Artículo original
SUMMARY RESUMEN
A method for studying cognitive conflicts using the repertory grid tech- En este estudio se presenta un método para el estudio de los conflictos
nique is presented. By means of this technique, implicative dilemmas cognitivos utilizando la técnica de rejilla. Por medio de ella, se identi-
can be identified, cognitive structures in which a personal construct ficaron los dilemas implicativos, una estructura cognitiva en la que un
for which change is wished for implies undesirable change on another constructo personal en el que se desea un cambio se asocia con otro
construct. We assessed the presence of dilemmas and the severity constructo en el que el cambio no es deseable. Se evaluó la presen-
of symptoms in 46 participants who met criteria for dysthymia and cia de dilemas y la gravedad sintomatológica en una muestra de 46
compared then to a non-clinical group composed of 496 participants. participantes que cumplían criterios diagnósticos para la distimia y se
Finally, an analysis of the specific content of the personal constructs comparó con un grupo control compuesto por 496 participantes. Por
forming such dilemmas was also performed. Implicative dilemmas último, se llevó a cabo un análisis del contenido de los constructos per-
were found in almost 70% of the dysthymic participants in contrast to sonales que forman los dilemas. Se encontraron dilemas en casi 70%
39% of controls and in greater quantity. In addition, participants in de la muestra clínica frente a 39% de la muestra control y en mayor
both groups with this type of conflict showed more depressive symp- cantidad. Por otro lado, los participantes de ambos grupos con este
toms and general distress than those without dilemmas. Furthermore, tipo de conflicto mostraron un nivel mayor de sintomatología depresiva
a greater number of implicative dilemmas was associated with higher y malestar general que aquellos sin dilemas. Además, se encontró una
levels of symptom severity. Finally, content analysis results showed that alta correlación entre el número de dilemas implicativos y la gravedad
implicative dilemmas are frequently composed of a constellation of de los síntomas. Los resultados del análisis de contenido mostraron que
moral values and emotion, indicating that symptoms are often related los dilemas estaban frecuentemente formados por una constelación de
to moral aspects of the self and so change processes may be hin- valores morales y constructos emocionales indicando que a menudo los
dered. Clinical implications of targeting implicative dilemmas in the síntomas están asociados a aspectos positivos del sí mismo, por lo que
therapy context are discussed. el proceso de cambio puede verse bloqueado. Se discuten las implica-
ciones clínicas de abordar los dilemas en el contexto terapéutico.
Key words: Dysthymia, Repertory Grid Technique, cognitive con-
flicts, implicative dilemmas, content analysis, personal constructs. Palabras clave: Distimia, técnica de rejilla, conflictos cognitivos,
dilemas implicativos, constructos personales, análisis de contenido.
1
Universitat de Barcelona, Facultat de Psicologia, Departament de Personalitat, Avaluaciò i Tractament Psicològics.
2
Department of Personality, Assessment and Psychological Treatments, Universitat de Barcelona, Spain.
3
Universidad Antonio Nariño, Cali, Colombia.
4
Department of Personality, Assessment and Psychological Treatments, Universidad Nacional de Educación a Distancia, Madrid, Spain.
5
Department of Psychology, College Lane, University of Hertfordshire, Hatfield, Hertfordshire, UK.
Correspondence: Adrián Montesano, Department of Personality, Assessment and Psychological Treatments, Faculty of Psychology, Universitat de Barcelona.
Passeig Vall d’Hebron, 171, 08035 Barcelona, Spain. E-mail: adrianmontesano@ub.edu
Received first version: July 23, 2012. Second version: August 29, 2013. Third version: November 11, 2013. Accepted: December 4, 2013.
studies have focused on Beck’s and colleagues’ original be hindered. From this point of view, symptom persistence
descriptions of depressive cognitions.2,3 However, the sys- could be better understood by considering the implication
tematic study of the subjective experience of depression (for lines among constructs and the conflict derived from these
instance, how patients particularly construe their selves and implications.
