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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.
Work and well-being in TGNC adults: The moderating effect of workplace protections. - September 13, 2018
The present study used a psychology of working theory (PWT) framework to test the direct and indirect relations of perceived social status and transgender and gender nonconforming (TGNC) marginalization (i.e., victimization, nonaffirmation of gender identity, negative expectations for the future) with work volition, overqualification, and vocational and emotional well-being outcomes (i.e., job satisfaction, meaningful work, satisfaction with life, depression) in a sample of 175 TGNC working adults. This study also tested the moderating effect of one form of structural marginalization (lack of legal protections from employment discrimination) on the overall pattern of results. Participants were recruited using online social media and discussion forums and completed the study survey online. For the full sample, perceived social status and nonaffirmation of gender identity were associated with vocational and emotional well-being outcomes through the mediating role of work volition, and for some paths, overqualification. Significant differences emerged in the overall pattern of results for those without protections, suggesting that protections from discrimination buffer the adverse links of some forms of TGNC marginalization with work volition and vocational outcomes. Implications of study findings for research, counseling, and advocacy are provided. (PsycINFO Database Record (c) 2019 APA, all rights reserved)
The development and psychometric evaluation of the Trans Discrimination Scale: TDS-21. - July 23, 2018
[Correction Notice: An Erratum for this article was reported in Vol 66(1) of Journal of Counseling Psychology (see record 2018-66276-001). In the article “The development and psychometric evaluation of the Trans Discrimination Scale: TDS-21” by Laurel B. Watson, Luke R. Allen, Mirella J. Flores, Christine Serpe, and Michelle Farrell (Journal of Counseling Psychology, 2018, Advance online publication. http://dx.doi.org/10 .1037/cou0000301), there were two errors in the Methods section of the article. In Study 1, Participants paragraph of The development and psychometric evaluation of the Trans Discrimination Scale: TDS-21 for the Methods section, the gender listed at birth was incorrect in the following sentence, The majority of participants in this study identified as trans women and along a trans feminine spectrum, were assigned male at birth, White, had attained some college but no degree, and were employed full time. The correct gender assigned at birth was predominantly female. In addition, the gender coding procedures was incorrectly described. Specifically, those who identified as FAAB and AFAB were actually coded as trans men or along a transmasculine spectrum, whereas those who identified as MAAB and AMAB were coded as trans women and along a trans feminine perspective. In Study 3, Participants paragraph of The development and psychometric evaluation of the Trans Discrimination Scale: TDS-21 for the Methods section, the gender identity listed in the following sentence was incorrect, The majority of participants identified as trans women and along the trans feminine spectrum, were assigned female at birth, White, had attained some college but no degree, and were students. Rather, participants primarily identified as non-binary trans.] To date, researchers assessing the role of discrimination in trans peoples’ lives have relied upon measures that were developed and normed on LGB populations, culled specific items from large-scale survey data, or used more generalized measures of discrimination that do not specifically assess the unique forms of discrimination that trans people may encounter. Thus, the purpose of this three-part study was to develop and provide psychometric support for a measure of trans peoples’ discrimination. In Study 1, a five-factor model emerged, which included: Microaggressions and Harassment, Restricted Career and Work Opportunities, Maltreatment in Health Care Settings, Harassment by Law Enforcement, and Bullying and Harassment in Educational Settings. Internal consistency estimates for subscale and total scale scores ranged from acceptable to excellent. Results from Study 2 revealed that a bifactor model provided the best fit to the data, revealing that the scale is essentially unidimensional. In addition, convergent and concurrent validity was supported, demonstrating significant positive correlations with another measure of trans discrimination, internalized transphobia, nondisclosure, negative expectations for the future, psychological distress, and perceived stress. In Study 3, results revealed excellent test–retest reliability up to a three-week period. Collectively, results suggested that the Transgender Discrimination Scale-21 (TDS-21) is a psychometrically sound measure that may be used to advance research on the role of discrimination in trans peoples’ lives. (PsycINFO Database Record (c) 2019 APA, all rights reserved)
“The Development and Psychometric Evaluation of the Trans Discrimination Scale: TDS-21”: Correction to Watson et al. (2018). - January 03, 2019
Reports an error in "The Development and Psychometric Evaluation of the Trans Discrimination Scale: TDS-21" by Laurel B. Watson, Luke R. Allen, Mirella J. Flores, Christine Serpe and Michelle Farrell (Journal of Counseling Psychology, Advanced Online Publication, Jul 23, 2018, np). In the article “The Development and Psychometric Evaluation of the Trans Discrimination Scale: TDS-21” by Laurel B. Watson, Luke R. Allen, Mirella J. Flores, Christine Serpe, and Michelle Farrell (Journal of Counseling Psychology, 2018, Advance online publication. http://dx.doi.org/10 .1037/cou0000301), there were two errors in the Methods section of the article. In Study 1, Participants paragraph of The Development and Psychometric Evaluation of the Trans Discrimination Scale: TDS-21 for the Methods section, the gender listed at birth was incorrect in the following sentence, The majority of participants in this study identified as trans women and along a trans feminine spectrum, were assigned male at birth, White, had attained some college but no degree, and were employed full time. The correct gender assigned at birth was predominantly female. In addition, the gender coding procedures was incorrectly