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Clinical applications of repertory grid techniques
46
TINS - February 1979
Clinical applications of repertory grid techniques Anthony Ryle This article describes the mechanisms of a technique used by many psychologists to present a semiquantitative analysis of psychological functions. As there are many areas of the neurosciences where it is only possible to produce a semiquantitative assessment, there are potential areas outside the immediate domain ofpsychology where this technique may be ofuse: for example, Anthony Ryle describes certain areas o f psychiatric study in which this approach has been employed. Psychological testing in the clinical setting has a number of possible functions. Many procedures, for example intelligence testing, provide scores on standardized scales measuring dimensions of psychological functioning so that an individual's test-results indicate how he is located in the population on these dimensions. Tests of this sort may provide elaborate profiles by combining numerous scores, or they may be linked to theories of personality, based upon two or three dimensions only, such as extraversion and neuroticism. The latter types of test produce typologies not unlike those expressed historically in terms of the four elements or four humours. Tests of this sort are nowadays developed from largescale population studies: they are reliable, and their validity is borne out by the fact that many behaviours or disorders occur with significantly different frequencies in groups contrasted in terms of the dimensions measured by them. However, in the understanding of individuals in clinical work, ideographic tests, designed to elucidate individual characteristics in greater detail, are often of more interest. Such tests aim to provide an economical means of deriving information of diagnostic value, and also, if possible, a basis for measuring the extent of pathology and for measuring change through time. Kelly's personal construct theory Tests for use in the climcal field will, of necessity, relate to some underlying theory or set of assumptions about the nature of the psychopathological processes being investigated. The repertory grid test, which is the subject of this paper, reflects very clearly the basic propositions Ehevier/North-Holland Biomedical Press 1979
of personal construct theory as enunciated by Kelly*: the increasing interest being shown in this method probably reflects psychology's slow recovery from the domination of behaviourism and increasing interest in cognition and in 'humanist' approaches, rather than a specific interest in Kelly's theory. Kelly's theory is basically a cognitive one, in which the central concern of the clinician or investigator is with the elucidation of how the subject constructs his view of the world, and in which the process of construction is seen essentially as the elaboration of a construct system based upon a hierarchical system of interrelated dichotomous 'either/or' judgements. The testing procedure, described in more detail below, represents a systematic enquiry into parts of this construct system by a method aiming to minimize the imposition of the tester's categories upon the subject. Kelly argues that this approach avoids the distortions of both 'objective' tests (where the subject guesses the meaning of the questions) and 'projective' tests (where the tester guesses the meaning of the subject's answers). Personal construct theory, now nearly a quarter of a century old, has acquired a band of followers, but remains strangely isolated from the rest of psychology. This may reflect the Kellian failure to engage seriously with other theories. Among little-acknowledged antecedents is William James who enunciated*, in rather more elegant terms, the basic posture which Kelly described in his phrase 'man as scientist', when he wrote as follows: "Whether by generalities or particulars, man thinks always by the same methods. He observes, discriminates, generalises,
classifies, looks for causes, traces analogies, and makes hypotheses . . . . All our thinking today has evolved gradually out of primitive human thought . . . . " Kelly shares James' concern with what James called the "conceptual translation of the perceptual flux", but so have many other workers in cognitive psychology in the last 30 years, whose studies, based on clinical observation, laboratory experiment, and computer simulation, have largely ignored Kelly and been ignored by KeUians. Moreover, both psychoanalysis, which is essentially concerned with the development of, and early distortions in, the individual's construct system, and social learning theory have been denied serious consideration by Ketlians. Fortunately, the isolation and oversimplifications of personal construct theory do not detract from the value of the repertory grid technique as a crude, but effective, means of inquiring into aspects of psychological functioning of considerable interest to the clinician, and results of repertory grid testing can be considered in terms of any theory which is concerned with the subject's cognitions. At this point, therefore, the nature of the testing procedure will be described, following which some of the clinical applications will be reviewed. Repertory grid technique test construction Repertory grid testing explores how the subject construes some aspect of his reality. The test demands the selection of a set of elements, the elucidation of the subject's constructs, and the systematic comparison of the elements in terms of the constructs. All of the elements considered in a given test must be within the same category, that is to say they must be, for example, either people, photographs of people, relations between people, behaviours, the anticipated consequences of behaviours, concepts, body parts, or brands of chocolate; but they cannot include members from more than one of these classes. Once the category of elements is agreed, the subject is usually asked to suggest the actual elements, although the tester may suggest certain categories within them; for example, in the original form of the test, Kelly elicited individual people's names in response to defined role categories. When the element list is assembled, the tester selects at random two or three elements and asks the subject to note points of similarity and contrast between these three, noting down the subject's vocabulary. This procedure,
47
TINS - February 1979
