sepi 2013 workshop guillem feixas working with internal conflicts
TRANSCRIPT
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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