemma to the client

3rd. Phase: Working with the dilemma

4th. Session
Goals: Assessing the implications of the dilemma Specifying the advantages and disadvantages of change Means: Ladering Tschudis ABC

Case example: Sara

32 years, living with her partner for 5 years At 23 she emigrated from Peru May: referred by physician for psychotherapy July: Assessment (BDI = 7) , complained for being insecure, dependent on others, conflicts with partner and also with mother after visit from the parents September: Father dies November: Therapy begins (BDI = 18)

Implicative dilemma
SELF, IDEAL SELF
Constructo Congruent Construct Congruente
Polo Congruente Congruent Pole

Undesirable Polo Indeseable Pole

mature SELF
Constructo Discrepant r >20 Discrepante Construct
Polo Actual Present Pole

crazy IDEAL SELF

Polo Desired Pole Deseado r >20

timid

extraverted

Tschudis ABC
Timid Disadvantages: Not making friends Extraverted Advantages: Express my views, secure, authentic, sincere Disadvantages: Being criticized and left alone

Advantages: Keep my image of a sweet, affectionate person

5th. Session
Goals: Putting the dilemma in the clients life Means: Reconstruction of the clients immediate experience (controlled elaboration)

6th. Session
Goals: Specify the relational implications of the dilemma Means: Exploring the role other people play in situations related to the dilemma

7th. & 8th. Sessions

Goals: Elucidate the genesis of the dilemma in the history of the client Means: Historical reconstruction of the dilemma

9th. Sessions
Goals: Exploring the alternatives to the dilemma Integrating the therapy process Means: Working with the exceptions to the problem Writing the history of the dilemma

4th. Phase: Dilemma resolution (Fixed role)

Sessions 10 to 14th.
Goals: Working with an alternative view Experimenting the alternative in real life Taking decissions about changes in the clients life Means: Fixed role in which the dilemma is solved Writing a letter to the character of the fixed role

5th. Phase: Termination

15th. Session (or 10th.)

Goals: Means: Evaluation and Reviewing the therapy visualization of the process gains from the therapy Focusing in future Relapse prevention difficulties and ways to cope with them

Thanks for your attention!

My e-mail address: gfeixas@ub.edu MULTI-CENTER DILEMMA PROJECT: www.usal.es/tcp The GRIDCOR program for analyzing repertory grids (including a Manual): www.terapiacognitiva.net/record