Background
General framework
Overview of the approach
Rationale for the treatment
Theoretical mechanism of action
Conception of the problem
Etiological factors
Factors associated with behavior change
Agent of change
Symptoms/disorder assessment by the therapist
Case formulation
Treatment goals
Specification of the treatment goals
Evaluation of patient’s goals
Identification of other relevant goals
Negotiation of change in goals
Contrast with other approaches
A: | Passive | Active |
B: |
Disadvantages
You don’t achieve what you intend You become bored |
Advantages
You fight for what you want You enjoy yourself |
C: |
Advantages
You make less mistakes You don’t have to think about what to do |
Disadvantages
You become more frustrated if you don’t achieve what you want You spend all day thinking what to do |
Similar approaches
Methods
Specification of defining interventions
Unique and essential elements
Essential but not unique elements
Recommended elements
Proscribed elements
General format
Format for delivery
Frequency and intensity of sessions
Flexibility in content
Session format and structure
Extra-session tasks
Required training for the DFI therapist
Session contents
Session 1: dilemma presentation
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Assess how the client is feeling, the changes that may have occurred since the end of the group therapy and the factors involved. This aspect may be especially important when the questionnaire scores have worsened or an increased risk of suicide is detected.
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One of the important objectives of this session is to begin to establish a good therapeutic alliance. In this sense it is important to bear in mind the concepts of active listening, empathy, authenticity or acceptance and communication skills.
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Description of the new “therapy framework” (group vs. individual). Part of the first session is spent exploring how the person has found the group sessions, without focusing on comments about other participants unless they are relevant to the dilemmas found during the assessment. The therapist explains the differences of this new therapy format in more or less these words: “These sessions we are going to do individually are somewhat different to the ones you have already done with the group. In this case we will focus exclusively on the things that are relevant to you, those that worry you or that which you would like to change. We will also be working from one of the instruments you used during the assessment phase, the grid technique, which we will discuss in today’s session.”
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Revision of the patient’s expectations in relation to therapy, after the group stage, once part of the treatment has already been completed.
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Therapist: According to the scores you gave in this questionnaire, it seems you feel quite depressed at the moment, but you would like to be happy, is that so?
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Patient: Yes, yes, I am quite depressed now.
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T: I also see that you consider yourself a very private person and you would like to be very sociable, is that so?
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P: Yes.
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T: From what I have seen in the scores you gave in this questionnaire it seems that for you, between being a passive or an aggressive person, your ideal is a 4, that is to say, a midpoint. What does that mean to you?
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P: Well I don’t know… that I think it’s best not to be passive nor aggressive either…
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T: All these are things that we can work on in the following sessions, would it be ok with you if we dedicated the sessions to one of these aspects you would like to change?
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P: Yes
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T: Which do you think is the most important to you? Which would you like to address first?
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How would you describe depressed people in general?
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How would you describe happy people?
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From what you say, your friend Pere (element in the grid) is a very happy person, as you would like to be. He is also quite active and cheerful… but maybe there are other aspects of Pere that are not so nice.
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(Allow space for if the patient offers one of these negative aspects)
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According to your point of view Pere is quite selfish and cares only about himself. Is that so? (explore also other examples)
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How would you say aggressive people are, in general?
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And passive ones?
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From what you say, your friend Elena (element in the grid) is very aggressive, while your mother (element in the grid) is quite passive. It seems you would not like to resemble any of them, as in this trait they are not how you would like to be. Is that so?
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T: Although Pere is very happy, it seems he is not the type of person you would like to be… Imagine if I were to have a magic wand (show a pencil) and I could quickly turn you into a happy person, like Pere, would you want me to do so?
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P: Maybe not…
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T: Why would that be?
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P: Often happy people don’t preoccupy themselves with people who aren’t happy, they don’t care much about others because they are already happy…
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T: It is as if being sad or depressed helps you bear in mind other people’s feelings… Would it seem useful to you if we dedicated these sessions to explore how you can be happy without disregarding other people’s feelings?
