In the Metacognitive Training study in which James is enrolled, a battery of instruments was administered in two sessions before the beginning of the therapy.

The instruments assessing psychopathology, shown in Table 1, were administered in the first session. James’s scores on the Positive and Negative Syndrome Scale (PANSS), Spanish adaptation of Peralta et al[14], and the Psychotic Symptom Rating Scales (PSYRATS), Spanish adaptation by González et al[15], showed a high severity for the positive symptoms. In addition, on PANSS items related to passive social withdrawal and active social avoidance the scores indicate moderate-severe social isolation, which is associated with his suspiciousness and persecutory fears. He also presented severe depressive symptomatology, as measured with the Beck Depression Inventory (BDI-II), Spanish adaptation by Sanz, Perdigón et al[16].

The severity of his psychopathology could also be observed during the second interview, when the repertory grid was administered. He was very cooperative and talkative, but he was also invaded by his delusions and made repeated verbalizations about them and the suffering that they brought him (“I’m scared. Before coming here I heard a man in a bar talking about killing me”).

The RGT is a structured interview exploring the patient’s personal meanings. The first phase is the selection of elements, which represent a sample of the most significant people for the patient. In the case of James, 17 elements were chosen. Four of them were provided by the clinician according to their possible clinical implications: “self now”, “ideal self” (which represents how he would like to be), “self before the psychotic crisis”, and the “non-grata person”, which represents a person he does not like (for James, this was his ex-girlfriend, his main persecutory figure). The remaining elements, elicited by James, were his parents, six members of the extended family who live far away but for whom he felt much appreciation (maternal grandparents, two uncles, and two cousins), two good friends from the time before the psychotic crisis, Ana, identified by him as his current partner, and a friend of his partner’s with whom he often talks. The selected items are recorded in the upper part of the protocol of the grid (Figure 1) defining the columns, the first column for the “self now” and the last for the “ideal self”.

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Figure 1 The repertory grid of James.

In the second phase, constructs are not provided by the clinician (like items in nomothetic research); rather, they are elicited directly from the person evaluated as a way to express his or her personal meanings. Personal constructs are elicited using the dyadic method, which consists of asking the subject about similarities and then differences in each pair of elements in terms of their perceived personality or character traits. For example, the first question for James was: “In terms of their personality, in which way would you say your mother and father are alike?” James answered, “Both of them are harsh”. This answer constitutes one pole of the first construct, so to obtain the other pole we asked “What would be the opposite of harsh for you?” and the answer was “tolerant”. Thereby, the first construct (“harsh vs tolerant”) was obtained and more similarity and difference questions were made for this and other pairs of elements. Elicited constructs were written down by the interviewer in the horizontal entries of the grid (Figure 1). After 19 constructs were obtained from James he started to repeat many constructs and showed fatigue. This is usually the time to end the elicitation process, which is known as the “saturation point”.

The last phase is the rating of the elements. Each element is assigned a value in a seven-point Likert-type scale for each construct. Taking as an example the cited construct, 1 means “very harsh”, 2 “quite harsh”, 3 “slightly harsh”, 4 “middle point”, 5 “slightly tolerant”, 6 “quite tolerant”, and 7 “very tolerant”.

Once the grid data matrix was filled (see James’s grid in Figure 1), the administration process ended, and the data were ready to be analyzed qualitatively or quantitatively, for which there is software available, the GRIDCOR, with a manual to guide interpretation of the data[17]. This software allows synthesizing and analyzing the great amount of information reflected in the grid using different statistical methods.

From the data of the grid we may grasp the personal views of James about himself. To do so, we should focus on the constructs in which James rates himself with extreme values (scores of 1-2 and 6-7). Once obtained, we can narratively formulate his self-definition: “I am a very attentive, generous person, with a great capacity to love. But I’m also very nervous and very cowardly. I also consider myself quite a good person, concerned and assertive, but I am also quite messy and detached from my family, for whom I feel I have little respect”.

We identify what James values about himself by finding congruent constructs in his grid. These are the constructs where the elements “self now” and “ideal self” are rated in the same pole, dimensions for which James does not wish any change. We found six such constructs: Attentive, assertive, capable of loving, generous, good person, and non-aggressive.

In contrast, discrepant constructs reveal aspects that James does not like about himself and which he would like to change. These are constructs in which the “ideal self” is rated at the opposite pole to the “self now”. These discrepant constructs can be also expressed narratively:“Contrary to what I am (harsh, nervous, messy, sad, boring, cowardly, detached, and someone who tires easily), I would like to be tolerant, quiet, happy, funny, a fighter, and even-tempered”.