subject's underlying construct system can be derived. This assumption is now backed up by accumulated evidence for the stability of construct relations when different groups of elements in the same category are tested against the same constructs, or when the same elements are retested after short time intervals. Various mathematical treatments may be applied to large grids to derive evidence concerning the person's constrnct system. Those concerned only with construct relationships can rely upon various forms of factor or cluster analysis. The principal component analysis, developed by Patrick Slater, which has been widely used clinically, offers the particular advantage of simultaneously considering construct and element relationships. Slater's programmes yield measures of relationship between constructs (expressed as correlations), measures of the similarity of elements (expressed as either correlations or distances), and measures relating the degree of simplicity/complexity of the system, and of the consistency with which the construct relationships are maintained across the elements. In addition, the principal component analysis allows the graphic display of element and construct relationships to be made. This is often the most accessible and useful summary of the underlying psychological structure. These displays are achieved by plotting elements and constructs in terms of their loadings on the first two principal components, extracted from the grid (a threedimensional projection is also possible), thus producing a map in which the construct loadings define different areas in terms of their meaning, within which elements are dispersed. A fictitious, simplified two-component graph ~s is given in Fig. 2; in real cases, more elements and constructs would be involved, and the percentage of variance accounted for by the first (horizontal) and second (vertical) component would be indicated. These two components, in most cases, account for 50-80% of the total variance in the grid. In this example, the grid is that of a male science student in academic difficulty. Inspection shows that
repeated with different pairs or triads, usually yields ten to thirty constructs, which are usually expressed in bi-polar form, such as 'clever versus dull', or 'someone I fear versus someone I trust'. Test completion The list of elements is now systematically compared in terms of each of the derived constructs, using either a forced dicbotomization (i.e. each element being placed at one or other pole of the construct) or, preferably, using ranking or rating methods. The resultant set of rows and columns of figures is the repertory grid. Mathematical treatment and interpretation of grids The test so assembled represents the subject's conscious comparison of elements he has chosen on constructs described in the terms he has provided. In this way, the imposition of the tester's language and preconceptions is largely avoided. The interest of the test lies in the fact that the relationships between these judgements are not always apparent to the subject, and the test can therefore provide evidence of the underlying system of judgements which he is using. Fig. 1 represents a segment of a fictitious grid in which the elements are people Is. Inspection of this can illustrate how grid results can be interpreted. (In practice, of course, conclusions about an individual's system would not be based upon so small a number of" constructs and elements.) Comparing the columns reveals the relationships between different constructs, as applied to these elements; for example, it is seen that 'warm-bearted' implies 'foolish', as the elements are almost identically rated on these two constructs. By comparing rows, the degree of similarity between different elements in terms of the constructs used is revealed. Here, for example, mother and girlfriend are similarly rated on three of the four constructs. The assumption behind the clinical uses of the test is that, by sampling sufficient and suitable element-construct interactions in this way, information about the
Warm-hearted v. cold
Foolish v. wise
Nags v. tolerant
Washes my socks v. won't wash my socks
Mother
4
5
4
5
Self
2
2
1
1
Girlfriend
5
5
4
1
Fig. 1
the self is located with the mother and other female elements, being def'med as happy, artistic, and sensitive, and is distant from father and male academic elements, which are seen as ambitious, strong, and disliked. These findings (which are not untypical) suggest that the individual's problems in his academic work as a science student could derive from the negative implications that strength and masculinity hold for him. The mathematical procedures and assumptions underlying Slater's programmes s° and the application of these problems to clinical issuess.xs are reviewed elsewhere. There is now a sufficient body of evidence to support the belief that the psychological deductions made from these mathematical procedures are intelligible and valuable. Clinical applications One of the earliest applications of the repertory grid was in the investigation of thought-disordered schizophrenics x. From this work there evolved a standard test procedure in which subjects construed a set of photographs and repeated the test after a short time interval. In this test, thought-disordered schizophrenics were shown to have significantly lower consistency; that is to say, the pattern of construct relationships was less well sustained than in the case of normals or other groups of patients. Further studies have called into question some of the claims made for this test, and it is now clear that it is not sufficiently discriminating to be of diagnostic value. Work evolving from it has, however, yielded data of interest, contributing to the understanding of schizophrenic thoughtdisorder. One interesting demonstration was that thought-disordered schizophrenics, when comparing people or photographs of people, showed more disorder when applying constructs referring to psychological variables than when using those applying to physical characteristicss.l°. Further, schizophrenics showing marked flattening of affect used very few psychological constructs °. These findings are consistent with a view of schizophrenia which accords importance, in the aetiology, to social and interpersonal experiences, and which relates the emotional withdrawal of schizophrenics to the lack of a coherent cognitive system with which to make sense of interpersonal and emotional events. McPberson and Gray u extended the work on psychological construing ir~
48
T I N S - February 1979
Happy • • Civil
Artistic •
• Ambitious Feminine •
FATHER
MOTHER AUNT
TUTORIAL PARTNER
SISTER SELF
•Masculine TUTOR
• Strong TUTOR • I dislike • Intelligent
Sensitive •
~.2.