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T: Sometimes it is complicated to stay in a middle point… You need a lot of balance! It is as if one finds oneself facing a dilemma with each situation: Should I be more aggressive? Less aggressive? More passive? Less? Sometimes one can feel blocked when facing so many decisions. Have you ever felt this way? Would it seem useful if we dedicated these sessions to finding a good solution or a new perspective for this dilemma?
Session 1: troubleshooting
Session 2: dilemma elaboration
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Empathic reading: how does one see the world through these eyes?
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The first part of the writing: usually constitutes a “safe base” on which to elaborate other aspects, the presentation the person uses when talking about him or herself. In this presentation we can often find the congruent constructs that are part of the dilemma and tend to be more nuclear in the sense of oneself.
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Repeated terms or with similar themes: indicate a greater weight in the person’s construct system. The therapist should pay special attention to those which reflect both poles of the dilemma, not only in the same terms used in the repertory grid, but also all those synonyms, paraphrases, expressions, etc. that lead us back to the dilemma, given that the narrative nature of this technique allows for a greater freedom of expression. If such phrasing is more appropriate for the patient, it is used hereafter to refer to the dilemma.
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Causal analysis: Do we encounter causal explanations of this dilemma? For example, “a betrayal changed me (implied: before I was different, naïve)”, “my mother was the same as me (implied: it is genetic, inheritance)”, “as my father never loved me (implied: I will not be able to change or do any good)”. It is important to pay attention to these causal theories so as to address them in so far as they affect the change process itself.
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Laddering up. This technique is appropriate in those cases where we are working with an implicative dilemma, in which case we use laddering up with the discrepant pole. It is not suitable to use laddering in dilemmatic construct cases, as the intrinsic difficulties selecting the desired pole would be an impediment to initiate this laddering procedure. It would not be appropriate either to use laddering up when the discrepant construct already presents a high level of abstraction (eg “happy-unhappy”). For example, with the discrepant construct “shy” vs. “sociable” (desired pole) the questions could be: “Why is being sociable preferable to you?” or, alternatively, “Why is being shy not desirable to you?”.The new construct that emerges from the reply to these questions constitutes a new rung in the ladder, where we ask for the preferred pole (when writing it down we underline it) and the reasons for its preference. The process is repeated until the patient cannot explain why they prefer a certain pole or when all the replies given are similar (see Fig. 3).
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Laddering down. This technique is appropriate when the dilemma’s labels have a high level of abstraction and our aim is to know what concrete meaning the person gives to the term. It is also appropriate to use with dilemmatic constructs, to understand why both poles are considered positive or negative. It would not be appropriate to use laddering down when the constructs are very specific (eg, “punctual-unpunctual”). For example with the discrepant construct “resentful-kind”, the questions could be: “How can you see when someone is kind?”“How would you tell if someone is kind?”“How do people know if one is resentful?”For each reply we enquire about the opposite. The process is repeated until the person is unable to offer new answers. On one of the rungs the patient may give more than one answer, focusing the following analysis on the one considered more relevant to the person’s current problem (see Fig. 4).
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Dialectical laddering. This technique is especially appropriate when working with a dilemmatic construct. For example, with “rejecting-fused” the questions could be:“If you had to find a label that encompassed both of these characteristics at the same time, to integrate them in some way, what would this label be?”“Can you think what these two characteristics might have in common?”After achieving this synthesis, we ask what the opposite would be. With this new construct, we ask the patient to indicate which would be his or her preferred pole. If they are unable to choose one of them, the process is repeated (see Fig. 5).
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Tschudi’s ABC. This technique is appropriate to explore both the discrepant construct in the implicative dilemma and the dilemmatic construct (see Table 1).
“As we were saying in the previous session, it seems that resolving this dilemma would help you to improve your mood. If you succeed in becoming a more sociable person and still be friendly and kind with others, you would feel happier. After what we have seen in today’s session, what do you think about this? In which sense would you be happier?”
Session 2: troubleshooting
Session 3: reconstruction of immediate experience
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A recent episode in which the dilemma was involved is selected and the patient is asked to describe it in detail from start to finish.
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Throughout the whole description, the therapist asks for details about how the patient felt in that moment, what he or she was thinking, what he or she did, etc.
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We explore in particular detail the moments where emotions appear either explicitly or implicitly (in this case, make them explicit) to make a connection with the meanings attributed by the patient to the situation.
