Introduction. Early studies on the cognitive factors affecting depression proved the prevalence of negative views of self, the world and the future and other attributional biases. More recent approaches focused on the processing of self-referential stimuli, memory (both implicit and explicit) and attentional biases. Little has been done, however, on the study of the conflictive nature of schemas involved in construing self and others. Aim. Based on Personal Construct Theory, this work presents some evidence of the interest of studying the role of implicative dilemmas (ID) (a type of cognitive conflict). Typically, an ID is a cognitive structure for which change is desired (e.g., using a patient’ construct, moving from “being depressed” to “staying out of bad moods”) is linked to a congruent construct for which change would result in invalidation (from “concerned about others” to “selfish”). Method. IDs were explored in a group of 41 patients. Assessment was carried out by well trained psychologists and it included careful diagnosis of Major Depressive Disorder using SCID-I, and the Repertory Grid Technique (RGT). RGT was designed to explore the subjective construing of self and others of individuals, and it has been refined to identify IDs. Results. 70.7% of patients presented with at least one ID in their grids. Discussion. Compared to non-clinical samples (ranging from 33-53%) the prevalence of IDs in notorious. This is a first step on a line of research studying the role of IDs as cognitive factors in depression and to develop therapy methods to solve them.

1. 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.

2. 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….

3. 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 ofconflict, 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 Transactional
Analysis, and other approaches.

4. 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).

5. • 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, anddefining 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)

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. Teresa’s grid

12. 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”

13. Types of cognitive conflict
identified with the Repertory Grid
• Implicative dilemmas
based on the association between abased 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

14. ConcernedConcerned
aboutabout othersothers
Selfish
Congruent
Construct
An example of Implicative Dilemma
Gets depressed
easily
Does not get
Depressed easily
Discrepant
Construct
r = 0,41

15. 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 tospecific 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”)

16. 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

17. EMPIRICAL STUDY
work in progress,
(data collected until April, 2011)

18. 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 toto 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.

19. 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.

20. 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%)

21. 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.

22. Results: Presence of Implicative Dilemma(s)
50
60
70
80
Percentageof participants with
ImplicativeDilemma(s)
50
60
70
80
Percentageof 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

23. Number of Implicative Dilemmas (I)
2,5
3
3,5
Proportionof Implicative Dilemmas
2,5
3
3,5
Proportion of Implicative
Dilemmas
0
0,5
1
1,5
2
MajorDep Dysthymia Students Community
0
0,5
1
1,5
2
Depression Control
p < 0.000 in all comparisons (dysthimia was not compared)

24. 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

25. 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

26. 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

27. 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)

28. 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)

29. 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.

30. 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 theusing 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

31. Many thanks for your attention!!
gfeixas@ub.edugfeixas@ub.edu
http://www.usal.es/tcp