described. Specifically, those who identified as FAAB and AFAB were actually coded as trans men or along a transmasculine spectrum, whereas those who identified as MAAB and AMAB were coded as trans women and along a trans feminine perspective. In Study 3, Participants paragraph of The Development and Psychometric Evaluation of the Trans Discrimination Scale: TDS-21 for the Methods section, the gender identity listed in the following sentence was incorrect, The majority of participants identified as trans women and along the trans feminine spectrum, were assigned female at birth, White, had attained some college but no degree, and were students. Rather, participants primarily identified as non-binary trans. (The following abstract of the original article appeared in record 2018-35350-001.) To date, researchers assessing the role of discrimination in trans peoples’ lives have relied upon measures that were developed and normed on LGB populations, culled specific items from large-scale survey data, or used more generalized measures of discrimination that do not specifically assess the unique forms of discrimination that trans people may encounter. Thus, the purpose of this three-part study was to develop and provide psychometric support for a measure of trans peoples’ discrimination. In Study 1, a five-factor model emerged, which included: Microaggressions and Harassment, Restricted Career and Work Opportunities, Maltreatment in Health Care Settings, Harassment by Law Enforcement, and Bullying and Harassment in Educational Settings. Internal consistency estimates for subscale and total scale scores ranged from acceptable to excellent. Results from Study 2 revealed that a bifactor model provided the best fit to the data, revealing that the scale is essentially unidimensional. In addition, convergent and concurrent validity was supported, demonstrating significant positive correlations with another measure of trans discrimination, internalized transphobia, nondisclosure, negative expectations for the future, psychological distress, and perceived stress. In Study 3, results revealed excellent test–retest reliability up to a three-week period. Collectively, results suggested that the Transgender Discrimination Scale-21 (TDS-21) is a psychometrically sound measure that may be used to advance research on the role of discrimination in trans peoples’ lives. (PsycINFO Database Record (c) 2019 APA, all rights reserved)
Testing intersectionality of race/ethnicity × gender in a social–cognitive career theory model with science identity. - October 04, 2018
Using social–cognitive career theory, we identified the experiential sources of learning that contribute to research self-efficacy beliefs, outcome expectations, and science identity for culturally diverse undergraduate students in science, technology, engineering, and math (i.e., STEM) majors. We examined group differences by race/ethnicity and gender to investigate potential cultural variations in a model to explain students’ research career intentions. Using a sample of 688 undergraduate students, we ran a series of path models testing the relationships between the experiential sources, research self-efficacy beliefs, outcome expectations, and science identity to research career intentions. Findings were largely consistent with our hypotheses in that research self-efficacy and outcome expectancies were directly and positively associated with research career intentions and the associations of the experiential sources to intentions were mediated via self-efficacy. Science identity contributed significant though modest variance to research career intentions indirectly via its positive association with outcome expectations. Science identity also partially mediated the efficacy-outcome expectancies path. The experiential sources of learning were associated in expected directions to research self-efficacy with 3 of the sources emerging as significantly correlated with science identity. An unexpected direct relationship from vicarious learning to intentions was observed. In testing for group differences by race/ethnicity and gender in subsamples of Black/African American and Latino/a students, we found that the hypothesized model incorporating science identity was supported, and most paths did not vary significantly across four Race/Ethnicity × Gender groups, except for 3 paths. Research and practice implications of the findings for supporting research career intentions of culturally diverse undergraduate students are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved)
Construction and validation of the Multicultural Orientation Inventory—Group Version. - July 12, 2018
Given the continued racial/ethnic diversification of the United States, it is not uncommon for therapy groups to consist of members with diverse racial/ethnic backgrounds and various cultural identities. Scholars have underscored how this cultural diversity can directly impact many processes and outcomes of group-based interventions (Chen, Kakkad, & Balzano, 2008). However, there is presently a paucity of empirical research testing the relationship between cultural processes of therapy groups and members’ outcomes. Moreover, no psychometrically sound measure of the cultural process that unfolds in group therapy currently exists. As such, this study sought to adapt the Multicultural Orientation Inventory to develop and validate the Multicultural Orientation Inventory—Group Version (MCO-G), a measure assessing the cultural humility, cultural comfort, and cultural missed opportunities in therapy groups. Data for this validation study consisted of 208 members of 49 therapy groups across 10 university counseling centers. Confirmatory factor analyses supported a 3-factor structure of the MCO-G Inventory, wherein the 3 factors corresponded with the underlying constructs of cultural humility, cultural comfort, and cultural missed opportunities. This study provides initial evidence for the estimated internal and convergent validity of the MCO-G, as measured by clients’ perceptions of a higher-order group therapeutic factor and improvement in therapy. Results provide initial support for the psychometric properties of the MCO-G. Moreover, groups’ cultural humility and cultural missed opportunities were related to members’ improvement in therapy. Clinical implications and future research are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved)

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