James’s congruent constructs are his “strong points”, those which might be central to his identity. Additionally, they may be seen as resources to validate and protect during the therapy process. However, James presents more discrepant than congruent constructs (eight to six), which could be a reflection of his current life moment in which he lives dominated by fears that stem from his persecutory delusions (“I would like to be a fighter, but I am a coward”), in a state of suffering and dissatisfaction with himself (“I would like to be happy and quiet, but instead I am sad and nervous”).

The GRIDCOR program outputs many quantitative measures that explain different aspects of how the patient construes himself and others, and also about the structure of his cognitive system. In the case of James, the most significant indices are shown in Table 2.

Construing self and others: Various aspects of the self can be evaluated taking the Euclidean distances between the elements “self now”, “ideal self” and “others” (an artificially generated element taking into account the average of the scores of all elements but “self now” and “ideal self”).

Self-ideal differentiation: The discrepancy in the ratings of the elements “self now” and “ideal self” can be considered as a measure of self-esteem, since by comparing these two elements the patient is evaluating himself on his own terms. High differentiation (e.g., d > 0.32) is usually taken as indicative of low self-esteem. This is the case with James: He feels very far away from the way he would like to be and he therefore feels great dissatisfaction with himself and serious distress. This finding matches with the self-definition of James, with many discrepant constructs, and with the clinical observations made during the assessment process.

Self-others differentiation: The discrepancy between self and others becomes an index of how people see themselves as different (or similar) with respect to the other elements in the grid. This differentiation is considered as a measure of perceived social isolation. High differentiation (e.g., d > 0.35) is an indication that a person experiences himself or herself as different from others, feeling that he or she shares few features with other people.

James presented high perceived social isolation, viewing himself as very different, which is compatible with feeling like “the weird guy”, accompanied by notable feelings of loneliness.

Ideal-others differentiation: The discrepancy between the ideal self and others is considered as an index of the degree of perceived adequacy of others. High dissimilarity (e.g., d > 0.28) means that the person has great dissatisfaction with others, while a lower score suggests a positive perception of them, as was the case with James. For a wider perspective, we can take into account his self-esteem, which is very low and negative, with others being closer to his ideal self than his current self; they are the “good ones”.

Self-construction profile: Five different self-construction profiles can be identified taking into account the joint interpretation of the three differentiation indices explored: Positivity, superiority, negativity, depressive isolation, and resentment profiles.

The conjoint interpretation of the three indices of James suggests a depressive isolation profile. This profile represents the combination of having a negative view of oneself, high perceived social isolation, and a positive perceived adequacy of others. This combination suggests that James views himself in negative terms and different from others, as if he was saying: “The others are great, but not me. I am the only one who is weird”. This profile usually applies to depressive patients and people with other psychiatric categories who manifest hopelessness, which is congruent with James’s depressive symptoms.

Interpersonal cognitive differentiation: Interpersonal cognitive differentiation refers to the extent to which a person can construe his or her social experiences from different points of view. The more differentiated a cognitive structure is, the more meaningful dimensions are available to the person to perceive and understand the behavior of others.

Several measures have been proposed to assess cognitive differentiation, but the percentage of variance accounted for by the first factor (PVAFF) resulting from the factor analysis is the one with the strongest reputation. This percentage indicates the importance or weight of the main dimension of meaning. It is estimated that a low PVAFF indicates a differentiated cognitive structure, favoring multidimensional thinking and allowing other dimensions to play relevant roles in the way the subject construes, while a high PVAFF indicates low cognitive differentiation, with a tendency to one-dimensional thinking. James’s score indicates a cognitive structure with low differentiation, with one dimension which plays the main role for the construction of himself and the others.

Polarized thinking: Polarization refers to the extent to which a person construes reality in an extreme way, and it is considered as a measure of cognitive rigidity. It is computed as the percentage of extreme scores in the grid. High percentages are indicative of a polarized structure. This score is very high in the case of James, suggesting a very rigid cognitive structure, with a tendency to construe himself and others in a dichotomous way.

Centrality of symptomatic constructs: The variance accounted for by each construct in the grid data matrix is calculated with Bannister’s[18] Intensity score, which is based on the strength of the correlations with the other constructs. Thus, those constructs with the highest intensity scores tend to be the ones with greater weight or importance in the cognitive system. When these constructs express aspects which can be considered as symptomatic, then potential difficulties for change in the therapeutic process may appear. For James, five constructs are the most intense or central to his cognitive system: “coward vs fighter”, “aggressive vs non-aggressive”, “unfriendly vs friendly”, “tires easily vs even-tempered” and “nervous vs calm”. Analyzing their content, most of these core constructs could be considered as symptomatic, reflecting his emotional experience of fear and anxiety, and his perception of threat in others, both in the context of the persecutory delusions. The construct “coward vs fighter” is central to the sense of identity of James. Additionally, it does have a very high percentage of polarization (87.50%). Checking his grid raw data matrix (Figure 1), we observe that he considers himself as the only element who is a “coward”, while all the others are perceived as “fighters” (as he would like to be). Clinically, this construct might be related to the suffering and permanent sense of fear and alertness that invades his personal life.

