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.
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 clients 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, 1993).
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 clients 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 clients 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, 1993), 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.