schizophrenics to a random group of psychiatric admissions, and showed that, within the group, there was a high correlation between the degree to which psychological constructs were used, and the patients' experience of psychological rather than physical symptoms. These authors point out that this supports work emphasizing the importance of cognitive factors in emotions l°, a view that has also been strongly emphasized by Bruch in her work s on anorexia nervosa. It is therefore of interest that some preliminary grid studies have been carried out on anorexics, investigating changes in self-concept with treatment4 and, in a new application of grid methods, comparing how two normal and two anorexic women construed the body parts of self, parents, and partners4. Apart from the work noted above, the most extensive clinical application of repertory grid technique has been in the study of individual, couple, or group therapy. Most commonly, such studies have used grids in which the elements were people and the self was often included in a number of forms (for example, ideal self, feared self). This approach offers a flexible and individual approach and avoids many of the pitfalls inseparable from the use of standardized inventories to assess change in treatment; individual eases can be assessed at the start of a treatment programme and specific predictions can be made, identifying those changes to be expected in grid measures if treatment is successful as. The dyad grid, where relationships between self and others, and others and self, form the elements, is, in many cases, a more sensitive approach for neurotic patients,
in whom interpersonal difficulties are central. Similar predictions can be made in respect of such grids. This approach is particularly appropriate where the relationship is the focus of treatment, as in marital therapy 16. The basis upon which predictions of desirable change are made in a grid may be common sense; for example, that the construction of the self should become less negative, or the self/ideal self discrepancy should become less extreme; but, as has been suggested more fully elsewhere 12, the applications of some insights derived from psychoanalysis can extend the subtlety with which grid data are considered. Thus, patterns of identification indicated by closeness between self and significant others on the grid may illuminate conflicts, for example, around sex roles or between sex roles and occupation. Ambivalence can be explored if the subject rates his reciprocal relationships with another under 'going well' and 'going badly' conditions. This approach demonstrated that individuals in conflict with their partners saw, when things were going badly, the self-to-partner as becoming more like parent-to-self, and the partner-to-self as becoming less like parent-to-selP~; this illustrates the spiral of deterioration as each becomes more demanding and less providing. The more primitive mechanisms of splitting and projection (concepts based upon objectrelations theory) may be suggested by the polarization of key persons in the standard grid, or in restrictive patterns of reciprocal relationships on the dyad grid. More generally, problems described in psychoanalytic terms as to do with conflict and resistance may be reformulated in
terms of the subject's personal definitions of options and the implications of change, as deduced from his grid. In addition to the use of grids in outcome research to demonstrate differences before and after treatment and to identify the location of change, the serial application of grids at shorter intervals, especially the use of grids which include the therapist, partner, or other members of a therapeutic group as elements, can throw some light on the nature of the therapeutic process. This approach has been applied particularly to therapeutic groups, and the results have been of some interest, although the complexity of the processes being studied, and of the grid meastires generated, can be' somewhat overwhelming 17~1. Theoretical implications Many would regard cognitive changes, including those concerned with the self, the body, and the emotions, as the essential effect of psychological treatments. Insofar as grid methods give some access to these changes, they can play a part not only in the research field, but also in clinical work. The clinician is always operating beyond the terrain adequately mapped by well-established theory, but he does need, as far as possible, to refer back to such theory. Recently, the theoretical bases of the very divergent therapeutic approaches of behaviourism and psychoanalysis have been undergoing revision, with an increasing emphasis being placed in both upon central cognitive processes, and the possibility of achieving a common theoretical language seems less remote 14. Human learning, including the essential learning about the body, the self, and relationships with others, takes place through the elaboration of hierarchical, interrelated mental schemata to which new experience is assimilated. These schemata (or construct systems) are in turn open to modification by new experience. Psychoanalysis, which played a crucial and pioneering part in identifying the inflexibilities, distortions, and idiosyncracies of thinking and feeling that date from early preverbal experience, has generated such a confusion of biological, mechanical, and structural metaphors that this essential contribution has been partially submerged. Data from grid studies re-emphasize that the task of therapy is to alter how an individual construes himself and others. The problems of most neurotic individuals are more extensive than those described in the
49
TINS - February 1979
language of traditional simple behaviourism; they are best understood as the effects of restrictions derived from the terms through which the world is construed. These. terms cannot always be conceptualized by the patient, and the first task of the dynamic therapist is to offer a new account of them; but behavioural and didactic techniques may also be effective in altering these terms and constructions. Whether the initial change is in behaviour, leading to an alteration in understanding, or in understanding, leading to an alteration in behaviour, is a less crucial difference than, in the heat of battle, it sometimes appears to be. Repertory grid studies are likely to continue to play a part in the study of how people change in response to treatment; more importantly, they may also play a part in the creation of a more adequate and unified human psychology by drawing attention to the common location of
change in therapies approaches.
