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November, 2000
Guillem Feixas i Viaplana
Luis Ángel Saúl Gutiérrez
INTRODUCTION
Several personal construct researchers have focussed their interests on the construction of symptoms. Fransella (1970) suggests, for example, that the symptoms can become a way of life for the client and a part of his/her identity. The alternative to presenting such symptoms might imply the relative absence of predictions about one's self. In the same vein, in this discussion of the resistance to change of anorexic clients, Button (1983) considers that such patients may tend to preserve their thinness because they do not have alternative dimensions available through which to anticipate themselves, both in themselves and in their relation to others. Also Winter (1982), has found that the constructions which clients make about their symptoms can maintain a highly consistent logic given that they represent strongly held beliefs.
A interesting starting point in the study of these conflicts was developed by Hinkle (1965) who focused on the clinical meaning of these dilemmas. In these studies, we observe in some situations patients symptom construction are associated with positive implications which are often related to characteristics which define the client's own identity. The abandonment of such symptoms would represent a threat for the self. In these situations the patient faces 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, 1990; and Tschudi, 1977). In Winter's (1982) more typical dilemma study, for example, it appears that many depressed subjects associate their symptoms with sensitivity and other virtues. Many people 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.). Ryle (1979) shows three ways of constructing the symptom which he calls dilemmas, traps and snags. Catina's (1990) outcome study shows that the way in which clients construe their symptom is of clinical relevance.
Some authors, for example Ryle (1979), argue that the success of brief dynamic therapy depends on adequate patient motivation, high therapeutic involvement and activity, and the clear identification of a focus for treatment. A purpose of our research project is to concentrate on the latter and determine ways in which the focus of brief therapy could be conceptualised more precisely. We believe that research focussed on dilemma detection and resolution (the therapeutic work's focus) could shed new light on the clarification of the 'resistance' to symptom change, and to the understanding of success in therapy.
A CONSTRUCTIVIST PERSPECTIVE
In spite of the fact that the client may be experiencing a certain amount of problems or suffering, the constructivist perspective believes that the stance which a person takes with regard to their life is coherent with their vision of themselves. The notion of dilemma which we present, based on the choice corollary (Kelly, 1955), assumes that a person chooses those alternatives from her own construct poles which are more meaningful and coherent with her construct system, i.e. those retaining the greater predictive power. To keep her world predictable, a person tries to protect her identity from invalidation, structured as a network of nuclear constructs. This constructivist view is in contrast with an hedonistic one (see Winter, 1985) suggesting that people organise their behaviour in order to search for pleasure and avoid suffering. If we take this latter view, how should we explain the presence of discrepant constructs in which the subject prefers one pole but instead of simply moving to the desired pole he/she continues at the same pole with some degree of suffering (Botella & Feixas, 1998; Mancini, 1992). By taking the constructivist stance mentioned above, we assume at the outset that the person is making a "wise" choice in terms of her personal coherence. This view contrasts with other more traditional views that label the client's processes with terms such as "distorted thoughts", "cognitive errors", "irrational beliefs", "dysfunctional learning processes", or others which attribute the problem to unconscious motives and conflicts. So the issue then becomes; why the desired change in the discrepant construct does not occur? In which sense this change, if occurring, would make the subject's world less predictable? Which aspects of her sense of coherence or of her sense of identity, would become invalidated? Which of the subject's construct poles are being validated by acting in a way that includes symptoms and suffering?. The idea is that by simply pushing for a shift to the desired pole of the discrepant construct we can trigger on the client a series of actions (traditionally labelled as "resistance") oriented to preserve her sense of identity, and thus the predictive power of her construct system. By detecting implicative dilemmas we intend to reveal the coherence of the client's actions according to their construct system. We hypothesise that working in therapy respecting this coherence will enhance the therapy alliance and preclude opposing actions (or "resistance"); this resulting in a better therapeutic outcome.
PREDICTED EFFECTS OF IMPLICATIVE DILEMMAS ON THERAPEUTIC OUTCOME
Were considered the construction of the symptom is an important issue for the reconstruction process during therapy. Because of the implications of these dilemmas, the patient feels him/herself divided between a desirable change and the symptom’s positive relation with the patient's self-definition. Catina, et al. (1990) found that the more positive implications the patient's symptomatic behaviour presented, the more difficult it was for him/her to reach his/her desired goals, whereas reduction of positive symptom implications led to a better treatment outcome.
Therapeutic success has been found to be positively related to the decrease of implicative dilemmas, for different therapy approaches (Winter, 1991). It is not clear, however the inverse, resolving dilemmas reduces the symptoms. If this inverse relationship were to be established it would be of enormous advantage, at least for cognitive and some brief psychodynamic therapies, due to the viability to detect foci (i.e. dilemmas) to work on from even the first sessions.
THE UTILITY OF THE DETECTING OF IMPLICATIVE DILEMMAS
In summary, we consider two important contributions in the detection and work with implicative dilemmas:
a) Understanding the symptom as a coherent option for the person
Unlike notions such as ‘resistance’ and ‘cognitive distortion’ found in other approaches, the focus on implicative dilemmas is advantageous because it understands the client’s in the context of coherence. Likewise, from the constructivist epistemology, the client's position of 'no change' is presented as a process of self-protection which shelters the coherence, the systemic integrity, and protects the client from a sudden 'nuclear' change (Feixas & Villegas, 1991).
This leads us towards a co-constructive psychotherapeutic endeavour which takes coherence into account such a fashion that the client can find a flexible space in his/her construct system which allows him/her elaborate an alternative construction.
The focus on the client’s construct system is in keeping with Kelly's goal of the 'acceptance of the client' (1955), a definition which leads the therapist to use the patient's own construct systems. According to Kelly (1955), the therapist ought to try and use the patient's vocabulary and meaning system.
Reframing the problem in terms of a dilemma involving the client’s sense of coherence and identity has the effect of making the client feel accepted, thereby reducing his or her anxiety. This allows him/her to begin to consider alternative constructs (Feixas & Villegas, 1991), a process which Kelly (1955) termed circumspection.
b) The focus of the therapy process
Focussing on the dilemma leads to a reframing of the patient's problem. This reframing has to be shared with the patient in terms which are acceptable to him/her. Using the same terms that the patient uses to make sense of his/her world, helps to not distance this interpretation from his/her frame of reference.
For the patient, this reframing involves seeing what he/she has communicated in a new way. By focusing on the dilemma, it is hoped that the patient will find a coherence and useful explanation of his/her suffering, both of which should facilitate symptom reduction across time.
The neurotic difficulties, and in particular the lack of agency or self-efficacy which are part of many patients' experience, are related to the terms by which he/she constructs his/her world. Those terms can be conceptualised as 'implicative dilemmas'. As long as the client can only see the possibility of actions within the terms of his/her dilemma, change will be unlikely. The degree to which these terms are known to the patient, or the degree to which he/she can be aware of them, varies. The first task for the therapist is to extend those understandings; once the implicative dilemmas are understandable by the patient, they can become an appropriate focus for therapy.
FUTURE DIRECTIONS
We believe that the study about clients’ constructions of their symptomatology can help us to understand better their system coherence with respect to non-change whilst helping to establish negotiated strategies with them in order to work on an alternative construction in which the dilemma does not appear. At the same time, we believe that a dilemma focussed approach provides us with both a focus for therapy and a frame which attributes coherence to the client’s suffering.
Although we see this type of approach as useful and promising, we believe that more detailed research is needed into the implications of dilemma focussed work with clients and its relationship with the disappearance of the given symptomatology.
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