How therapists in cognitive behavioral and psychodynamic therapy reflect upon the use of metaphors in therapy: a qualitative study

A Malkomsen, J I Røssberg, T Dammen, T Wilberg, A Løvgren, R Ulberg, J Evensen, A Malkomsen, J I Røssberg, T Dammen, T Wilberg, A Løvgren, R Ulberg, J Evensen

Abstract

Background: Research suggests that metaphors are integral to psychotherapeutic practice. We wanted to explore how 10 therapists reflect upon the use of metaphors in therapy, and how they react to some metaphors expressed by patients treated for of major depressive disorder (MDD).

Methods: Five therapists practicing psychodynamic therapy (PDT) and five practicing cognitive behavioral therapy (CBT) were interviewed with a semi-structured qualitative interview. Transcripts were analyzed using a thematic analysis approach.

Results: Our analysis resulted in two main themes: the therapeutic use of metaphors, and conflicting feelings towards metaphors used by depressed patients. Most therapists said that they do not actively listen for metaphors in therapy and many said that they seldom use metaphors deliberately. While PDT-therapists appeared more attentive to patient-generated metaphors, CBT-therapists seemed more focused on therapist-generated metaphors. Most therapists did not try to alter the patient-generated metaphors they evaluated as unhelpful or harmful. Some therapists expressed strong negative feelings towards some of the metaphors used by patients. PDT-therapists were the most critical towards the metaphor of tools and the metaphor of depression as an opponent. CBT-therapists were the most critical towards the metaphor of surface-and-depth.

Conclusions: These results remind us of the complexity of using metaphors in therapy, and can hopefully be an inspiration for therapists to reflect upon their own use of metaphors. Open therapeutic dialogue on the metaphor of tools, surface-depth and depression as an opponent may be necessary to avoid patient-therapist-conflicts.

Trial registration: Clinical Trial gov. Identifier: NCT03022071 . Date of registration: 16/01/2017.

Keywords: Cognitive behavioral therapy; Major depressive disorder; Metaphor; Psychodynamic therapy; Qualitative research; Thematic analysis.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022. The Author(s).