using
different
Reading list l. Bannister, D. (1960)./. ?dent. Sci. 106,445 and 1230-1249. 2. Bruch, H. (1973) Eating Disorders: Obesity, Anorexia Nervosa and the Person Within, Basic Books, New York. 3. Crisp, A. H. and Fransella,F. (1972) Br. J. Med. PsychoL 45, 395-405. 4. Feldmann, M. M. (1975) Br. J. Med. Psychol. 48, 317-332. 5. FranseUa, F. and Bannister, D. (1977) A Manual for Repertory Grid Technique,
Academic Press, London. 6. Heather, N. (1978) Br. J. Soc. Clin. Psychol. 15 131-137. 7. James, W. (1911) Some Problems of Philosophy, Longman Green & Co., London. 8. Kelly,G. A. (1955) The Psychology of Personal Constructs, Norton, New York. 9. McPherson, F. M., Barden, V. and Buckley, F. (1970) Br. J. Med. Psychol. 43, 291-293. 10. McPherson,F. M. and Buckley,F. (1970) Br. J. Soc. Clin. Psychol. 9, 380-381.
Schizot)hrenia
Do parents cause schizophrenia? Steven R. Hirsch While various laboratories are putting a concerted effort into trying to discover the molecular causes o f schizophrenia - - which neural pathways are involved, which molecular process is disrupted, which neurotransmitters are involved - - the disease is being studied from another angle. This angle follows the enquiry into whether the environment o f the individual can cause, or bring out a potential for, the symptoms o f schizophrenia. In this article Steven Hirsch examines the evidence for the various theories which have been proposed.
The view that schizophrenia is somehow due to the way parents treat their children has had wide publicity over the last 15 years and has gained much support. But such a view has severe implications for the parents of the 196 of the population who will suffer from schizophrenia-at some stage in their lives; it means that millions of parents may fmd themselves accused of having caused a dreadful mental disturbance in their child. The theory that parents are to blame has also led to conflict between psychiatrists, who are critical of the theory, and their nonpsychiatrist colleagues, who accept it: the parents of schizophrenics have found themselves caught in the cross-fire. Some parents have fought back and have formed
a society* to help them cope with their problems, including the blame and censure which they experience from the 'helping' professions. There are many theories which attempt to explain how parents cause schizophrenia, so we must ask why choose one over another. Even more fundamental is whether there is adequate evidence to conclude that parents do, in any way, cause schizophrenia. We set out to answer these questions by examining the more important evidence from over 200 scientific reports, to summarize the hard facts The Schizophrenia Fellowship, 29 Victoria Road, Surbiton, Surrey KT6 4JT, U.K. (tel. (01) 390 3651).
11. McPherson, F. M. and Gray, A. (1976) Br. Z Med. Psychol. 49, 73-79. 12. Ryle, A. (1975) Frames and Cages: The Repertory Grid Approach to Human Understanding, Sussex University Press, Chatto &
Windus, London. 13. Ryle, A. (1975) New Behoviour 326-329. 14. Ryle, A. (1978) Br. I. Psychiat. 132, 585--594. 15. Ryle, A. and Breen, D. (1972) Br. J. Med. Psychol. 45, 375-382. 16. Ryle, A. and Lipshitz, S. (1975) Br. J. Med. Psychol. 48, 39--48. 17. Ryle,A. and Lipshitz,S. (1976) Br. J. Psychiat. 128, 581-588. 18. Ryle,A. and Lunghi,M. (1969) Br. J. Psychiat. 115, 1297-1304. 19. Schachier, S. (1964) In: I. Berkowitz (ed.), Advances in Experimental Social Psychology,
Vol. 1, Academic Press, New York. 20. Slater, P. (1977) (ed.) The Measurement of Interpersonal Space by Grid Technique, Wiley, London. 21. Winter, D. A. and TrippeR, C. J. (1977) Br. J. Med. Psychol. 50, 341-348. A. Ryle is Directorof the University Health Service of the University of Sussex, Falmer,Brighton BN I 9QZ, Sussex, U.K.
