sepi 2013 workshop guillem feixas working with internal conflicts

7/28/2019 SEPI 2013 Workshop Guillem Feixas Working With Internal Conflicts

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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 canbe 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 internalconflicts 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 areunacceptable 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.


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The notion of internal conflict

Conflicts and personal dilemmas have beencredited for their importance in psychology

Psychoanalysis is founded on the notion of

conflict, in terms of the internal dynamicsof the psyche

Piaget used the term cognitive conflict to

refer to contradictions the child encounterswhen trying to explain events


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Bernes Transactional Analysis

Greenwalds Decission therapy

Gestalt therapy


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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)


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Cognitive Analytic Therapy

Coming from and object relations and personal constructbackgraound, Ryle (1979) underlined the importance ofdilemmas. They were one of the seeds for his cognitiveanalytic approach which was developed later:

"Dilemmas can be expressed in the form of "either/or" (falsedichotomies that restrict the range of choice), or of "if/then"(false assumptions of association that similarly inhibitchange). Two common dilemmas could be expressed asfollows: 1) "in relationships I am eitherclose to someone

and feel smothered, or I am cut off and feel lonely"; () 2)"I feel that ifI am masculine thenI have to be insensitive"(italicsin the original).


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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.


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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 thosethat define the person's identity.

In addition, there are more peripheral constructsthat, although subordinate to these core constructs,are actively involved in construing events andfurther actions.


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Repertory Grid Technique (RGT)

The RGT is a structured procedure designed to elicit

a repertoire of constructs and to explore theirstructure and interrelations.

Its aim is to describe the ways in which people givemeaning 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 makethose constructs with which persons organise theirworld more explicit.


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A Repertory Grid consists of:

a series ofelements that are representative

of the content area under study,

a set ofpersonal constructs that the

subject uses to compare and contrast theseelements,

a rating system (e.g., from 1 to 7) that

evaluates the elements based on the

bipolar arrangement of each construct.


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Teresas grid


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Self-congruency and

self-discrepancy in the RGT

To study the construction of the self, theRGT 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


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Implicative dilemma

Polo Congruente Polo Indeseable

Polo ActualPolo

Deseador >20

Constructo

Congruente

Constructo

Discrepanter >20

Congruent

Construct

Discrepant

Construct

Congruent Pole UndesirablePole

Present PoleDesired

Pole

timid social

modest arrogant

SELF, IDEAL SELF

SELF IDEAL SELF


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Implicative dilemmas

in a clinical sampleFeixas & Saul (2004) 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 < .01


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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 implicativedilemmas 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).


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Presence of implicative dilemmas

before and after therapy

Presence of

implicative

dilemmas

After therapy

NO YES TOTAL

Before therapy

NO 35 (92%) 3 (8%) 38 (45%)

YES 34 (69%) 15 (31%) 49 (55%)

TOTAL 69 18 87

Therapy results in a significant (p < .001; McNemars test) decrease in

the number of subjects presenting with implicative dilemmas.

(Feixas & Sal, 2004)


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Conflict resolution and change

Data suggest that psychological therapy, evenwhen it is not specifically addressed to resolve

previously identified dilemmas, produces a

statistically significant reduction in the number ofpatients presenting with implicative dilemmas .

Looking at the outcome measures we found that

resolution of dilemmas during the therapyprocess was consistently related to symptom

improvement.


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Dilemma Focused Therapy:

A Manual

Guillem Feixas (UB)

Joana Senra & Eugenia Fernandes

(Universidade do Minho, Portugal)


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OverviewBased on the proposal of Feixas & Sal

(2000), a more general protocol, a set ofguidelines

Designed primarily for research protocols

but also suitable for clinical practice andtraining

Addressed to neurotic clients showingimplicative dilemmas in their rep grids

Limited to those cases in which the client

agrees to work on his or her dilemma


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Recommendations

Clinical training with a constructivist/TCPemphasis

Training in the especific techniques

included in the manual

Supervision


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Formal issues

Five phases:1. Initial (admittance & assessment)

2. Dilemma formulation

3. Working with the dilemma4. Dilemma resolution (Fixed role)

5. Termination

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


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Initial Phase


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1st. Session

Goals:Establishing a good

therapeutic alliance

Defining the complainin psychologicalterms

Setting therapy goals

Assessing self-construction

Means:Clinical interview,

empathic attitude

Analysis of thecomplain

Self-characterization


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2nd. Session

Goals:Assessing the clients

construct system

Identifying implicatgivedilemmas

Means:Repertory Grid

Technique


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2nd. Phase:

Dilemma formulation


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3rd. Session

Goals:Feedback on assessment

Reframing the problem

in terms of thedilemma

Reaching an agreement

for working with thedilemma

Means:Presenting the dilemma

to the client


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3rd. Phase:

Working with the dilemma


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4th. Session

Goals:Assessing the

implications of the

dilemmaSpecifying the

advantages and

disadvantages ofchange

Means:Ladering

Tschudis ABC


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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 forbeing insecure, dependent on others, conflicts

with partner and also with mother after visit from

the parentsSeptember: Father dies

November: Therapy begins (BDI = 18)


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Implicative dilemma

Polo Congruente Polo Indeseable

Polo ActualPolo

Deseado

r >20

Constructo

Congruente

Constructo

Discrepante

r >20

Congruent

Construct

Discrepant

Construct

Congruent Pole UndesirablePole

Present PoleDesired

Pole

timid extraverted

mature

SELF, IDEAL SELF

SELF IDEAL SELF

crazy


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Tschudis ABCTimid

Disadvantages:Not making friends

Advantages:

Keep my image of a sweet,

affectionate person

Extraverted

Advantages:Express my views, secure,

authentic, sincere

Disadvantages:

Being criticized and left alone


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5th. Session

Goals:Putting the dilemma in

the clients life

Means:Reconstruction of the

clients immediate

experience(controlled elaboration)


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6th. Session

Goals:Specify the relational

implications of the

dilemma

Means:Exploring the role other

people play in

situations related tothe dilemma


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7th. & 8th. Sessions

Goals:Elucidate the genesis of

the dilemma in the

history of the client

Means:Historical reconstruction

of the dilemma


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9th. Sessions

Goals:Exploring the

alternatives to the

dilemmaIntegrating the therapy

process

Means:Working with the

exceptions to the

problemWriting the history of

the dilemma


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4th. Phase:Dilemma resolution

(Fixed role)


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Sessions 10 to 14th.

Goals:Working with an

alternative view

Experimenting thealternative in real life

Taking decissions about

changes in the clientslife

Means:Fixed role in which the

dilemma is solved

Writing a letter to thecharacter of the fixed

role


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5th. Phase:Termination


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15th. Session (or 10th.)

Goals:Evaluation and

visualization of the

gains from the therapyRelapse prevention

Means:Reviewing the therapy

process

Focusing in futuredifficulties and ways

to cope with them


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Thanks for your attention!

My e-mail address: [email protected]

MULTI-CENTER DILEMMA PROJECT:

www.usal.es/tcp

The GRIDCOR program for analyzing

repertory grids (including a Manual):

www.terapiacognitiva.net/record

sepi 2013 workshop guillem feixas working with internal conflicts

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