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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.

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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.
The scientific future of counseling psychology: Five specific areas of predictions. - June 29, 2017
To honor the 125th anniversary of the American Psychological Association, the scientific future of counseling psychology is highlighted in this special section. Five areas of research growth are covered: three in psychotherapy (research relative to sexual and gender minorities, the importance of the client perspective, and applications of machine learning), one in the application of the cultural lens approach, and one on aspects of privilege. Each of these areas has specific, testable hypotheses that can serve as stimuli for future research. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
White male power and privilege: The relationship between White supremacy and social class. - June 29, 2017
Counseling psychologists have studied privilege as an individual behavior, belief, and attitude related to an individual’s privileged identity such as masculinity, Whiteness, or Christianity. Conceptualizing individual privileged identities in this way means that privileged identities may exist alongside marginalized intersectional identities. However, in this article, the author defines privilege as a multi-identity act that is facilitated and supported by institutions and organizations (e.g., banks, law enforcement, and schools). These institutions are defined as power-governors that regulate access to scaffolds of privilege afforded to the affluent and wealthy. The author posits that power-governors were created to support an ideology of White supremacy and to organize actors within the system to perpetuate and legitimize the status quo. The author describes the ways in which White wealthy men use privilege as a means to access and gain power while White men in lower- and working-classes use privilege to build relationships and legitimize inequality. The author also discusses the proxy privilege of White women and people of color and how this privilege is in fact restricted to specific physical spaces and is limited due to their overt marginalized identities. Recommendations for privilege research are provided. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
The future of counseling psychology research viewed through the cultural lens approach. - June 29, 2017
In this article, we address the need for the future of counseling psychology research to adequately address issues of relevance and application of our theories across cultural groups. We bring the cultural lens approach (CLA; Hardin, Robitschek, Flores, Navarro, & Ashton, 2014) home to its roots in counseling psychology and address the approach’s application specifically within counseling psychology theory. First we provide a brief description of the CLA. Then we offer an in-depth example of how to apply the CLA to a specific theory, using Super’s (1953, 1957) Life-Span, Life-Space Theory of Career Development, and more specifically, the self-concept as an example. Importantly, we articulate how the CLA yields specific, testable hypotheses, providing multiple examples. We conclude with implications of the CLA for implementation of counseling psychology values, evaluating psychological theory, and research training. Adopting the CLA in future counseling psychology research will increase the cultural sensitivity of our work and widen the relevance and applicability of our findings. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Client-focused psychotherapy research. - June 29, 2017
Although the field of professional psychology has definitive evidence that therapy is effective, we do not yet have a good understanding of how therapy works or what makes it so effective. Although hundreds of research studies have been conducted on various aspects of psychotherapy, including client factors and outcome, in the current paper we argue that a key component of the psychotherapy enterprise that warrants additional empirical attention is the client. We readily acknowledge the need for researchers to continue to examine other aspects of psychotherapy, such as therapist factors, the therapy relationship, and the effectiveness of certain therapies or interventions for specific psychological conditions and problems. However, we believe that by pursuing research questions from the perspective of the client that we might be able to better understand clients’ experience in therapy and ways to tailor therapies and interventions to clients, uncover evidence about what actually engages and motivates the client, and gain a broader perspective about the nature of the therapy relationship. In the current paper we highlight fruitful areas for client-focused research, and within each area, we propose research questions that might stimulate further thinking and future empirical inquiries. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Improving the lives of sexual and gender minorities: The promise of psychotherapy research. - June 29, 2017
Current psychotherapy research with sexual and gender minorities (SGMs) is inadequate to address the health disparities in this population. Psychotherapy can benefit from research demonstrating the unique experiences of SGMs with respect to behavioral health, internalized stigma, coping, and resilience. This article describes research approaches, questions, and measurement that can be employed to study psychotherapy. Given the impact of minority stress and microaggressions on SGM individuals, many of the recommendations provided in this article focus on how these components should be infused throughout a diverse range of psychotherapy interventions. Namely, we provide recommendations for researchers focusing on SGM populations in randomized controlled trials and psychotherapy process research. We also provide 7 specific recommendations that focus on psychotherapy research measurement with SGM populations and how researchers can focus their efforts to reduce disparities for SGM individuals. Finally, we identify additional constructs to consider for future intervention research with SGM individuals. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

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