that emerge, and to see how the numerous disputed theories can be reconciled with the facts, such as they are. Schizophrenia may show itself at almost any stage of life, and may occur in single or repeated episodes, or as a persistent or permanent condition. The concern in this article is with causal factors which act long before the condition manifests itself and which cause individuals to be vulnerable or predisposed to developing schizophrenia later in life. Theories about the effects of parental behaviour as a cause of schizophrenia largely confine themselves to the influence parents have in the child's formative years. Possibly the most influential theory in the field, laying down a rationale which is basic to almost all subsequent theories, is the double-bind hypothesis. It was first formulated by Bateson, a British zoologist, and his psychiatric colleagues working in California and was published 1 in 1956. The double-bind hypothesis Double-bind communications are said to occur in emotionally heightened situations when the child feels it is essential to understand what is being communicated and to respond appropriately. The speaker, someone important to the child, conveys two or more messages which are mutually contradictory. This creates an intolerable and insoluble conflict if the family rules and social context prohibit the child from commenting on the situation or escaping from it. A further condition necessary to create the 'bind' is that the child cannot try to resolve (~ Elsevier/North-HollandBiomedicalPress 1979
TINS - February 1979
Clinical applications of repertory grid techniques Anthony Ryle This article describes the mechanisms of a technique used by many psychologists to present a semiquantitative analysis of psychological functions. As there are many areas of the neurosciences where it is only possible to produce a semiquantitative assessment, there are potential areas outside the immediate domain ofpsychology where this technique may be ofuse: for example, Anthony Ryle describes certain areas o f psychiatric study in which this approach has been employed. Psychological testing in the clinical setting has a number of possible functions. Many procedures, for example intelligence testing, provide scores on standardized scales measuring dimensions of psychological functioning so that an individual's test-results indicate how he is located in the population on these dimensions. Tests of this sort may provide elaborate profiles by combining numerous scores, or they may be linked to theories of personality, based upon two or three dimensions only, such as extraversion and neuroticism. The latter types of test produce typologies not unlike those expressed historically in terms of the four elements or four humours. Tests of this sort are nowadays developed from largescale population studies: they are reliable, and their validity is borne out by the fact that many behaviours or disorders occur with significantly different frequencies in groups contrasted in terms of the dimensions measured by them. However, in the understanding of individuals in clinical work, ideographic tests, designed to elucidate individual characteristics in greater detail, are often of more interest. Such tests aim to provide an economical means of deriving information of diagnostic value, and also, if possible, a basis for measuring the extent of pathology and for measuring change through time. Kelly's personal construct theory Tests for use in the climcal field will, of necessity, relate to some underlying theory or set of assumptions about the nature of the psychopathological processes being investigated. The repertory grid test, which is the subject of this paper, reflects very clearly the basic propositions Ehevier/North-Holland Biomedical Press 1979
of personal construct theory as enunciated by Kelly*: the increasing interest being shown in this method probably reflects psychology's slow recovery from the domination of behaviourism and increasing interest in cognition and in 'humanist' approaches, rather than a specific interest in Kelly's theory. Kelly's theory is basically a cognitive one, in which the central concern of the clinician or investigator is with the elucidation of how the subject constructs his view of the world, and in which the process of construction is seen essentially as the elaboration of a construct system based upon a hierarchical system of interrelated dichotomous 'either/or' judgements. The testing procedure, described in more detail below, represents a systematic enquiry into parts of this construct system by a method aiming to minimize the imposition of the tester's categories upon the subject. Kelly argues that this approach avoids the distortions of both 'objective' tests (where the subject guesses the meaning of the questions) and 'projective' tests (where the tester guesses the meaning of the subject's answers). Personal construct theory, now nearly a quarter of a century old, has acquired a band of followers, but remains strangely isolated from the rest of psychology. This may reflect the Kellian failure to engage seriously with other theories. Among little-acknowledged antecedents is William James who enunciated*, in rather more elegant terms, the basic posture which Kelly described in his phrase 'man as scientist', when he wrote as follows: "Whether by generalities or particulars, man thinks always by the same methods. He observes, discriminates, generalises,
classifies, looks for causes, traces analogies, and makes hypotheses . . . . All our thinking today has evolved gradually out of primitive human thought . . . . " Kelly shares James' concern with what James called the "conceptual translation of the perceptual flux", but so have many other workers in cognitive psychology in the last 30 years, whose studies, based on clinical observation, laboratory experiment, and computer simulation, have largely ignored Kelly and been ignored by KeUians. Moreover, both psychoanalysis, which is essentially concerned with the development of, and early distortions in, the individual's construct system, and social learning theory have been denied serious consideration by Ketlians. Fortunately, the isolation and oversimplifications of personal construct theory do not detract from the value of the repertory grid technique as a crude, but effective, means of inquiring into aspects of psychological functioning of considerable interest to the clinician, and results of repertory grid testing can be considered in terms of any theory which is concerned with the subject's cognitions. At this point, therefore, the nature of the testing procedure will be described, following which some of the clinical applications will be reviewed. Repertory grid technique test construction Repertory grid testing explores how the subject construes some aspect of his reality. The test demands the selection of a set of elements, the elucidation of the subject's constructs, and the systematic comparison of the elements in terms of the constructs. All of the elements considered in a given test must be within the same category, that is to say they must be, for example, either people, photographs of people, relations between people, behaviours, the anticipated consequences of behaviours, concepts, body parts, or brands of chocolate; but they cannot include members from more than one of these classes. Once the category of elements is agreed, the subject is usually asked to suggest the actual elements, although the tester may suggest certain categories within them; for example, in the original form of the test, Kelly elicited individual people's names in response to defined role categories. When the element list is assembled, the tester selects at random two or three elements and asks the subject to note points of similarity and contrast between these three, noting down the subject's vocabulary. This procedure,
