Efficacy of a dilemma-focused intervention for unipolar depression: study protocol for a multicenter randomized controlled trial

Background Depression is one of the more severe and serious health problems because of its morbidity, disabling effects and for its societal and economic burden. Despite the variety of existing pharmacological and psychological treatments, most of the cases evolve with only partial remission, relapse and recurrence. Cognitive models have contributed significantly to the understanding of unipolar depression and its psychological treatment. However, success is only partial and many authors affirm the need to improve those models and also the treatment programs derived from them. One of the issues that requires further elaboration is the difficulty these patients experience in responding to treatment and in maintaining therapeutic gains across time without relapse or recurrence. Our research group has been working on the notion of cognitive conflict viewed as personal dilemmas according to personal construct theory. We use a novel method for identifying those conflicts using the repertory grid technique (RGT). Preliminary results with depressive patients show that about 90% of them have one or more of those conflicts. This fact might explain the blockage and the difficult progress of these patients, especially the more severe and/or chronic. These results justify the need for specific interventions focused on the resolution of these internal conflicts. This study aims to empirically test the hypothesis that an intervention focused on the dilemma(s) specifically detected for each patient will enhance the efficacy of cognitive behavioral therapy (CBT) for depression. Design A therapy manual for a dilemma-focused intervention will be tested using a randomized clinical trial by comparing the outcome of two treatment conditions: combined group CBT (eight, 2-hour weekly sessions) plus individual dilemma-focused therapy (eight, 1-hour weekly sessions) and CBT alone (eight, 2-hour group weekly sessions plus eight, 1-hour individual weekly sessions). Method Participants are patients aged over 18 years meeting diagnostic criteria for major depressive disorder or dysthymic disorder, with a score of 19 or above on the Beck depression inventory, second edition (BDI-II) and presenting at least one cognitive conflict (implicative dilemma or dilemmatic construct) as assessed using the RGT. The BDI-II is the primary outcome measure, collected at baseline, at the end of therapy, and at 3- and 12-month follow-up; other secondary measures are also used. Discussion We expect that adding a dilemma-focused intervention to CBT will increase the efficacy of one of the more prestigious therapies for depression, thus resulting in a significant contribution to the psychological treatment of depression. Trial registration ISRCTN92443999; ClinicalTrials.gov Identifier: NCT01542957.

El grupo autobiográfico como modelo constructivista de intervención gerontológica primaria: propuesta teórica y estudio de un caso

Desde una perspectiva constructivista (Kelly, 1955) la actividad autobiográfica se constituye como un ingrediente de desarrollo personal esencia1 en la senectud (Butler, 1963). En un grupo de sujetos voluntarios de edad avanzada (x = 68, n = 8) se empleó el método de autobiografia guiada (Birren y Hedlund, 1987) para promover la reconstrucción de su experiencia pasada. Los resultados (evaluados mediante un diseño combinado de rejilla y el análisis constructivista de textos autobiográficos propuesto por Feixas 1988) muestran que el GA produjo un cambio signifcativo y gradual en el sistema de construcción de 1os participantes, acercando significativamente la construcción de sí mismos a la de su yo-ideal y haciendo disminuir el aislamiento yo-ideal/otros. El GA parece ser un instrumento adecuado para promover la reconstrucción positiva de la experiencia en personas de edad avanzada.

Somatización y conflictos cognitivos: estudio exploratorio con una muestra clínica

Los problemas de somatización generan un elevado consumo de recursos y algunos tratamientos habituales resultan ineficaces o contraproducentes. Parece necesario un abordaje multidisciplinar que ofrezca un tratamiento integral a estos pacientes. Esta perspectiva debería tener en cuenta factores cognitivos poco estudiados como la construcción subjetiva del sí mismo, los síntomas y los demás. De ahí el interés de estudiar los conflictos cognitivos, que podrían erigirse en barreras subjetivas para la curación. El objetivo de este estudio es investigar las relaciones entre los dilemas implicativos, un tipo de conflicto cognitivo que puede detectarse con la Técnica de Rejilla, y una escala de somatización. Los resultados sugieren que las puntuaciones en somatización son más elevadas en personas con dilemas implicativos, y la presencia de estos conflictos predice mejor la somatización que el sexo, la edad, la autoestima o la diferenciación cognitiva.

Aportaciones de la Técnica de Rejilla en la comprensión de los trastornos alimentarios

El objetivo de investigación fue identificar características estructurales y de contenido del sistema de constructos de hijas diagnosticadas con trastornos de conducta alimentaria y de sus madres. En este estudio descriptivo, se aplicó a 14 hijas, de 18 a 29 años, y madres, técnica de rejilla interpersonal y entrevista focalizada. En los resultados destaca que el 70% de hijas y la totalidad de madres presentan rigidez cognitiva. En el contenido de los constructos de autodefinición de las hijas destacan aspectos emocionales y en las madres, aspectos personales. Los contenidos de los constructos discrepantes de ambas, se agrupan en aspectos emocionales. En los dilemas implicativos se presenta con mayor frecuencia la búsqueda de autonomía/autoafimación que implica abandono de los demás.