To analyze the identity implications of this construct, the correlation matrix among constructs can be used to explore its personal meaning in the context of his cognitive system. In Figure 2, the network of constructs associated with the pole “coward” is represented. All the constructs that are associated with it have negative connotations. The construct pole “coward” is strongly associated, by this order, with the poles “detached” (r = 0.94), “boring” (r = 0.90), “selfish” (r = 0.83), “sad” (r = 0.81), “bad person” (r = 0.79) and “unfriendly” (r = 0.61). Therefore, this highly interrelated meaning configuration articulated around the core construct “coward vs fighter” helps us to understand how invalidating it must have been for James to experience intense fears (such as those caused by the perceived threat of others). We may infer here a massive invalidation of his most central aspirations (becoming “fighter”, “funny”, “altruist”, “happy”, a “good person”, “friendly”, and someone who “respects his family”). In PCT, this invalidation of core constructs is linked to intense negative emotions.

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Figure 2 Main construct correlations for “coward”.

A graphic display of the main axes of construction: The GRIDCOR program employs Correspondence Analysis, a multivariate statistical technique similar to principal component analysis, in order to simultaneously compute both constructs and elements expressed in the grid data matrix. It aims to represent the main dimensions of meaning employed by the subject in order to understand his interpersonal world. Each axis or dimension is composed of both elements and constructs with their corresponding loads (which varies across axes).

In the case of James, as mentioned before, the first factor explained 54.11% of variance while the second one accounted for 16.54%. Taken together, these two axes are responsible for 70.66% of the variance in the grid data. The GRIDCOR software yields a graph placing both axes orthogonally, creating a two-dimensional space, which allows us to get an approximate picture of how James perceives himself and others from his main dimensions of meaning (Figure 3). As explained before, each axis represents a dimension of meaning, comprising a particular combination of specific constructs and elements, which are arranged along the axis, being allocated the ones that account for major weight in each axis at the extremes, and around the central area the ones with less weight in that dimension of meaning. In this graph, the final allocation of both constructs and elements results from the combination of the dimensions of meaning of both axes, the first axis represented in the horizontal (abscissa) plane and the second axis in the vertical (ordinate). In this case, for instance, the extremes of the first axe are delimited by the elements “self before” and the “ideal self” or “current partner”, whereas the extremes of the second axis are represented by “father” and “self now”. The selected constructs and elements that appear in the graph account for the major weight in both axes, and, therefore, it represents the meanings that James gives the most importance to in his view of his interpersonal world, according to grid data. From the distribution of people and meanings in this graph we may derive three different groupings with which James categorizes and interprets his interpersonal world.

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Figure 3 Graph output for the main axes of James. Note: (1) The construct poles “even-tempered”, “quiet” and “calm” are also allocated here; (2) The construct poles “happy”, “respects family” and “good person” a real so allocated here.

James’s group, the lonely guy: Me and my “self before the crisis”. According to his grid, James perceived his current and past selves in negative terms (“coward”, “detached”, and “boring”), different and far from other people, reflecting his experience of self-isolation. Looking at the direct ratings in the grid, the only notable difference is that his current self is now seen as quite a “good person” while the self before the crisis is rated as quite a “bad person”. This could be an important aspect to explore in the therapy process to understand the meanings of this change for James.

The group of the good ones: Where James wants to belong. The ideal self of James is situated in an opposite quadrant, with his current partner and his grandmother. Although they do not appear in the graph due to lack of space and lesser variance loading, most of the other elements are located there as well. All the constructs with positive connotations appear there; James would like to be a “fighter”, which would imply also being “happy” and “respectful of family”, as others are perceived. Another constellation of constructs in this area is related to a desired change in the anxiety of James: He would like to become “even-tempered”, “quiet” and “calm”, like the others.

The threatening group: The parents and the persecutory figure. In this group we find Mary, his ex-girlfriend, whom he identifies as one of his main persecutors. His parents, with whom he has had many severe conflicts and from whom he feels little support, are there as well. Unexpectedly, these three people are located very close to each other. It may be seen that James gives meaning to them mainly in terms of a constellation of constructs with hostile content (“harsh”, “argumentative”, “aggressive”, and as people who “tire easily”).

A 25-year-old man with severe persecutory delusions and hallucinations with threatening content without improvement following antipsychotic medication.

Psychiatric diagnosis of schizophrenia and personality disorder not otherwise specified. The onset of the disorder was 2 years ago.

Olanzapine 20 mg/d and Aripiprazole 400 mg/mo as depo. The case is going to start metacognitive individual training for psychosis.

The authors highlight the possibilities of the repertory grid technique to understand the personal meanings behind the symptoms and to identify targets for psychotherapy.

The article is very good as of its scientific.