47
TINS - February 1979
subject's underlying construct system can be derived. This assumption is now backed up by accumulated evidence for the stability of construct relations when different groups of elements in the same category are tested against the same constructs, or when the same elements are retested after short time intervals. Various mathematical treatments may be applied to large grids to derive evidence concerning the person's constrnct system. Those concerned only with construct relationships can rely upon various forms of factor or cluster analysis. The principal component analysis, developed by Patrick Slater, which has been widely used clinically, offers the particular advantage of simultaneously considering construct and element relationships. Slater's programmes yield measures of relationship between constructs (expressed as correlations), measures of the similarity of elements (expressed as either correlations or distances), and measures relating the degree of simplicity/complexity of the system, and of the consistency with which the construct relationships are maintained across the elements. In addition, the principal component analysis allows the graphic display of element and construct relationships to be made. This is often the most accessible and useful summary of the underlying psychological structure. These displays are achieved by plotting elements and constructs in terms of their loadings on the first two principal components, extracted from the grid (a threedimensional projection is also possible), thus producing a map in which the construct loadings define different areas in terms of their meaning, within which elements are dispersed. A fictitious, simplified two-component graph ~s is given in Fig. 2; in real cases, more elements and constructs would be involved, and the percentage of variance accounted for by the first (horizontal) and second (vertical) component would be indicated. These two components, in most cases, account for 50-80% of the total variance in the grid. In this example, the grid is that of a male science student in academic difficulty. Inspection shows that
repeated with different pairs or triads, usually yields ten to thirty constructs, which are usually expressed in bi-polar form, such as 'clever versus dull', or 'someone I fear versus someone I trust'. Test completion The list of elements is now systematically compared in terms of each of the derived constructs, using either a forced dicbotomization (i.e. each element being placed at one or other pole of the construct) or, preferably, using ranking or rating methods. The resultant set of rows and columns of figures is the repertory grid. Mathematical treatment and interpretation of grids The test so assembled represents the subject's conscious comparison of elements he has chosen on constructs described in the terms he has provided. In this way, the imposition of the tester's language and preconceptions is largely avoided. The interest of the test lies in the fact that the relationships between these judgements are not always apparent to the subject, and the test can therefore provide evidence of the underlying system of judgements which he is using. Fig. 1 represents a segment of a fictitious grid in which the elements are people Is. Inspection of this can illustrate how grid results can be interpreted. (In practice, of course, conclusions about an individual's system would not be based upon so small a number of" constructs and elements.) Comparing the columns reveals the relationships between different constructs, as applied to these elements; for example, it is seen that 'warm-bearted' implies 'foolish', as the elements are almost identically rated on these two constructs. By comparing rows, the degree of similarity between different elements in terms of the constructs used is revealed. Here, for example, mother and girlfriend are similarly rated on three of the four constructs. The assumption behind the clinical uses of the test is that, by sampling sufficient and suitable element-construct interactions in this way, information about the
Warm-hearted v. cold
Foolish v. wise
Nags v. tolerant
Washes my socks v. won't wash my socks
Mother
4
5
4
5
Self
2
2
1
1
Girlfriend
5
5
4
1
Fig. 1
the self is located with the mother and other female elements, being def'med as happy, artistic, and sensitive, and is distant from father and male academic elements, which are seen as ambitious, strong, and disliked. These findings (which are not untypical) suggest that the individual's problems in his academic work as a science student could derive from the negative implications that strength and masculinity hold for him. The mathematical procedures and assumptions underlying Slater's programmes s° and the application of these problems to clinical issuess.xs are reviewed elsewhere. There is now a sufficient body of evidence to support the belief that the psychological deductions made from these mathematical procedures are intelligible and valuable. Clinical applications One of the earliest applications of the repertory grid was in the investigation of thought-disordered schizophrenics x. From this work there evolved a standard test procedure in which subjects construed a set of photographs and repeated the test after a short time interval. In this test, thought-disordered schizophrenics were shown to have significantly lower consistency; that is to say, the pattern of construct relationships was less well sustained than in the case of normals or other groups of patients. Further studies have called into question some of the claims made for this test, and it is now clear that it is not sufficiently discriminating to be of diagnostic value. Work evolving from it has, however, yielded data of interest, contributing to the understanding of schizophrenic thoughtdisorder. One interesting demonstration was that thought-disordered schizophrenics, when comparing people or photographs of people, showed more disorder when applying constructs referring to psychological variables than when using those applying to physical characteristicss.l°. Further, schizophrenics showing marked flattening of affect used very few psychological constructs °. These findings are consistent with a view of schizophrenia which accords importance, in the aetiology, to social and interpersonal experiences, and which relates the emotional withdrawal of schizophrenics to the lack of a coherent cognitive system with which to make sense of interpersonal and emotional events. McPberson and Gray u extended the work on psychological construing ir~
48
T I N S - February 1979
Happy • • Civil
Artistic •
• Ambitious Feminine •
FATHER
MOTHER AUNT
TUTORIAL PARTNER
SISTER SELF
•Masculine TUTOR
• Strong TUTOR • I dislike • Intelligent
Sensitive •
~.2.
