Personal dilemmas as cognitive

vulnerability factors

in unipolar depression

42nd. International Meeting of the

Society for Psychotherapy Research

June 29 – July 2, 2011

Bern, Switzerland

in unipolar depression

Guillem Feixas (UB), Victoria Compañ (UB),

Adrián Montesano (UB), Luis Angel Saúl (UNED)

This work has been supported by the Spanish Ministry of Science

and Innovation, grant ref. PSI2008-00406.

Cognitive factors affecting depression

• Early models (Beck et al in the seventies)– negative views of self, the world and the future

– cognitive errors and other attribution biases

• Recent contributions– processing of self-referential stimuli– processing of self-referential stimuli

– memory (both implicit and explicit) biases

– deficits in the control of attention (rumination)

– need for assessing self-relevant stimuli and depth of processing (Wisco, 2009)

… no traces of cognitive or internal conflicts….

The notion of internal conflict

• Conflicts and personal dilemmas have been credited for their importance in psychology

• Psychoanalysis was founded on the notion of conflict, in terms of the internal dynamics 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

• Also in Gestalt Therapy, Berne’s TransactionalAnalysis, and other approaches.

In Cognitive Analytic Therapy

Coming from and object relations and personal construct background, Ryle (1979) underlined the importance of dilemmas. They were one of the seeds for his cognitive analytic approach which was developed later: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).

• 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 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)

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. 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.

PCT: core vs. peripheral constructs

• 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 • 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.

PCT: Identity, fragmentation

• 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. 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.

• 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 • 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.

Teresa’s 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?)• 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”

Types of cognitive conflict

identified with the Repertory Grid

• Implicative dilemmas

based on the association between a based on the association between a

congruent and a discrepant construct

• Dilemmatic constructs

based on the central position of the IDEAL

SELF in a given construct

ConcernedConcerned

aboutabout othersothersSelfish

Congruent

Construct

An example of Implicative Dilemma

Gets depressed

easily

Does not get

Depressed easily

Discrepant

Construct

r = 0,41

Cognitive conflict

• A type of cognitive structure

• Related to identity (core constructs), implicit or

tacit, resistant to change

• A particular form of organization that links

specific cognitive contents (e.g., “I wish to specific cognitive contents (e.g., “I wish to

overcome my shyness”) to core values (e.g., “I am

modest”) in a conflictive way (e.g., “If I become

social I might also end up being arrogant” BUT “If

I want to keep my modesty I have to remain

timid”)

Cognitive conflict: Clinical Implications

• Leaving the symptom pole of a construct, while desirable, may carry negative implications

• Having a symptom is associated with other • Having a symptom is associated with other traits central to the client’s sense of identity

• Abandoning the symptom would involve a major change in the system ⇒⇒⇒⇒ being a different, undesirable, type of person

EMPIRICAL STUDY

work in progress,

(data collected until April, 2011)

MAIN HYPOTHESIS

• Cognitive conflicts are especially prevalent in unipolar depression, and may therefore play a role in its etiopathogenesis and/or its maintenance. Thus, cognitive conflicts may help to explain the difficulty of these patients to to explain the difficulty of these patients to overcome their disphoric mood.

• The role of these conflicts varies depending on the type of depression (dysthimic vs. major depressive disorder)

• A higher presence of conflicts is associated with symptom severity and chronicity.

Participants: clinical sample

• Group A: Major Depression (n = 69, 55 women and 14 men). Inclusion criteria: Meet diagnostic criteria for major depressive disorder according to DSM-IV-TR (APA, 2002) and a score above 19 in the BDI-II questionnaire.

• Group B: Dysthymia (n = 12, 9 women and 3 men): Criteria for inclusion: Meet diagnostic criteria for dysthymic disorder according to DSM-IV-TR and score above 19 in the BDI-II questionnaire. to DSM-IV-TR and score above 19 in the BDI-II questionnaire.

•Exclusion criteria: are excluded from groups A and B persons having bipolar disorder, psychotic symptoms, substance abuse, organic brain dysfunction or mental retardation. The presence of other comorbidities (anxiety disorders, eating, personality, etc.) will not be a reason for exclusion but will be evaluated for statistical control. Depending on the number of participants who met criteria for both diagnoses (called "double depression") assess its treatment as a distinct group or their exclusion from the study.

