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Enhancing Your Therapy with Gestalt Approaches
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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.

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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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The article above contains foundational information. Articles below contain optional updates.
Introduction to special section on advanced methodology: Counseling the dog to wag its methodological tail. - November 20, 2017
In this article, we introduce a special section focused on the application of advanced methodologies to specific research questions in counseling psychology. The articles include applications of natural language processing, dynamic systems, mediation analyses in single studies and meta-analysis, and synthesis of qualitative research. We provide a brief overview of each article. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Topics in the Journal of Counseling Psychology, 1963–2015. - November 20, 2017
Historical trends in a scientific field should be apparent in the changing content of journal articles over time. Using a topic modeling approach, a statistical method for quantifying the thematic content of text, 70 topics were extracted from the abstracts of 3,603 articles published in the Journal of Counseling Psychology from 1963 to 2015. After examining interpretability of 70 topics derived from the model, 64 meaningful topics and their trends were named. In addition, the authors also classified some of the related topics into 4 categories—counseling process and outcome, multiculturalism, research methodology, and vocational psychology. Counseling process and outcome related topics have decreased recently, while topics relating to multiculturalism and diversity have shown increasing trends. The authors also discussed trends that were observed and tried to account for the changing frequencies of some important research topics within these categories. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
A multivariate dynamic systems model for psychotherapy with more than one client. - November 20, 2017
The dynamics of the give and take between therapist and client(s) is frequently of interest to therapy process researchers. Characterizing the ways that therapists respond to clients and clients respond to therapists can be challenging in therapeutic encounters involving a single therapist and a single client. The complexity of this challenge increases as the number of people involved in a therapeutic encounter increases not only because there are more people responding to one another but also because the patterns of responding can become more complex. This manuscript demonstrates how dyadic cross-lagged panel models can be extended to psychotherapeutic encounters involving 3 people and used to test processes that exist between dyadic subsets of the larger group as well as the group as one cohesive unit. Three hundred seventy-nine talk turns of fundamental frequency from a couple therapy session were modeled using 3 dyadic cross-lagged panel models, and each individual’s respiratory sinus arrhythmia (RSA) was treated as a moderator. Although the regression coefficients for each dyadic subset (e.g., therapist–husband) were nonsignificant, an eigenvalue/eigenvector decomposition of the regression coefficients from the 3 dyadic cross-lagged panel models suggests that interdependence exists at the level of the whole group (i.e., therapist–husband–wife) rather than between pairs of individuals within the group (e.g., husband–wife). Further, an interaction involving husband’s RSA suggested that interdependence involving the husband ceased when the husband displayed greater regulatory effort. This combination of statistical methods allows for clearly distinguishing between dyadic therapeutic processes and group-level therapeutic processes. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Metamethod study of qualitative psychotherapy research on clients’ experiences: Review and recommendations. - November 20, 2017
A metamethod study is a qualitative meta-analysis focused upon the methods and procedures used in a given research domain. These studies are rare in psychological research. They permit both the documentation of the informal standards within a field of research and recommendations for future work in that area. This paper presents a metamethod analysis of a substantial body of qualitative research that focused on clients’ experiences in psychotherapy (109 studies). This review examined the ways that methodological integrity has been established across qualitative research methods. It identified the numbers of participants recruited and the form of data collection used (e.g., semistructured interviews, diaries). As well, it examined the types of checks employed to increase methodological integrity, such as participant counts, saturation, reflexivity techniques, participant feedback, or consensus and auditing processes. Central findings indicated that the researchers quite flexibly integrated procedures associated with one method into studies using other methods in order to strengthen their rigor. It appeared normative to adjust procedures to advance methodological integrity. These findings encourage manuscript reviewers to assess the function of procedures within a study rather than to require researchers to adhere to the set of procedures associated with a method. In addition, when epistemological approaches were mentioned they were overwhelmingly constructivist in nature, despite the increasing use of procedures traditionally associated with objectivist perspectives. It is recommended that future researchers do more to explicitly describe the functions of their procedures so that they are coherently situated within the epistemological approaches in use. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Unique effects and moderators of effects of sources on self-efficacy: A model-based meta-analysis. - November 20, 2017
Self-efficacy beliefs are strong predictors of academic pursuits, performance, and persistence, and in theory are developed and maintained by 4 classes of experiences Bandura (1986) referred to as sources: performance accomplishments (PA), vicarious learning (VL), social persuasion (SP), and affective arousal (AA). The effects of sources on self-efficacy vary by performance domain and individual difference factors. In this meta-analysis (k = 61 studies of academic self-efficacy; N = 8,965), we employed B. J. Becker’s (2009) model-based approach to examine cumulative effects of the sources as a set and unique effects of each source, controlling for the others. Following Becker’s recommendations, we used available data to create a correlation matrix for the 4 sources and self-efficacy, then used these meta-analytically derived correlations to test our path model. We further examined moderation of these associations by subject area (STEM vs. non-STEM), grade, sex, and ethnicity. PA showed by far the strongest unique association with self-efficacy beliefs. Subject area was a significant moderator, with sources collectively predicting self-efficacy more strongly in non-STEM (k = 14) compared with STEM (k = 47) subjects (R2 = .37 and .22, respectively). Within studies of STEM subjects, grade level was a significant moderator of the coefficients in our path model, as were 2 continuous study characteristics (percent non-White and percent female). Practical implications of the findings and future research directions are discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

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