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Enhancing Your Therapy with Gestalt Approaches
Gestalt Therapy continuing education counselor CEUs

Section 19
Gestalt Techniques and Metaphor Analysis
in the Treatment of Depression

CEU Question 19 | CEU Answer Booklet | Table of Contents | Gestalt
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

Apart from aiding in expression, metaphors can serve several functions during psychotherapy. They may facilitate (e.g. Barlow et al., 1977; Strong, 1989), provide novel avenues of self growth and suggest new solutions (Berlin et al., 1991; McMullen, 1985; Strong, 1989) as well as enhance the communication between the client and the therapist by introducing new experiential terminology into the session (Angus & Rennie, 1988; Huckins, 1992; Ingram, 1994; McMullen, 1985; Rasmussen & Angus, 1996, 1997).

The present study involves the application of two process measures, the Narrative Process Coding System (NPCS; Angus et al., 1996) and the Experiencing Scale (Klein et al., 1970), to discourse units (narrative sequences) which include metaphors relating to themes of 'burden' (or, for the sake of brevity, 'metaphored-sequences') in one good and one poor-outcome process experiential dyad.  The process-experiential approach to psychotherapy combines various aspects of client-centered and gestalt approaches (Greenberg et al., 1993). It focuses on clients' present experience and expression in order to facilitate emotional change and experiential processing. Active interventions are used including empathy work, such as Gendlin's (1996) focusing, and process-directive techniques, such as gestalt two-chair exercises and the evocation and intensification of emotion.

The purpose of the present study is to develop an understanding of how 'burden' metaphors were used in a productive therapy, in contrast with the less successful approaches, as well as to further explore how metaphors may be used as markers of client change in psychotherapy. For this study, frequency of metaphoric phrases are not being used as a measure of outcome (a battery of client-rated outcome measures are employed for this purpose) but rather the relationship between the occurrence of metaphor phrases and therapy outcome will be examined. Since little is known about how metaphors evolve over the course of therapy, this investigation is exploratory in nature with the goal of developing grounded hypotheses for future analyses.

Outcome measures. Standardized client-report measures were used to evaluate therapy outcome. Pretherapy and post-therapy client ratings on the Beck Depression Inventory (BDI; Beck et al. 1961), the Symptom Check List-90 (SCL-90R; Derogatis, 1983), the Inventory for Interpersonal Problems (IIP; Horowitz et al., 1988), the Rosenberg Self-Esteem Scale (RSE; Rosenberg, 1965) and the Target Complaints (Battle et al., 1968) were compared in order to identify the therapies as either a good or a poor outcome.

The experiencing scale. The Experiencing Scale (Klein et al., 1970) is a measure of the clients' emotional involvement in therapy. It examines the construct of 'experiencing' which is defined as 'the extent to which inner referents become the felt data of attention, and the degree to which efforts are made to focus on, expand, and probe those data' (Klein et al., 1986, p. 21). The Experiencing Scale is derived from Gendlin's experiential theory and Roger's client-centered theory and is one of the first widely used therapeutic process measures (Hill & Corbett, 1993).

Narrative process coding system. Angus et al. (1992,1996) have developed a method of examining the similarities and differences between approaches to therapy. At first, topic segments are identified, which are based upon the changing thematic content within a therapy session transcript. Then, within these topic segments, psychotherapeutic discourse is divided into units conceptualized according to one of three narrative process codes: external or story-telling sequences (e.g. 'My mother told me a horrible story yesterday, it was about...'); internal or emotion-related sequences (e.g. 'Sadness just wells up in me. I hate hearing about other people in pain...'); and reflexive or self-analytic sequences (e.g. 'It seems that I'd rather run away and not listen, just like my father used to do'). This generic, comprehensive classification system, derived from research on several therapeutic approaches, can provide sequences upon which process measures can be applied and contrasted (Angus & Hardtke, 1994; Levitt & Angus, 2000). The smallest units in the system must include at least four complete sentences, in order to provide enough data to be meaningfully rated, the average narrative sequence in the NPCS system has been found to be 30 sentences in length (Hardtke, 1996; Levitt, 1993).

Metaphor analysis. Metaphors were identified using Lakoff and Johnson's inclusive definition, that being 'the understanding of one thing in terms of another' (1980,p. 3). Metaphors initiated by either the client or therapist were identified. Inter-rater reliability on the identification of metaphors in two therapy sessions achieved an agreement level of 87%. The two raters identified a total of 365 metaphors in these sessions.

In this study, the 'burden' metaphor theme was selected as it was found to capture an essential element of the client experience of depression (Korman & Angus, under review). All metaphors were identified in both the good and the poor outcome therapies. Once it was established that the good and poor dyads shared the theme of 'carrying a heavy burden' the analysis was focused on that theme. Only those metaphors which were agreed upon by two of the researchers to have a 'burden' theme were included in the study.