significant others) has received less attention. Contributions Preliminary data from the Multi-Centre Dilemma Proj-
from Personal Construct Theory4 (PCT) may be helpful in ect research group13 (see at www.usal.es/tcp) indicated that
complementing current models of depression by investigat- Implicative Dilemmas (IDs) were the most explanatory type
ing subjective processes and structures of self-construing. In of cognitive conflict detected in the personal construct sys-
addition, research on cognitive features of depression has tems of a large clinical sample. Furthermore, the number of
mainly focused on patients with major depression, whereas IDs was associated with higher levels of symptoms13 and the
the milder condition of dysthymia has received little atten- resolution of IDs, after a psychotherapeutic process, was re-
tion.5 Thus, the goal of this study is to explore, from a con- lated to symptom improvement.14
structivist framework, the personal constructs of patients Two types of constructs are involved in an ID. On the
with a diagnosis of dysthymia. Concretely, we study the one hand, discrepant constructs indicate discrepancies in
role and the content of identity-related cognitive conflicts self-representations. These self-discrepant cognitions occur
and their relationship with symptom severity. when people’s beliefs about themselves do not match their
Similar to subsequent cognitive therapies, PCT pro- own expectations (self versus ideal self). Thus, discrepant
pounds that the process of attributing meaning to experi- constructs reveal dissatisfaction areas, usually reflecting
ence is the most important activity of human psychological symptomatic aspects. On the other hand, congruent con-
functioning.4 In Kelly’s view, we strive to give meaning to structs are those in which people see their actual selves akin
our universe, ourselves and the ongoing experience of ev- to how they would ideally like to be. Therefore, congruent
eryday life. To this end, humans create an evolving theoreti- constructs are often related to personal values and quali-
cal framework. Just as scientific theories are made of theo- ties which persons would not like to change at all. So, an ID
retical constructs, personal theories are composed of what arises whenever there exists a strong association between
Kelly termed “personal constructs”. They represent bipolar a construct in which the person wishes to change (discrep-
dimensions of meaning which are organized in a hierarchi- ant) and another construct in which change is not desirable
cal and (more or less) complex network system. In short, the (congruent) such that change in a desirable direction on the
personal construct system comprises the specific subjective former is associated with movement away from the ideal
way in which each person construes experience.6 self on the latter. This association between constructs within
Inspired by PCT, researchers have developed tools for the context of a personal construct system could constitute
the systematic study of subjective experience. The most an explanation of the relative resistance to change of a de-
widely used instrument is the Repertory Grid Technique pressed patient.
(RGT), aimed at the elicitation, through a semi-structured As said before, the personal construct system is hier-
interview, and exploration of a person’s personal con- archically organized, and so some subordinate constructs
structs.7 One of the advantages of the RGT is that it allows could be directly related to others of greater significance
one to perform and combine quantitative and qualitative for the individual. For example, the construct “sad-happy”
analyses based on the grid data matrix resulting from the could be related to higher order constructs such as “good
ratings of constructs across a set of elements (usually self, person-bad person” which belong to the core of the system.
ideal self and significant others). Indeed, several measures Core constructs provide a sense of continuity of the self and,
of self-construing and system organization can be derived thus, define the person’s identity. Consequently, whenever
from the RGT analyses. a person holds an ID, trying to move to the desired pole of
Various studies8-11 have pointed out the utility of ex- the discrepant construct may also imply moving away from
ploring the construct system in the evaluation of depressive a core quality that the person estimates as part of his or her
disorders. For example, Neimeyer and Feixas8 showed that identity. Arguably, such a process challenges the person’s
measures derived from the RGT tapped some cognitive fea- identity and might generate greater distress, eventually
tures (e.g., rigidity) that symptom and standard cognitive impeding the achievement of the desired change and main-
measures of cognitive distortions did not account for. Of taining the symptoms.
great importance here is the study of cognitive structures For instance, the patient illustrated in figure 1 desired a
involved in change processes as long as dysthymic patients, change from having low self-esteem to being a person with
by definition, show a chronic course of the disorder.12 With high self-esteem (note that here “self-esteem” is a personal
regard to change, a PCT-based line of research explored the construct, not a theoretical one). However, the dilemma oc-
idea that symptoms (e.g., low self-esteem) can be associat- curred because changing on this discrepant construct im-
ed, by construct implications, to positive aspects of the self plied an undesired change on the congruent construct, that
(e.g., being sensitive) so that the process of change might is, becoming a “bad person”. In other terms, a movement
Present self – Ideal self be carried out to better understand the role of moral values,
Congruent
construct
Good
person
Bad
person
for which differences were not found, and emotion, insofar as
these are crucial areas of content for this kind of patient.
r = 0.712 r = 0.712
MATERIALS AND METHODS
Discrepant
construct
Low
self esteem
Present self
High
self esteem
Ideal self
Participants
struct and those given to a congruent construct is .35 or chotherapists, who had a minimum of six years of experi-
higher, indicating an association between the desired ence. Those who agreed to participate were interviewed on
pole of the discrepant construct and the undesired pole at least two occasions before therapy started. At the initial
of the congruent one. This is a dichotomous variable interview, participants were asked to provide informed con-
scoring «1» for those participants for whom at least one sent and all doubts about the research were discussed. So-
ID is found, and «0» for those for whom none is found. ciodemographic data was also gathered. Then, the RGT was
b) The percentage of implicative dilemma (PID). The PID administered, the elicitation and rating phases being carried
reveals the number of IDs in a grid taking into account out conjointly by the participant and the interviewer. Before
its size. The number of constructs elicited during ad- initiating the therapy, participants also completed the SCL-
ministration varies from one grid to other, influencing 90-R.