References

    1. Jung CG. Man and his symbols. United States of America: Dell; 1968. p. 432.
    1. Lakoff G, Johnson M. Metaphors We Live By. Chicago: University of Chicago press; 1980.
    1. Siegelman EY. Metaphor and meaning in psychotherapy. New York: Guilford; 1990.
    1. Mathieson F, Jordan J, Carter JD, Stubbe M. Nailing Down Metaphors in CBT: Definition, Identification and Frequency. Behav Cogn Psychother. 2016;44(2):236–248. doi: 10.1017/S1352465815000156.
    1. Kauschke C, Mueller N, Kircher T, Nagels A. Do Patients With Depression Prefer Literal or Metaphorical Expressions for Internal States? Evidence From Sentence Completion and Elicited Production. Front Psychol. 2018;9:1326. doi: 10.3389/fpsyg.2018.01326.
    1. Citron FMM, Cacciari C, Funcke JM, Hsu CT, Jacobs AM. Idiomatic expressions evoke stronger emotional responses in the brain than literal sentences. Neuropsychologia. 2019;131:233–248. doi: 10.1016/j.neuropsychologia.2019.05.020.
    1. Bohrn IC, Altmann U, Jacobs AM. Looking at the brains behind figurative language - a quantitative meta-analysis of neuroimaging studies on metaphor, idiom, and irony processing. Neuropsychologia. 2012;50(11):2669–83. doi: 10.1016/j.neuropsychologia.2012.07.021.
    1. Mathieson F, Jordan J, Bennett-Levy J, Stubbe M. Keeping metaphor in mind: training therapists in metaphor-enhanced cognitive behaviour therapy. Cogn Behav Ther. 2018;11.
    1. Mathieson F, Jordan J, Merrick P, Stubbe M. Juicy Conceptualizations: Increasing Alliance Through Attending to Client Metaphoric Language. Behav Cogn Psychother. 2017;45(6):577–589. doi: 10.1017/S1352465817000339.
    1. Landau MJ, Oyserman D, Keefer LA, Smith GC. The college journey and academic engagement: how metaphor use enhances identity-based motivation. J Pers Soc Psychol. 2014;106(5):679–698. doi: 10.1037/a0036414.
    1. Sarpavaara H, Koski-Jännes A. Change as a Journey—Clients’ Metaphoric Change Talk as an Outcome Predictor in Initial Motivational Sessions with Probationers. Qual Res Psychol. 2012;10(1):86–101.
    1. Levitt H, Korman Y, Angus L. A metaphor analysis in treatments of depression: Metaphor as a marker of change. Couns Psychol Q. 2000;13(1):23–35. doi: 10.1080/09515070050011042.
    1. McMullen LM. Use of Figurative Language in Successful and Unsuccessful Cases of Psychotherapy: three Comparisons. Metaphor Symb. 1989;4:203–225.
    1. McMullen L, Conway J. Dominance and Nurturance in the Figurative Expressions of Psychotherapy Clients. Psychother Res. 2010;4(1):43–57. doi: 10.1080/10503309412331333892.
    1. Stott R, Mansell W, Salkovskis P, Lavender A, Cartwright-Hatton S. Oxford guide to metaphors in CBT: building cognitive bridges. Oxford: Oxford University Press; 2010.
    1. Killick S, Curry V, Myles P. The mighty metaphor: a collection of therapists’ favourite metaphors and analogies. Cogn Behav Ther. 2016;9.
    1. Enckell H. Metaphor and the Psychodynamic Functions of the Mind. Finland: Kuopio University; 2002.
    1. Reider N. Metaphor as interpretation. Int J Psychoanal. 1972;53(4):463–469.
    1. Shengold L. Insight as Metaphor. Psychoanal Study Child. 1981;36(1):289–306. doi: 10.1080/00797308.1981.11823345.
    1. Rizzuto A-M. Metaphors of a Bodily Mind. J Am Psychoanal Assoc. 2001;49(2):535–568. doi: 10.1177/00030651010490021601.
    1. Borbely AF. Toward a Psychodynamic Understanding of Metaphor and Metonymy: Their Role in Awareness and Defense. Metaphor Symb. 2004;19(2):91–114. doi: 10.1207/s15327868ms1902_1.
    1. Rihacek T, Roubal J, Motalova K. Facets of the psychotherapy relationship: a metaphorical approach. Res Psychother. 2020;23(3):468.
    1. Rossberg JI, Evensen J, Dammen T, Wilberg T, Klungsoyr O, Jones M, et al. Mechanisms of change and heterogeneous treatment effects in psychodynamic and cognitive behavioural therapy for patients with depressive disorder: a randomized controlled trial. BMC Psychol. 2021;9(1):11. doi: 10.1186/s40359-021-00517-6.
    1. Malkomsen A, Rossberg JI, Dammen T, Wilberg T, Lovgren A, Ulberg R, et al. Digging down or scratching the surface: how patients use metaphors to describe their experiences of psychotherapy. BMC Psychiatry. 2021;21(1):533. doi: 10.1186/s12888-021-03551-1.
    1. Beck AT, Rush AJ, Shaw BF. Emery G. Cognitive Therapy of Depression: Guilford Publications; 1978. p. 425.
    1. Gabbard GO. Long-term psychodynamic psychotherapy: A basic text: American Psychiatric Pub. 2017.
    1. Høglend PA. Dynamisk korttidsterapi (Brief Dynamic Psychotherapy). In: Alnes R, P. E, P. J, editors. Poliklinikken Psykiatrisk Klinikk 25 år. Oslo: University of Oslo, Norway, Psykiatrisk Klinikk Vinderen.; 1990. p. 27–38.
    1. Ulberg R, Hersoug AG, Høglend P. Treatment of adolescents with depression: the effect of transference interventions in a randomized controlled study of dynamic psychotherapy. Trials. 2012;13:159. doi: 10.1186/1745-6215-13-159.
    1. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. doi: 10.1191/1478088706qp063oa.
    1. Patton MQ. Qualitative evaluation and research methods. 2. Newsbury Park, CA: Sage; 1990.
    1. Malterud K. Kvalitative metoder i medisinsk forskning: en innføring (Qualitative methods in medical research: an introduction). 3rd ed: Universitetsforlaget; 2011.
    1. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–357. doi: 10.1093/intqhc/mzm042.
    1. Hill CE, Knox S, Thompson BJ, Williams EN, Hess SA, Ladany N. Consensual qualitative research: An update. J Couns Psychol. 2005;52(2):196–205. doi: 10.1037/0022-0167.52.2.196.
    1. Caruth E, Ekstein R. Interpretation within the metaphor. Further considerations. J Am Acad Child Psychiatry. 1966;5(1):35–45. doi: 10.1016/S0002-7138(09)62035-5.
    1. Cain AC, Maupin BM. Interpretation within the metaphor. Bull Menninger Clin. 1961;25:307–311.
    1. Forrest DV. On one’s own onymy. Psychiatry. 1973;36(3):266–90.
    1. Wright KJ. Metaphor and symptom: A study of integration and its failure. International Review of Psycho-Analysis. 1976;3(1):97–109.
    1. Mathieson F, Jordan J, Carter JD, Stubbe M. The metaphoric dance: co-construction of metaphor in cognitive behaviour therapy. The Cogn Behav Ther. 2015;8.
    1. Kuyken W, Padesky C, Dudley R. Collaborative Case Conceptualization: Working Effectively with Clients in Cognitive Behavioral Therapy. New York: Guilford; 2009.
    1. Fluckiger C, Del Re AC, Wampold BE, Horvath AO. The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy (Chic) 2018;55(4):316–340. doi: 10.1037/pst0000172.
    1. Stuart J. Novel Figurative Language and Patient Experiencing in Psychodynamic Therapy. Psychother Res. 1997;7(3):219–237. doi: 10.1080/10503309712331331983.
    1. Borbely AF. Chapter 23: Metaphor and Psychoanalysis. In: Gibbs JRW, editor. The Cambridge Handbook of Metaphor and Thought. United States of America: Cambridge University Press; 2008.
    1. Cabaniss DL, Cherry S, Douglas CJ, Schwartz AR. Psychodynamic psychotherapy: A clinical manual: Wiley-Blackwell; 2011. xiii, 379-xiii, p.
    1. Gibbs RW. Introspection and cognitive linguistics: Should we trust our own intuitions? Review of Cognitive Linguistics Published under the auspices of the Spanish Cognitive Linguistics Association. 2006;4:135–151.
    1. Essential statistics for the behavioral sciences. Thousand Oaks: Sage Publications, Inc; 2016.
    1. Anderson C. Presenting and evaluating qualitative research. Am J Pharm Educ. 2010;74(8):141. doi: 10.5688/aj7408141.
    1. Almirabi MM. When Metaphors Cross Cultures. J Lang Teach Res. 2015;6(1):204–9. doi: 10.17507/jltr.0601.25.
    1. Barkham M, Lutz W, Castonguay LG. Bergin and Garfield's Handbook of Psychotherapy and Behavior Change. 7th ed. New Jersey: Wiley; 2021.

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