schizophrenics to a random group of psychiatric admissions, and showed that, within the group, there was a high correlation between the degree to which psychological constructs were used, and the patients' experience of psychological rather than physical symptoms. These authors point out that this supports work emphasizing the importance of cognitive factors in emotions l°, a view that has also been strongly emphasized by Bruch in her work s on anorexia nervosa. It is therefore of interest that some preliminary grid studies have been carried out on anorexics, investigating changes in self-concept with treatment4 and, in a new application of grid methods, comparing how two normal and two anorexic women construed the body parts of self, parents, and partners4. Apart from the work noted above, the most extensive clinical application of repertory grid technique has been in the study of individual, couple, or group therapy. Most commonly, such studies have used grids in which the elements were people and the self was often included in a number of forms (for example, ideal self, feared self). This approach offers a flexible and individual approach and avoids many of the pitfalls inseparable from the use of standardized inventories to assess change in treatment; individual eases can be assessed at the start of a treatment programme and specific predictions can be made, identifying those changes to be expected in grid measures if treatment is successful as. The dyad grid, where relationships between self and others, and others and self, form the elements, is, in many cases, a more sensitive approach for neurotic patients,
in whom interpersonal difficulties are central. Similar predictions can be made in respect of such grids. This approach is particularly appropriate where the relationship is the focus of treatment, as in marital therapy 16. The basis upon which predictions of desirable change are made in a grid may be common sense; for example, that the construction of the self should become less negative, or the self/ideal self discrepancy should become less extreme; but, as has been suggested more fully elsewhere 12, the applications of some insights derived from psychoanalysis can extend the subtlety with which grid data are considered. Thus, patterns of identification indicated by closeness between self and significant others on the grid may illuminate conflicts, for example, around sex roles or between sex roles and occupation. Ambivalence can be explored if the subject rates his reciprocal relationships with another under 'going well' and 'going badly' conditions. This approach demonstrated that individuals in conflict with their partners saw, when things were going badly, the self-to-partner as becoming more like parent-to-self, and the partner-to-self as becoming less like parent-to-selP~; this illustrates the spiral of deterioration as each becomes more demanding and less providing. The more primitive mechanisms of splitting and projection (concepts based upon objectrelations theory) may be suggested by the polarization of key persons in the standard grid, or in restrictive patterns of reciprocal relationships on the dyad grid. More generally, problems described in psychoanalytic terms as to do with conflict and resistance may be reformulated in
terms of the subject's personal definitions of options and the implications of change, as deduced from his grid. In addition to the use of grids in outcome research to demonstrate differences before and after treatment and to identify the location of change, the serial application of grids at shorter intervals, especially the use of grids which include the therapist, partner, or other members of a therapeutic group as elements, can throw some light on the nature of the therapeutic process. This approach has been applied particularly to therapeutic groups, and the results have been of some interest, although the complexity of the processes being studied, and of the grid meastires generated, can be' somewhat overwhelming 17~1. Theoretical implications Many would regard cognitive changes, including those concerned with the self, the body, and the emotions, as the essential effect of psychological treatments. Insofar as grid methods give some access to these changes, they can play a part not only in the research field, but also in clinical work. The clinician is always operating beyond the terrain adequately mapped by well-established theory, but he does need, as far as possible, to refer back to such theory. Recently, the theoretical bases of the very divergent therapeutic approaches of behaviourism and psychoanalysis have been undergoing revision, with an increasing emphasis being placed in both upon central cognitive processes, and the possibility of achieving a common theoretical language seems less remote 14. Human learning, including the essential learning about the body, the self, and relationships with others, takes place through the elaboration of hierarchical, interrelated mental schemata to which new experience is assimilated. These schemata (or construct systems) are in turn open to modification by new experience. Psychoanalysis, which played a crucial and pioneering part in identifying the inflexibilities, distortions, and idiosyncracies of thinking and feeling that date from early preverbal experience, has generated such a confusion of biological, mechanical, and structural metaphors that this essential contribution has been partially submerged. Data from grid studies re-emphasize that the task of therapy is to alter how an individual construes himself and others. The problems of most neurotic individuals are more extensive than those described in the
49
TINS - February 1979
language of traditional simple behaviourism; they are best understood as the effects of restrictions derived from the terms through which the world is construed. These. terms cannot always be conceptualized by the patient, and the first task of the dynamic therapist is to offer a new account of them; but behavioural and didactic techniques may also be effective in altering these terms and constructions. Whether the initial change is in behaviour, leading to an alteration in understanding, or in understanding, leading to an alteration in behaviour, is a less crucial difference than, in the heat of battle, it sometimes appears to be. Repertory grid studies are likely to continue to play a part in the study of how people change in response to treatment; more importantly, they may also play a part in the creation of a more adequate and unified human psychology by drawing attention to the common location of
change in therapies approaches.