Metaphors were identified as either having a 'burdened' or 'unloading' quality, in correspondence with the findings from the Korman and Angus study (under review). The good- outcome dyad examined in the present study was one of the dyads analyzed in the Korman and Angus study.

The metaphors in the good outcome therapy were found to evolve from an emphasis on the experience of 'carrying a burden' in the initial sessions to the experience of 'unloading the burden' in later sessions (Korman, 1995). As the client in this therapy made progress in terms of realizing that she was not responsible for the behavior of others around her, she began to feel relieved of her depression. In contrast, the poor outcome dyad had no such pattern. Although metaphors of weight or heaviness continued throughout the therapy and the client would occasionally use metaphors of unloading, these were often in a wishful tone rather than as an expression of ongoing relief (e.g. 'I wish I could get this off my back' versus 'I feel like a burden has been lifted from me'). The expression of burden in these two dyads did seem to mirror their respective outcomes and to symbolize the clients' struggle with their depression.

Metaphor-theme research provides a heuristic for tracking clients' evolution in psychotherapy. In this study, the analysis of metaphored-sequences seemed to differentiate the good and the poor outcome therapy dyads in two key ways: (1) the content of the metaphor phrases; and (2) the processes which occurred when the metaphors were used, as indicated by differences in experiencing scale ratings and NPCS coding. In terms of content change, metaphors seem to be a useful marker for psychotherapeutic change, as the 'burdened' theme in the good-outcome was transformed into an 'unloading' theme, a change which was not evident in the poor outcome.

A limitation of this study results from its focus on only one dyad from each outcome condition. Although the purpose of this study was to generate hypotheses about the use of metaphors in psychotherapy in relation to outcome, the therapeutic outcome variable was confounded with therapist and client variables making it difficult to separate these causal factors. Caution should be exercised therefore when generalizing these results to other dyads. The study has, however, generated grounded and useful hypotheses in an area in which there has been limited empirical research.  First, it suggests that it may be beneficial for therapists to focus clients on the feelings embedded in their metaphors (e.g. engaging internal narrative processes and middle levels of experiencing) and to help clients to comprehend the meaning or metaphors in the context of their lives (e.g. engaging in reflexive narrative processes and high levels of experiencing). Second, as sequences in the poor outcome dyad with 'burden' metaphors introduced by the therapist had lower experiencing ratings than client- introduced metaphor sequences, while the reverse was found in the good outcome dyad, it appears useful to explore whether productive therapists might use metaphor in a way which encourages emotional-connection in contrast with less productive therapists. It would be of interest to examine these hypotheses in a future outcome study using a larger sample size, and including both good and poor outcome dyads by the same therapist, in order to distinguish therapeutic outcome from therapist and client variables. As a marker of client-change, metaphor analyses can provide a targeted method of examining shifts in client's experience of depression, which can be useful for therapy researchers and therapists alike. This current study indicates that metaphor analysis can be used to track therapeutic change and can be a powerful representation of human experience.
- Levitt, Heidi; Korman, Yifaht; Angus, Lynne; A metaphor analysis in treatments of depression: metaphor as a marker of change; Counselling Psychology Quarterly, Mar2000, Vol. 13 Issue 1
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #5
The preceding section contained information about Gestalt techniques and metaphor analysis in the treatment of depression.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 19
According to Levitt, why is metaphor analysis useful in the treatment of depression? Record the letter of the correct answer the CEU Answer Booklet.