Participants: non-clinical samples

• 65 psychology students (graduate and

undergraduate):

50 women (77%) 15 hombres (23%)

• 80 participants from a community sample

45 women (56%) 35 men (44%)

Instruments

• SCID-I (First, Spitzer, Gibbon and Williams, 1999) for the diagnosis of mental disorders and the collection of socio-demographic data and consumption of psychotropic drugs.

• BDI-II (Sanz, shot and Vazquez, 2003) for assessing • BDI-II (Sanz, shot and Vazquez, 2003) for assessing depressive symptoms.

• Repertory Grid Technique (Fransella, Bell & Bannister, 2004; Feixas and Cornejo, 1996) for evaluating the presence, number and intensity of cognitive conflicts, construction of the self and cognitive structure.

Results: Presence of Implicative Dilemma(s)

50

60

70

80

Percentage of participants with

Implicative Dilemma(s)

50

60

70

80

Percentage of participants with

Implicative Dilemma(s)

0

10

20

30

40

50

MajorDep Dysthimya Students Community

0

10

20

30

40

Depression Control

p = 0.02

Number of Implicative Dilemmas (I)

2,5

3

3,5

Proportion of Implicative Dilemmas

2,5

3

3,5

Proportion of Implicative

Dilemmas

0

0,5

1

1,5

2

MajorDep Dysthymia Students Community0

0,5

1

1,5

2

Depression Control

p < 0.000 in all comparisons (dysthimia was not compared)

Number of Implicative Dilemmas (II)

Major Depression Dysthymia Students Community

N = 69

X = 3,08

(SD = 3,89)

N =12

X = 2,58

(SD = 4,43)

N = 65

X = 1,22

(SD = 1,95)

N = 80

X = 0,85

(SD =1,73)

Comparing with Major Depression p = 0,000 p = 0,000

Presence of ID(s) and depressive symptoms

10

15

20

25

30

35

40

Absence of IDs

Presence of ID(s)BDI-II

0

5

10

Depression Control

ID(s) Depression group Control group

Absence N = 23; X = 37,13 (DT = 11,40) N = 74; X = 4,43 (DT = 3,88)

Presence N = 58; X = 33,53 (DT = 9,35) N = 71; X = 7,90 (DT = 6,70)

p 0,147 0,000

Presence of ID(s) and depressive symptoms (II)

ID(s) Major Depression Students Community

Abasence N = 19

X = 37,47

(SD = 11,34)

N = 26

X = 4,12

(SD = 3,83)

N = 48

X = 4,60

(SD = 3,94)(SD = 11,34) (SD = 3,83) (SD = 3,94)

Presence N = 50

X = 34,16

(SD = 9,48)

N = 39

X = 8,64

(SD = 7,57)

N = 32

X = 7,00

(SD = 5,45)

p 0,224 0,007 0,025

Presence of ID(s) and cronicity

MDD (single e.)

N = 32

MDD (recurrent)

N = 37

Dysthymia

N = 12

Presence of

Implicative

Dilemma(s)

68,8% (22) 75,7% (28) 66,7% (8)

Dilemma(s)

Presence of Dilemmatic Construct(s) (DC)

Major Depression Dysthymia Students Community

60,87 % (42) 58,3 % (7) 75,4 % (49) 71,3 % (57)

Depression Control

60,5% (49) 73,1 % (106)

60,87 % (42) 58,3 % (7) 75,4 % (49) 71,3 % (57)

About 90% of the clinical sample presented either ID(s) or DC(s)

Conclusions

• Cognitive conflicts might explain the blockage

and the difficult progress of patients with

depression

• Need for specific interventions focused in the • Need for specific interventions focused in the

resolution of these internal conflicts.

New project

An intervention focused on the cognitive conflict(s) specifically detected for each patient will contribute to enhance the efficacy of psychotherapy for depression.

A therapy manual is being developed and tested using a randomized clinical trial by comparing the using a randomized clinical trial by comparing the outcome of two treatment conditions: 1. A cognitive-behavioral treatment package (8 group

+ 8 individual sessions)

2. A package combining CBT (8 group sessions) and a dilemma-focused intervention (8 individual sessions)

We expect that this combined package will increase the efficacy in the treatment of depression

Many thanks for your attention!!

gfeixas@ub.edugfeixas@ub.edu

http://www.usal.es/tcp