Luis Ángel Saúl

Viewing Cognitive Conflicts as Dilemmas: Implications for Mental Health

The idea that internal conflicts play a significant role in mental health has been extensively addressed in various psychological traditions, including personal construct theory. In the context of the latter, several measures of conflict have been operationalized using the Repertory Grid Technique (RGT). All of them capture the notion that change, although desirable from the viewpoint of a given set of constructs, becomes undesirable from the perspective of other constructs. The goal of this study is to explore the presence of cognitive conflicts in a clinical sample (n = 284) and compare it to a control sample (n = 322). It is also meant to clarify which among the different types of conflict studied provides a greater clinical value and to investigate its relationship to symptom severity (SCL-90-R). Of the types of cognitive conflict studied, implicative dilemmas were the only ones to discriminate between clinical and nonclinical samples. These dilemmas were found in 34% of the nonclinical sample and in 53% of the clinical sample. Participants with implicative dilemmas showed higher symptom severity, and those from the clinical sample displayed a higher frequency of dilemmas than those from the nonclinical sample.

COGNITIVE FACTORS IN FIBROMYALGIA: THE ROLE OF SELF-CONCEPT AND IDENTITY RELATED CONFLICTS

Fibromyalgia is a syndrome characterized by the presence of diffuse and chronic musculoskeletal pain of unknown etiology. Clinical diagnosis and the merely palliative treatments considerably affect the patients experience and the chronic course of the disease. Therefore, several authors have emphasized the need to explore issues related to self in these patients. The repertory grid technique (RGT), derived from personal construct theory, is a method designed to assess the patients construction of self and others. A group of women with fibromyalgia (n = 30) and a control group (n = 30) were assessed using RGT. Women with fibromyalgia also completed the Fibromyalgia Impact Questionnaire and a visual-analogue scale for pain, and painful tender points were explored. Results suggest that these women had a higher present self–ideal self discrepancy and a lower perceived adequacy of others, and it was more likely to find implicative dilemmas among them compared to controls. These dilemmas are a type of cognitive conflict in which the symptom is construed as “enmeshed” with positive characteristics of the self. Finally, implications of these results for the psychological treatment of fibromyalgia are suggested to give a more central role to self-identity issues and to the related cognitive conflicts.

Cognitive conflicts in major depression: Between desired change and personal coherence

Objectives The notion of intrapsychic conflict has been present in psychopathology for more than a century within different theoretical orientations. However, internal conflicts have not received enough empirical attention, nor has their importance in depression been fully elaborated. This study is based on the notion of cognitive conflict, understood as implicative dilemma (ID), and on a new way of identifying these conflicts by means of the Repertory Grid Technique. Our aim was to explore the relevance of cognitive conflicts among depressive patients. Design Comparison between persons with a diagnosis of major depressive disorder and community controls. Methods A total of 161 patients with major depression and 110 non-depressed participants were assessed for presence of IDs and level of symptom severity. The content of these cognitive conflicts was also analysed. Results Repertory grid analysis indicated conflict (presence of ID/s) in a greater proportion of depressive patients than in controls. Taking only those grids with conflict, the average number of IDs per person was higher in the depression group. In addition, participants with cognitive conflicts displayed higher symptom severity. Within the clinical sample, patients with IDs presented lower levels of global functioning and a more frequent history of suicide attempts. Conclusions Cognitive conflicts were more prevalent in depressive patients and were associated with clinical severity. Conflict assessment at pre-therapy could aid in treatment planning to fit patient characteristics. Practitioner points Internal conflicts have been postulated in clinical psychology for a long time but there is little evidence about its relevance due to the lack of methods to measure them. We developed a method for identifying conflicts using the Repertory Grid Technique. Depressive patients have higher presence and number of conflicts than controls. Conflicts (implicative dilemmas) can be a new target for intervention in depression. Cautions/Limitations A cross-sectional design precluded causal conclusions. The role of implicative dilemmas in the causation or maintenance of depression cannot be ascertained from this study.

Bibliometric Review of the Repertory Grid Technique: 1998–2007

This bibliometric review covers the scientific production with or about the repertory grid technique (RGT; Kelly, 1955/1991) between 1998 and 2007. An analysis of previous reviews suggests the need for a more careful and broad process of bibliographic research. With this aim, 24 bibliographic sources were used to cover a wide range of specialties. We began by drawing up an explicit protocol in which the research terms were detailed. Then we consulted the bibliographic sources, taking into account a specification of inclusion and exclusion criteria. As a result of this process, 973 references were obtained: 468 journal papers, 335 book chapters, 108 doctoral theses, and 62 books. The review also evaluates the types of documents found, the evolution of the number of works published, the repertory grids fields of application, and the degree of openness to other disciplines. The most relevant authors, their affiliations, countries, and the publication language are also revealed in this article, as well as the major journals contributing to dissemination of the work done with this technique.