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Table of Contents

The article above contains foundational information. Articles below contain optional updates.
Enhancing psychotherapy process with common factors feedback: A randomized, clinical trial.
In this study, we developed and tested a common factors feedback (CFF) system. The CFF system was designed to provide ongoing feedback to clients and therapists about client ratings of three common factors: (a) outcome expectations, (b) empathy, and (c) the therapeutic alliance. We evaluated the CFF system using randomized, clinical trial (RCT) methodology. Participants: Clients were 79 undergraduates who reported mild, moderate, or severe depressive symptoms at screening and pretreatment assessments. These clients were randomized to either: (a) treatment as usual (TAU) or (b) treatment as usual plus the CFF system (TAU + CFF). Both conditions entailed 5 weekly sessions of evidence-based therapy delivered by doctoral students in clinical psychology. Clients completed measures of common factors (i.e., outcome expectations, empathy, therapeutic alliance) and outcome at each session. Clients and therapists in TAU + CFF received feedback on client ratings of common factors at the beginning of Sessions 2 through 5. When surveyed, clients and therapists indicated that that they were satisfied with the CFF system and found it useful. Multilevel modeling revealed that TAU + CFF clients reported larger gains in perceived empathy and alliance over the course of treatment compared with TAU clients. No between-groups effects were found for outcome expectations or treatment outcome. These results imply that our CFF system was well received and has the potential to improve therapy process for clients with depressive symptoms. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Can reflecting on personal values online increase positive beliefs about counseling?
This research developed and tested an online values-affirmation exercise to attenuate threat and enhance positive beliefs about counseling among individuals struggling with mental health concerns. There is evidence that reflecting on personal values (values-affirmation) is an effective approach to eliciting self-affirmation—a psychological process that temporarily bolsters self-worth in order to forestall maladaptive, self-protective responses to counseling information. The present study utilized a randomized 2-group between-subjects design to test the effectiveness of a values-affirmation exercise with an online sample (N = 186) of adults who reported struggling with a mental health concern. It was predicted that values-affirmation would reduce threat related to reading mental health information and increase positive beliefs about counseling. Results indicated that those in the values-affirmation condition reported fewer negative emotions such as feeling upset, irritable, hostile, and scared after reading mental health information, indicating that the information was perceived as less threatening. There was also evidence that engaging in values-affirmation was associated with greater anticipated growth in counseling and greater intent to seek counseling, reflecting greater positive beliefs about counseling. Overall, the results suggest that reflecting on personal values may have the potential to enhance the positive effects of online psychoeducation. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Depression symptoms moderate the association between emotion and communal behavior.
Depression is associated with emotion regulation deficits which manifest as elevated negative affect and greater continuation of negative affect over time. The present study examined a possible emotion regulatory deficit, whether depression symptoms attenuate the association between communal (i.e., agreeable, quarrelsome) behavior and affect. A community sample reported on depression and anxiety symptoms before recording their affect and behavior following naturally occurring interpersonal interactions over 21 days. Participants’ behaviors were measured using items selected to represent the Interpersonal Circumplex Model of behavior. Results indicated an association between affect and communal behavior, which was stronger for negative than positive affect. Depression symptoms moderated this association; elevated depression symptoms were associated with decreased association of affect and interpersonal behavior. Comorbid anxiety symptoms did not moderate this association. Results suggest that elevated depression symptoms are associated with a diminished ability to adapt communal behavior to emotion cues. Given prior evidence of elevated overall quarrelsome behavior among individuals with elevated depression symptoms, this may demonstrate an interpersonal mechanism by which emotion regulation deficits impact the generation of interpersonal problems. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Thwarted belongingness, perceived burdensomeness, and depression among asian americans: A longitudinal study of interpersonal shame as a mediator and perfectionistic family discrepancy as a moderator.
This short-term longitudinal study applied Joiner’s (2005) Interpersonal-Psychological Theory of Suicide to Asian Americans’ experiences with depression. Interpersonal shame (i.e., the experience of inadequacy arising from interpersonal concerns) was hypothesized to mediate the effects of (a) thwarted belongingness and (b) perceived burdensomeness on future depression. Furthermore, the positive associations between (a) thwarted belongingness and (b) perceived burdensomeness on future depression were hypothesized to vary depending on students’ experiences with perfectionistic family discrepancy (PFD; their perceived gap between their actual performance and what their parents expect of them). A total of 605 Asian Americans attending predominantly White, Midwestern universities completed 3 online surveys. Conditional process modeling via Hayes’s (2013) PROCESS was used to analyze the data. Results demonstrated that (a) thwarted belongingness and (b) perceived burdensomeness contributed to higher interpersonal shame, which influenced students’ future depression. Furthermore, the effect of thwarted belongingness on future depression was significantly positive for those with PFD levels greater than the 12th percentile, after taking into account students’ initial level of depression. The effect of perceived burdensomeness on future depression was not significant for those with PFD levels greater than the 3.5th percentile. This study identified that students with perfectionistic family discrepancy may be at higher risk for depression while experiencing thwarted belongingness. Overall, findings supported using Joiner’s (2005) theory to understand Asian American students’ risk for future depression. Future studies may gather data across Asian American students’ years in college. Counselors can apply these findings to increase students’ awareness about possible risk factors for depression. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Distress disclosure and psychological functioning among Taiwanese nationals and European Americans: The moderating roles of mindfulness and nationality.
Research using Western samples shows that talking about unpleasant emotions—distress disclosure—is associated with fewer psychological symptoms and higher well-being. These benefits of distress disclosure may or may not be observed in East Asia where emotional control is valued. Instead, mindfulness may be more relevant to emotion regulation in East Asia (e.g., Taiwan). In the present study, cultural context (Taiwanese nationals vs. European Americans) and mindfulness were examined as moderators of the relation between distress disclosure and both depression symptoms and life satisfaction. A sample of 256 Taiwanese college students and a sample of 209 European American college students completed self-report measures in their native language. Moderated multiple regression analyses revealed significant interaction effects of mindfulness and distress disclosure on both depression symptoms and life satisfaction for Taiwanese participants but not for European Americans. Specifically, distress disclosure was negatively associated with depression symptoms and positively associated with life satisfaction for Taiwanese low in mindfulness but not for Taiwanese high in mindfulness. For European Americans, distress disclosure was not associated with depression symptoms but was associated with higher life satisfaction, regardless of one’s level of mindfulness. These findings suggest that the potential benefits of disclosing distress are a function of one’s cultural context as well as, for those from Taiwan, one’s mindfulness. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

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