Conflictos cognitivos (dilemas) en pacientes diagnosticados con Trastornos de Ansiedad

El siguiente estudio tiene por objetivo identificar un tipo de conflicto cognitivo, los dilemas implicativos (DI), en pacientes con Trastorno de Ansiedad (TA). El concepto de DI se refiere a las implicaciones positivas y negativas que tiene el síntoma para la persona que lo sufre. La alternativa deseada, es decir, la dirección en la que el cliente quiere ir, tiene implicaciones negativas, por lo cual se resiste al cambio; pudiendo acarrear consecuencias negativas para su sentido de identidad. Desde un enfoque constructivista y mediante la Técnica de la Rejilla de Kelly, se pretende comparar la presencia y número de dilemas en una muestra de 45 pacientes y un grupo de 39 controles. Los resultados evidencian una diferencia significativa entre la presencia de dilemas en los pacientes ansiosos (49%) y el grupo control (25%). Si los DI implican conflicto psicológico y sufrimiento, la ansiedad podría ser una expresión sintomática del conflicto y de su intensidad. Ello plantea la necesidad de tratar a los pacientes con TA tanto sintomáticamente como en sus conflictos cognitivos. Estos resultados son particularmente relevantes al planificar y desarrollaruna intervención terapéutica que debería ser focalizada, eficiente y adecuada a las necesidades del paciente y a sus estructuras cognitivas.

Camino hacia el coraje: terapia de constructos personales en un caso de depresión mayor, fibromialgia y otras comorbilidades

Se presenta el caso de Sara, una mujer con fibromialgia, depresión, y otras comorbilidades. A nivel psicológico, una de sus mayores dificultades estriba en poner límites a los demás. Ello perjudica la relación que mantiene tanto con sus seres queridos como con ella misma. Analizando sus constructos personales con la técnica de rejilla y la autocaracterización se observa que vive como incompatibles la satisfacción de sus necesidades y el acceder a las demandas de los demás. Termina por ceder con el fin de preservar para sí misma una imagen de buena persona que resulta central en su sentido de identidad y nuclear en su sistema de constructos. La terapia de constructos personales realizada en un formato breve aborda este dilema y se producen algunos cambios significativos que perduran al seguimiento.

Una perspectiva constructivista de la cognición: Implicaciones para las terapias cognitivas

Desde la epistemología constructivista se considera la cognición como la actividad básica del vivir: interpretar la experiencia, otorgar significado al flujo de los acontecimientos. Por tanto, no se la ve como una actividad intelectual, racional o mental sino holística porque implica al sujeto en su totalidad; aunque se pueda manifestar en forma de pensamientos, emociones, imágenes, etc. Las distintas terapias cognitivas de inspiración constructivista comparten la visión de la persona como un agente que construye de forma proactiva los acontecimientos, incorporando los significados generados en un sistema cuyo núcleo es el sentido de identidad. Los esfuerzos para promover el cambio pueden provocar resistencias a menos que se armonicen con la necesidad esencial de la persona de proteger su sentido de identidad, continuidad y, en consecuencia, su unicidad.

Manual de intervención en dilemas implicativos

The notion that human beings face internal conflicts is very old in the field of psychotherapy. Also, it is common the idea that symptoms could be derived from those conflicts. However, attempts for developing ways of appraising those conflicts so that they can be measured and tested empirically are almost inexistent. Precisely, the Multi- Centre Dilemma Project is aimed at investigating the role of those conflicts, termed implicative dilemmas or dilemmatic constructs, in health using the Repertory Grid Technique as a method to identify them. So far, a higher presence of those conflicts has been found in a variety of clinical problems (depression, social phobia, somatic problems, etc.) in comparison to non-clinical samples. Therefore, it seems convenient to develop a form of intervention aimed to dealing and resolving these conflicts. In this paper a therapy manual focused on implicative dilemmas resolution is presented. It consists of a structured intervention for 15 sessions, designed mainly for research and training in psychotherapy, and based on Personal Construct Psychotherapy.

Dilemas implicativos, psicopatologia e construção do self: mudança durante o primeiro ano da Universidade.

O objectivo deste estudo foi comparar os indicadores de sintomatologia psicológica, competências de resolução de problemas e de construção pessoal, quando avaliados no início e no final do primeiro ano da Universidade. Analisámos também os preditores quer de sintomatologia psicológica, quer de competências de resolução de problemas avaliadas no final do ano lectivo. Vinte e oito estudantes do primeiro ano da Universidade do Minho, preencheram uma medida de sintomatologia psicológica (SCL-90-R), uma medida de competências de resolução de problemas (IRP) e a grelha de repertório para análise da sua construção pessoal. Os resultados indicam uma diminuição significativa na sintomatologia e um aumento significativo da auto-estima, no segundo período de avaliação. Verificámos que a sintomatologia e as competências manifestadas no início do ano são, respectivamente, os melhores preditores de sintomatologia e competências no final do ano. Os resultados são discutidos sublinhando as implicações para a promoção da adaptação dos estudantes universitários.