the possible number of IDs within a grid. This measure Participants in the control group were volunteers re-
is calculated by dividing the number of dilemmas of a cruited and assessed by psychology undergraduate or mas-
grid by the total number of possible combinations of ter students (trained in the application of RGT) in face-to-
constructs in such a grid taking two at a time. The re- face interviews. All participants provided informed consent
sulting proportion is multiplied by 100 to obtain the on forms approved by local research ethics committees.
percentage. The mathematical analysis of the RGT was Finally, pairs of independent graduate and undergradu-
performed using the GRIDCOR v. 4.0 software created ate students well-trained in the CSPC performed the content
by Feixas and Cornejo.24 analysis of the personal constructs. The training consisted in
rating a set of 150 constructs from a sample used in another
Classification System for Personal Constructs (CSPC)
study. To avoid biased ratings, the coders were blind to the
The CSPC is a system developed by Feixas, Geldschläger hypothesis of the study and did not know whether the grids
and Neimeyer26 designed to analyse and classify the content belonged to the clinical or the control sample. Inter-rater
of personal constructs derived from constructivist assess- analysis yielded high levels of agreement (K=.91; p<.001).
ment procedures, and particularly from the RGT. The CSPC
is composed of 45 comprehensive and mutually exclusive Statistical analyses
categories arranged into six thematic areas (moral, emo-
tional, relational, personal, intellectual, specific values and Data collected from RGT was analyzed with the software
interests). Those areas are hierarchically ordered as listed GRIDCOR v. 4.024 and dumped into the Statistical Package
above to increase the reliability of the system by eliminat- for Social Sciences version 20.0(IBM Corporation, Armonk,
ing potential overlap among them: whenever a construct fits New York, USA) datasheet for further analyses. First, the
within two or more areas, it is coded in the area of higher clinical and control groups were compared in order to
level. Categories belonging to the same area are considered identify differences in the presence and number of IDs. We
at the same hierarchical level. It is considered an instrument used the Student-T test for continuous variables and the
with high methodological quality, versatility and with a Chi-square test for categorical variables. Second, Student-
promising applicability.27 It has already been applied to per- T test and non-parametric Spearman’s rank order Correla-
sonal constructs of depressed23 and other patients,17 but not tion were used to describe the relationship between IDs and
of dysthymics and the content of the constructs forming IDs symptom severity. Finally, Chi-square test and confidence
has not been analysed. Feixas et al.26 reported a high reliabil- intervals were used to compare the content of congruent
ity index for the CSPC (Cohen’s Kappa=0.93). and discrepant constructs within the clinical sample.
Table 1. Presence of Implicative Dilemmas in both groups Content analysis of implicative dilemmas
Presence Absence
Table 2 illustrates the coding of congruent and discrepant
Clinical n 32 14
% 69.6 30.4 constructs forming IDs in the clinical sample. A chi-squared
Control n 195 301
test showed that these types of constructs differed in their
% 39.3 60.7 content (χ2 [5]=71.16; p<.001, Cramer’s V=.49). In order to
know in which particular areas they were differentiated, ad-
justed standardized residuals where compared to the criti-
SD=1.7) samples. The significant difference found between cal value of ± 1.96 (α=0.05). Differences were found in the
the two groups (t [47.03]=-3.25; p=.002; d=.62) indicated a moral, emotional, and interest areas.
greater number of IDs in the former, with a medium effect Once the difference in content between the types of con-
size. structs was established, we estimated, separately, the confi-
dence intervals of proportion for congruent and discrepant
Implicative dilemmas constructs in each area of the CSPC. While the proportion
and symptomatology of congruent constructs that belonged to the moral area
differed significantly from the proportion in the rest of the
Data of the SCL-90-R were available for 234 participants, areas, most of the discrepant constructs were significantly
199 from the non-clinical sample and 35 from the clinical associated with the emotional area (table 3).
one. First, two independent samples t-tests were conduct- In order to analyse in more detail the content of the IDs,
ed to compare GSI (t [32.99]=4.47, p<.001, d=1.41) and DS we observed the frequency of congruent and discrepant
(t [32.94]=6.29, p<.001, d=1.99) scores within the clinical constructs in each category of the relevant areas described
sample. Participants with IDs (n=25) yielded an average above. In regard to congruent constructs, the categories
score on the GSI of 1.19 (SD=.44) and on the DS of 1.86 “altruist-egoist” and “responsible-irresponsible” were the
(SD=.67), whereas for those without IDs (n=10) it was .72 most frequently rated. For discrepant constructs, the catego-
(SD=.17) and .85 (SD=.27), respectively. Second, the same ry “balanced-unbalanced” significantly stood out from the
analyses were conducted for the non-clinical group. Par- rest of the categories. The categories “optimist-pessimist”,
ticipants with IDs (n=84) showed an average on the GSI of “warm-cold” and “specific emotions” were also frequent
.66 (SD=.39) and on the DS of .89 (SD=.63), whereas for the (table 4).
remainder (n=115) it was .49 (SD=.34) for the GSI and .64
(SD=.50) for the DS. Independent samples t-tests showed
significant differences for both the GSI (t [197]=3.33, p=.001, DISCUSSION
d=0.48) and the DS (t [153.86]=3.13, p=.002, d=.44).