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We explore the experience of the dilemma in this situation: how the congruent construct manifests itself, qualities of this experience and emotions that appear, etc. Following the example shown in the graph, the objective is to explore if somewhat positive emotions exist in the narrated episode, when feeling “humble” in front of others who have shown “arrogance”.
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All of this is aimed towards obtaining the implied meanings in the construction of the experience, the anticipations, often barely conscious, which guide their actions, and which become invalidated with the experience, with consequent negative emotions (or positive emotions in the case of validation).
Session 3: troubleshooting
Session 4: relational implications of the dilemma
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Asking the patient to describe in detail a recent episode in which the dilemma was highlighted.
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Asking the patient to describe the people participating in this episode according to the constructs implicated in one of the dilemmas being worked on, paying special attention to the people who, more or less explicitly, are blocking the change (for example, warning the patient of the negative consequences of change). If it is considered acceptable to the patient, these people could be called “dilemma accomplices”. The patient is asked the weight he or she believes they have in the maintenance of his or her dilemmatic construction, and if he or she would like this to change. If that is so, would this change regarding these people facilitate the patient encountering alternatives or solutions to the dilemma?
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Next, people who can be considered an exception to the dilemma are identified in the grid of the patient, that is to say, those who simultaneously occupy the desired and congruent pole (eg those who are “sociable” and “humble”). If there are no such people in the grid, the patient is asked if he or she knows someone who might be so (even if it is a historical figure or a person of current fame). The therapist explores jointly with the patient how these people might respond in that situation. The idea is to generate alternative constructions to those of the dilemma which might help to cope with the situation in a different way.
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P: … it was strange because it was a day I was feeling better. I woke up earlier and even put on make-up. My husband was very happy when he saw me, he said I looked pretty… he also said if I was going to go out and flirt around now… I don’t know, he said it jokingly… but it made me feel bad…
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T: What did you feel in that moment?
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P: That maybe I’d overdone it… maybe I shouldn’t wear make-up on a normal day, maybe it was too much.
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T. As if you had changed too much?
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P: Yes, something like that. Like I was vain.
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T: Do you think this has something to do with the dilemma we’re working on?
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T: What do you think Maria would have said (exception to the dilemma) if she had seen you wearing make-up on a regular day?
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P: She would have been very glad! She always tells me I’m pretty, that I should dress up more often.
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T: Do you think that somehow she might have seen you as being “vain”?
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P: No! She always tells me I’m not ostentatious at all…
Session 4: troubleshooting
Session 5: historical reconstruction of the dilemma
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Review of the chapters of life which the patient brings. We ask the patient to explain briefly: Why have you titled them in this particular way? What do they mean in your life?, etc. The last chapter corresponds to the future, and is reserved to be commented on at the end of this process.
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For each of the chapters, we ask the patient to position him/herself regarding the constructs implicated in the dilemma. We pay special attention to the changes produced in this positioning. We explore, for example, if the position of the self on the discrepant construct has varied at any time, or if the now dilemmatic construct was not so in the past, tending clearly to one of the poles in some situations.
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Gathering the information obtained in previous sessions, we also explore the position the “dilemma accomplices” have occupied progressively for the explored dilemmas and how they have reacted to the variations the patient has experienced throughout his or her history.
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Finally, the chapter dedicated to the future of life without the dilemma is reviewed. This review is done without going into details (which will be worked on in the session dedicated to future projection). The aim is to observe the coherence of this chapter within the patient’s life story. The issues to consider here are, mainly, whether the future chapter results from a personal evolution (or rather is a kind of magical or idealized leap), whether it makes sense within the patient’s history, and whether it integrates the relevant issues of that history.
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T: You dedicated the first chapter of this autobiography to your childhood. You named it “those wonderful years”. It seems it was a good period for you. How do you remember it?
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P: Calm, it was a calm period. I was with my parents and siblings… I played with my brothers often, and our parents left us to our own devices, mostly…
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T: I don’t know if in that period it was already important whether you were shy or sociable…
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P: Well, it was different, because I have always been shy, but it didn’t worry me then. I was a bit shy and that was all, I also had friends.