Cognitive conflicts and symptom severity in dysthymia: "I'd rather be good than happy"

SUMMARY A method for studying cognitive conflicts using the repertory grid technique is presented. By means of this technique, implicative dilemmas can be identified, cognitive structures in which a personal construct for which change is wished for implies undesirable change on another construct. We assessed the presence of dilemmas and the severity of symptoms in 46 participants who met criteria for dysthymia and compared then to a non-clinical group composed of 496 participants. Finally, an analysis of the specific content of the personal constructs forming such dilemmas was also performed. Implicative dilemmas were found in almost 70% of the dysthymic participants in contrast to 39% of controls and in greater quantity. In addition, participants in both groups with this type of conflict showed more depressive symptoms and general distress than those without dilemmas. Furthermore, a greater number of implicative dilemmas was associated with higher levels of symptom severity. Finally, content analysis results showed that implicative dilemmas are frequently composed of a constellation of moral values and emotion, indicating that symptoms are often related to moral aspects of the self and so change processes may be hindered. Clinical implications of targeting implicative dilemmas in the therapy context are discussed.

A review of cognitive conflicts research: a meta-analytic study of prevalence and relation to symptoms

Recent research has highlighted the role of implicative dilemmas in a variety of clinical conditions. These dilemmas are a type of cognitive conflict, in which different aspects of the self are countered in such a way that a desired change in a personal dimension (eg, symptom improvement) may be hindered by the need of personal coherence in another dimension. The aim of this study was to summarize, using a meta-analytical approach, the evidence relating to the presence and the level of this conflict, as well as its relationship with well-being, in various clinical samples. A systematic review using multiple electronic databases found that out of 37 articles assessed for eligibility, nine fulfilled the inclusion criteria for meta-analysis. Random effects model was applied when computing mean effect sizes and testing for heterogeneity level. Statistically significant associations were observed between the clinical status and the presence of dilemmas, as well as level of conflict across several clinical conditions. Likewise, the level of conflict was associated with symptom severity. Results highlighted the clinical relevance and the transdiagnostic nature of implicative dilemmas.

Detection and Analysis of Cognitive Conflicts

The idea that change can be “resisted” because of a conflict between desired change and core values can be found in Personal Construct Theory (see Feixas, Saul & Sanchez, 2000 for a review). An interesting starting point in the study of these conflicts was developed by Hinkle (1965) who observed that for some patients construct-related symptoms are associated with positive aspects of the client’s own identity. The abandonment of such symptoms would represent a threat for the self. In these situations the patient faces a cognitive conflict, a dilemma, in which he/she wishes to abandon the symptoms, with all their negative effects and yet, this symptomatology has positive connotations and implications for the self. Its abandonment would involve the patient shifting to an opposed, unclear and undesirable pole (see also Catina, et al., 1990; Button, 1983; Fransella, 1970, Fransella, 1972; and Tschudi, 1977). (1982) Winter (1992), has found that the constructions which clients make about their symptoms can maintain a highly consistent logic given that they represent strongly held beliefs. In Winter’s (1982) more typical cognitive conflict study, for example, it appears that many depressed subjects associate their symptoms with sensitivity and other virtues; many others with agoraphobic symptoms associate being independent with a high possibility of being unfaithful. Subjects that consider themselves timid appear to associate being socially skilled with a wide variety of negative characteristics (selfish, vain, insensitive, arrogant, inconsiderate, etc.).

The Body Grid as an Assessment Tool for Body Image

The aim of this study was to analyze the body grid (BG) as an assessment tool for body image in a sample of patients with breast cancer, after surgery. We explored two measures of cognitive structure, percentage of variance accounted for by the first factor (PVAFF) and polarization, and we compared measures of body image and body self-esteem obtained by means of the BG with those obtained via a validated body image questionnaire. Our sample was composed of 23 patients (12 subjected to radical mastectomy, 11 subjected to conserving surgery) and 24 healthy controls. Participants were administered the BG and the Multidimensional Body Self Relations Questionnaire (MBSRQ). We analyzed the similarities between instruments using correlations and nonparametric tests. We have also provided two case studies to exemplify the use of the BG.  We found statistical differences in cognitive structure between patients and healthy controls. There were no differences between women subjected to mastectomy and women with breast conserving surgery in the level of PVAFF, but there were significant differences between them in the level of polarization. We found significant correlations between body image indices of both instruments, especially self-evaluated attractiveness (MBSRQ) and distance between real and ideal body (BG). We found similar distributions of these indices in all of the samples. We concluded that the BG provides useful information about body image. The results show that both instruments assess similar constructs. This suggests that the BG is a valid instrument for body image assessment.

On the Relation Between Subjective Importance and Elicitation Order of Constructs

The subjective importance of constructs elicited with the repertory grid technique (RGT) has been conjectured to depend on elicitation order. Constructs elicited early in an interview are assumed to be subjectively more important than later ones. For the RGT, this conjecture is based on only one empirical study with a small sample size using person role titles as elements. This study has not been replicated or tested for other domains. The research for other elicitation techniques shows that the conjecture does not always hold true for nonperson domains. To assess if the order importance relation can be replicated for person and nonperson domains, we conducted two RGT studies with different designs (German study, triadic, nonperson elements, N = 60; Spanish study, dyadic, person elements, N = 61). Construct importance was assessed using importance rankings and ratings. We found no relation between the order of elicitation and importance for the nonperson elements and only a small significant relation using persons as elements. The results indicate that the conjecture should be treated with caution, as it may be weaker than previously assumed for the personal domain and not generalizable to other domains.