Finally, the relationship between PDI and SCL-90-R Results obtained in this study were in line with previous
scores was inspected using Spearman’s coefficient due to findings,13,15-18 which consistently pointed towards a higher
the skewed distribution of the former. In the clinical sam- rate of IDs in clinical samples. We found IDs in over two
ple there were strong correlations between PDI and GSI thirds of dysthymic patients in contrast to only 39% of con-
(rho=.48, n=35, p<.001) and between PDI and DS (rho=.57, trols. Moreover, differences between groups were under-
n=35, p<.001). Likewise, significant correlations were found lined by the fact that dysthymic participants significantly
in the control group (rho=.22, n=199, p=.002, for the GSI and presented a higher quantity of IDs.
rho=.21, n=199, p=.004 for the DS). Although conflictual configurations of constructs have
proved their relevance for patients with other diagnoses,30-32
Table 4. Confidence intervals of proportion for congruent and discrepant constructs within categories
of content
results from this and other preliminary* studies suggest that analysis results have also provided evidence for the construct
cognitive conflicts are particularly pertinent for depressive validity of congruent and discrepant constructs.
disorders due to the prototypical pattern of self-construing Congruent constructs, which provide people with a
among these patients. Self-construing in depression often crucial source of coherence and continuity, mostly were of a
entails not just elevated self-ideal discrepancies but a mixed moral nature. Conversely, discrepant constructs usually pre-
pattern of positive and negative perceptions.33 sented content related to the degree of emotional balance but
Although IDs are a natural constellation of constructs, also to the “optimism-pessimism” and “warm-cold” dimen-
their relation to symptom behaviour became more evi- sions, and other specific emotions such as melancholy, apa-
dent when exploring correlations with symptom severity. thy and sadness. Ostensibly, these areas of content are partic-
Among dysthymic participants, those who presented one ularly relevant dimensions of meaning for understanding the
or more IDs displayed significantly (and with large effect psychological distress of dysthymic patients if we consider
sizes) higher levels of depressive and global symptom se- central features of the disorder such as emotional dysregula-
verity. Furthermore, a greater number of IDs was strongly tion, low self-esteem and feelings of hopelessness.12
associated with higher levels of distress. In fact, correla- It seems that the manner of conflictual self-construing
tions from this study were much higher than in previous in most dysthymic patients in the present study conforms to
research.18 Future research should clarify whether the rela- the observations made by Rowe34,35 and Winter36 about the
tionship between the number of dilemmas and the severity dilemmatic implications for change of depressive patients.
of symptoms is linear or not. Nevertheless, findings from They pointed out that they typically embrace self-construc-
our study suggested that the higher level of severity is re- tions whereby they should choose either being depressed but
lated to a higher number of dilemmatic implications within human or being happy but unpleasant: “I’d rather be good
the construct network of dysthymic patients. To a certain than happy”. In view of such a dilemma, it is not surprising
extent, the persistence of symptoms and the tendency to- that they might decide to maintain their positive features
wards chronicity in dysthymia could be explained by a high even though when not changing implies suffering, inasmuch
level of conflicts and, in turn, this might be the reason of the as from this position they avoid the invalidation of core con-
greater correlations found in this study. structs and preserve their sense of personal identity.
The results from the content analysis of the IDs offered a We do not consider this thematic composition of IDs as
much more detailed picture of not only the nature of these con- specific for dysthymic patients. As we said above, IDs are
flicts, but also of the role of moral and emotional constructs in common across different disorders. Thus, we look upon this
the clinical participants’ construction of their experience. An- thematic composition as a general constellation of content in
other study,16 in which the general content of personal con- which congruent constructs are mostly of a moral nature and
structs was analysed, did not demonstrate the relevance of discrepant ones refer to symptomatic areas, which thereby,
moral constructs in the grids of depressed patients. However, may subtly vary across different diagnoses. However, the
the strategy of analysing the content of the specific constructs conflictual construct configuration found in this study and its
forming IDs has yielded more precise findings. The content content seems really pertinent to understand the kind of di-
lemmas depressive patients might face. For instance, accord-
ing to the hypothesis of Linares and Campo,37 the identity of
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RESPUESTAS DE LA SECCION
AVANCES EN LA PSIQUIATRIA
Autoevaluación
1. C
2. D
3. B
4. D
5. B
6. B
7. D
8. D
9. A
10. A
11. C
12. A