SEPI XXIXth ANNUAL MEETING, Barcelona Plenary session, June 8th, 2013 Contemporary approaches to case formulations: A dialogue

between approaches

USING PERSONAL DILEMMAS FOR

CASE CONCEPTUALIZATION
Guillem Feixas (with some help from Gloria Dada) gfeixas@ub.edu

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

45
45

Ramona

Father

Mother

54

50

41

Mar

Brother

Isabella

Richard

Sister

17

11

Veronica Manu

Richard
45

Charles

60

Cristine 1995

Husband 4 years (10 years living together)

Annie

28

29

2001

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 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 husbands company (one of the employees had a terrible accident at work) A friends 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 her husbands workplace; Mother-in-law died recently. Axis V: 70

RESULTS: SCL-90R
4 3 2 1 0

Post-Therapy

Pre-Therapy

RESULTS: BDI-II
60 50 40 30

30 13

20 10 0 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 persons 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.

Measures of Self-Construing: Targets for Therapy?

SELF-IDEAL

(r: 0.006)

Poor self-esteem

SELFOTHERS

(r: 0.208)

Moderate perceived social isolation Poor perceived adequacy of others

IDEALOTHERS

(r: 0.130)

GETTING TO KNOW ANNIE: SELF-DEFINITION

Very
sentimental familial not jealous Mother Teresa fool expressive protective fighter unpractical critical far-sighted vs. cold vs. distant vs. jealous vs. looks after herself vs. smart vs. inexpressive vs. non protective vs. lazy vs. practical vs. critical vs. materialist

Quite
responsible demanding active emotive affectionated vs. vs. vs. vs. Vs. irresponsible tolerant calm rational sour rude

well-mannered Vs.

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 Demanding Mother Teresa Present Ideal Self Tolerant

vs.

vs. Ideal looks after her self Self Self

Scores difference: 4

CONGRUENT CONSTRUCTS

Present Affectionate
Fool

Self vs. Ideal Self Sour

Scores difference: 1 Smart vs.

vs. vs. Rude Not-protective

Well-mannered protective

IMPLICATIVE DILEMMAS
Fool Protective Self/ideal self Smart Non protective

Mother Teresa Self

Looks after herself 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

Working with implicative dilemmas

Mother Teresa Advantages
You dont have to decide No risk of making mistakes People pat your back

Look for herself

Serenity Balance To be aware of what you want and what you think Face facets of my life that Im avoiding to. Have to make my own decisions

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.

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 HEALTH

Feixas, Saul & Avila-Espada (2009) J Constructivist Psych n= Presence of implicative dilemmas TOTAL (n = 606)
Differences

Sample Clinical 136 47,9 % 148 52,1 % 284 Non-clinical 213 66,1 % 109 33,9 % 322

NO

% n=

YES

% n=

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 < .001; eta2 = 0.5

CONCLUSIONS
Implicative dilemmas a measurable type of internal conflict They may help to explain some difficulties and setbacks 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