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USING PERSONAL DILEMMAS FOR
CASE CONCEPTUALIZATIONGuillem Feixas
(with some help from Gloria Dada)
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.