What's the difference under the gown? : new professors' development as university teachers

This study explores how new university teachers develop a teaching identity. Despite the significance ofteaching, which usually comprises 40% of a Canadian academic's workload, few new professors have any formal preparation for that aspect of their role. Discipline-specific education for postsecondary professors is a well-defined path; graduates applying for faculty positions will have the terminal degree to attest to their knowledge and skill conducting research in the discipline. While teaching is usually given the same workload balance as research, it is not clear how professors create themselves as teaching professionals. Drawing on Kelly's (1955) personal construct theory and Kegan's (1982, 1994) model ofdevelopmental constructivism through differentiation and integration, this study used a phenomenographic framework~(Marton, 1986, 1994; Trigwell & Prosser, 1996) to investigate the question of how new faculty members construe their identity as university teachers. Further, my own role development as researcher was used as an additional lens through which to view the study results. The study focused particularly on the challenges and supports to teaching role development and outlines recommendations the participants made for supporting other newcomers. In addition, the variations and similarities in the results suggest a developmental model to conceptions ofteaching roles, one in which teaching, research, and service roles are viewed as more integrated over time. Developing a teacher identity was seen as a progression on a hierarchical model similar to Maslow's (1968) hierarchy of needs.

Construing social dimensions of personality development: nurses as educators

A convenience sample of twenty registered nurses was recruited from two' general hospitals and two community college nursing schools. Kelly's (1955) Personal Construct Theory provided the theoretical framework to discover how nurses perceived themselves as educators. The nurses completed a self-administered Self-Perception Inventory (Soares, 1983) to determine their perception of self as nurse and ideal self as nurse. In an interview, each of the nurses constructed a rank-order repertory grid adapted from Kelly's (1955) Role Repertory Construct Test. Twelve constructs derived from the Self-Perception Inventory (Soares, 1983) were ranked according to a list of ten elements common to a teaching situation. Rank order correlations among the constructs were determined with Spearman's rho. Using a dependent samples t-test, significant differences were found between perceptions of current and ideal self for staff nurses. Significant differences were also found between nurse educators' perceptions of self and ideal self as nurse. No significant differences were determined in perceptions of self as nurse and ideal self as nurse between the staff nurse and nurse educator groups with an independent samples t-test. However, observations of single constructs revealed that although several constructs are shared between the groups in the perception of self in a teaching situation, both groups hold constructs that operate exclusively in their separate domains. The nature and strength of the relationships between the common and unique constructs are different for each group. Nurses I self-perceptions appear to be influenced by the historical development of nursing, role socialization during nursing education, social expectations and gender issues in the health care system.

The impact of hospital downsizing on registered nurses displaced from full-time employment

This research identified and explored the various responses often women Registered Nurses displaced from full-time elnployment as staff nurses in general hospitals in southern Ontario. These nurses were among the hundreds in Ontario who were displaced between October 1991 and October 1995 as a result of organizational downsizing and other health care reform initiatives. The purpose ofthis research was to document tIle responses of nurses to job displacement, and how that experience impacted on a nurse's professional identity and her understanding of the nature and utilization of nursing labour. This study incorporated techniques consistent with the principles of naturalistic inquiry and the narrative tradition. A purposive sample was drawn from the Health Sector Training and Adjustment Program database. Data collection and analysis was a three-step process wherein the data collection in each step was informed by the data analysis in the preceding step. The main technique used for qualitative data collection was semistructured, individual and group interviews. Emerging from the data was a rich and textured story ofhow job displacement disrupted the meaningful connections nurses had with their work. In making meaning of this change, displaced nurses journeyed along a three-step path toward labour adjustment. Structural analysis was the interpretive lens used to view the historical, sociopolitical and ideological forces which constrained the choices reasonably available to displaced nurses while Kelly's personal construct theory was the lens used to view the process of making choices and reconstruing their professional identity.

The person inside the nurse : the professional socialization of baccalaureate nursing students

The goal ofthis research was to gain an understanding ofthe process ofprofessional socialization by accessing role meaning ofstudents engaged in a BScN program. Students from each ofthe four years and faculty members from the school ofnursing volunteered as participants. G. Kelly's (1955) Personal Construct Theory provided the framework to determine awareness and constructed meanings. A reflective tool, called LifeMapping, was adapted and utilized to relate student experiences within education that have attributed to nurse role meaning. Focus group interviews verified data interpretation. Students are informed oftheir choice to study nursing through part-time and volunteer work, secondary school cooperative placements. Descriptions reveal that choices are tested and both positive and negative aspects ofthe role observed. Bipolar images of good and bad nurses seem to be context-related. These images may establish biases in choices related to learning experiences. The person inside ofeach aspiring nurse interprets, revises and understands experiences to incorporate individual meaning into their value and belief structures. Students are aware ofchanges and descnbe them as developments that occur personally up to Year ill and role-image changes that begin in Year II. The major difficulty that students encountered was descnbed as negative attitudes towards their anticipated role. Humanistic-interactionist philosophies are echoed in student accounts of learning experiences. Growth and role development corresponds to process factors of small group, problem-base learning.

Repertory grid adaptations in detecting connotative trends and social behaviour problems in education

Please consult the paper edition of this thesis to read. It is available on the 5th Floor of the Library at Call Number: Z 9999 E38 K66 1983