using
different
Reading list l. Bannister, D. (1960)./. ?dent. Sci. 106,445 and 1230-1249. 2. Bruch, H. (1973) Eating Disorders: Obesity, Anorexia Nervosa and the Person Within, Basic Books, New York. 3. Crisp, A. H. and Fransella,F. (1972) Br. J. Med. PsychoL 45, 395-405. 4. Feldmann, M. M. (1975) Br. J. Med. Psychol. 48, 317-332. 5. FranseUa, F. and Bannister, D. (1977) A Manual for Repertory Grid Technique,
Academic Press, London. 6. Heather, N. (1978) Br. J. Soc. Clin. Psychol. 15 131-137. 7. James, W. (1911) Some Problems of Philosophy, Longman Green & Co., London. 8. Kelly,G. A. (1955) The Psychology of Personal Constructs, Norton, New York. 9. McPherson, F. M., Barden, V. and Buckley, F. (1970) Br. J. Med. Psychol. 43, 291-293. 10. McPherson,F. M. and Buckley,F. (1970) Br. J. Soc. Clin. Psychol. 9, 380-381.
Schizot)hrenia
Do parents cause schizophrenia? Steven R. Hirsch While various laboratories are putting a concerted effort into trying to discover the molecular causes o f schizophrenia - - which neural pathways are involved, which molecular process is disrupted, which neurotransmitters are involved - - the disease is being studied from another angle. This angle follows the enquiry into whether the environment o f the individual can cause, or bring out a potential for, the symptoms o f schizophrenia. In this article Steven Hirsch examines the evidence for the various theories which have been proposed.
The view that schizophrenia is somehow due to the way parents treat their children has had wide publicity over the last 15 years and has gained much support. But such a view has severe implications for the parents of the 196 of the population who will suffer from schizophrenia-at some stage in their lives; it means that millions of parents may fmd themselves accused of having caused a dreadful mental disturbance in their child. The theory that parents are to blame has also led to conflict between psychiatrists, who are critical of the theory, and their nonpsychiatrist colleagues, who accept it: the parents of schizophrenics have found themselves caught in the cross-fire. Some parents have fought back and have formed
a society* to help them cope with their problems, including the blame and censure which they experience from the 'helping' professions. There are many theories which attempt to explain how parents cause schizophrenia, so we must ask why choose one over another. Even more fundamental is whether there is adequate evidence to conclude that parents do, in any way, cause schizophrenia. We set out to answer these questions by examining the more important evidence from over 200 scientific reports, to summarize the hard facts The Schizophrenia Fellowship, 29 Victoria Road, Surbiton, Surrey KT6 4JT, U.K. (tel. (01) 390 3651).
11. McPherson, F. M. and Gray, A. (1976) Br. Z Med. Psychol. 49, 73-79. 12. Ryle, A. (1975) Frames and Cages: The Repertory Grid Approach to Human Understanding, Sussex University Press, Chatto &
Windus, London. 13. Ryle, A. (1975) New Behoviour 326-329. 14. Ryle, A. (1978) Br. I. Psychiat. 132, 585--594. 15. Ryle, A. and Breen, D. (1972) Br. J. Med. Psychol. 45, 375-382. 16. Ryle, A. and Lipshitz, S. (1975) Br. J. Med. Psychol. 48, 39--48. 17. Ryle,A. and Lipshitz,S. (1976) Br. J. Psychiat. 128, 581-588. 18. Ryle,A. and Lunghi,M. (1969) Br. J. Psychiat. 115, 1297-1304. 19. Schachier, S. (1964) In: I. Berkowitz (ed.), Advances in Experimental Social Psychology,
Vol. 1, Academic Press, New York. 20. Slater, P. (1977) (ed.) The Measurement of Interpersonal Space by Grid Technique, Wiley, London. 21. Winter, D. A. and TrippeR, C. J. (1977) Br. J. Med. Psychol. 50, 341-348. A. Ryle is Directorof the University Health Service of the University of Sussex, Falmer,Brighton BN I 9QZ, Sussex, U.K.
that emerge, and to see how the numerous disputed theories can be reconciled with the facts, such as they are. Schizophrenia may show itself at almost any stage of life, and may occur in single or repeated episodes, or as a persistent or permanent condition. The concern in this article is with causal factors which act long before the condition manifests itself and which cause individuals to be vulnerable or predisposed to developing schizophrenia later in life. Theories about the effects of parental behaviour as a cause of schizophrenia largely confine themselves to the influence parents have in the child's formative years. Possibly the most influential theory in the field, laying down a rationale which is basic to almost all subsequent theories, is the double-bind hypothesis. It was first formulated by Bateson, a British zoologist, and his psychiatric colleagues working in California and was published 1 in 1956. The double-bind hypothesis Double-bind communications are said to occur in emotionally heightened situations when the child feels it is essential to understand what is being communicated and to respond appropriately. The speaker, someone important to the child, conveys two or more messages which are mutually contradictory. This creates an intolerable and insoluble conflict if the family rules and social context prohibit the child from commenting on the situation or escaping from it. A further condition necessary to create the 'bind' is that the child cannot try to resolve (~ Elsevier/North-HollandBiomedicalPress 1979