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T: Would you say your parents saw you as a shy person? What did they say to you?
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T: Afterwards it comes the chapter entitled “beetroot”. How do you remember that time?
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P: Terrible, that was when my problem really started, because I felt much shier with everything, and it was the time girls went out with boys… I wanted to be more sociable, not so shy.
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T: At that time, how did you feel in regard to the other traits we have talked about, like being humble?
Session 5: troubleshooting
Session 6: integration of the dilemma
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The technique is presented to the patient, explaining what it consists of and its aim. In this presentation, it is important to clarify any doubts or reluctance on the patient’s part in regard to the technique. For that purpose, the following phrasing could be used: “In today’s session, I would like us to use a technique that is a little different to the ones we have used until now. It consists in establishing a dialog between the two parts of you, of your dilemma, so that each one can express what it feels and what it wants. In this way, we can search for an agreement between them. To establish this dialog, we are going to use two chairs that we will put opposite each another. On one of the chairs will be the part of you that wishes to change, the one that wants to stop being an X person (for example, “shy” or “depressed”). On the other chair the part of you that would rather not change so as to not become a Y person (for example, “arrogant” or “selfish”). In this exercise you will not have to talk with me, rather directly to the other part of you, the one that will be in the other chair. Does that seem alright to you? Do you think it could be useful? Do you have any questions?”
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The patient sits in the chair of “the change”. The therapist must help him/her visualize in the chair in front of him/her the other part of her or himself, the one that does not wish to change, imagining how she or he is dressed, how she or he is sitting in the chair, what her or his posture is, etc. In this way differentiation of both parts is facilitated, and the patient talks from each of them according to her or his position.
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Next, the therapist asks the patient to explain to the other part of him or herself why it is valuable to change: the advantages of the change, the disadvantages of not changing, etc. The patient is reminded he or she must address the other part directly and try not to talk to the therapist.
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In the next step, the patient is asked to change seats, and from the part of him/herself that does not want to change, explain why this change is not advisable, and what risks it may entail. The patient is asked, if possible, to respond to the arguments the other part has used from the other chair. If necessary, the patient is reminded again to talk to the other part of her or himself rather than to the therapist.
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From this moment on, the therapist must facilitate a flowing dialog between the two parts, in which each part expresses what it wants or needs. To this end the patient is asked to change seats as many times as necessary. The dialog must flow towards a point in which each part expresses a petition to the other part and a satisfactory agreement, which respects both parts’ needs, is searched for.
“Now you are seated in the chair of change. In front of you is the part of you that does not wish to change which, as we have seen in these sessions, would rather continue being X (for example, “shy” or “depressed”) to not risk turning into someone Y (for example, “arrogant” or “selfish”). I would like you to imagine how this part would be seated in front of you, what her or his posture is like, how she or he looks at you, even, how she or he’s dressed! Can you imagine it?”“Could you explain to the other part why you would like to change?”“What advantages does this change have for you?”“What would the disadvantages of not changing be?”“If you could ask this other part of you one thing that you do not wish to change, what would it be?”“How could you reassure him/her about the change you want to make?”“How could you assure him/her that you will not turn into a Y person (for example, arrogant or selfish)?”“Could you explain to him/her why it would not be good to change?”“What worries you if P (name of the patient) manages to turn into a Z person (for example, sociable or happy)? What could happen?”“If you could ask something of this part of you that wants to change, what would you ask?”“What could that part do to reassure you about the appropriateness of change?”“How would you be sure that she or he doesn’t turn into someone Y (for example, arrogant or selfish)?”
Session 6: troubleshooting
Session 7: future projection: living without the dilemma
“What would you notice first once the dilemma is resolved?”“What things will you do differently?”“What will other important people to you (your partner, father, mother) notice?”“How do you think these people will react regarding the dilemma’s resolution?”“What things will remain the same, won’t change?”
“From all of these changes we have been talking about, which do you think have already begun?”“I would like us to focus on these changes; it does not matter if they are small changes.”“What has happened?”“How did you feel?”“How did X (your partner, mother, father) react?”“What would have to occur for it to happen again?”“In which other situations could this change occur again?”“What should you or someone else do to reverse change and return to the problematic situation?”