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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.
The development and validation of the Contemporary Critical Consciousness Measure II. - August 30, 2018
Critical consciousness (CC) has been heralded as an antidote to oppression. Developed by the Brazilian educator, Paulo Freire, CC represents the process by which individuals gain awareness of societal inequities and subsequently take action to dismantle the systems and institutions that sustain them. Empirically supported instruments intended to assess this important construct have only been recently introduced to the literature and have focused specifically on racism, classism, and heterosexism. The purpose of this project was to develop a psychometrically sound measure of CC that expands assessment into sexism, cissexism (genderism/transphobia), and ableism. Two studies with a total of 569 observations provided initial reliability and validity evidence on the Contemporary Critical Consciousness Measure II (CCCMII). Results from exploratory and confirmatory factor analyses suggest that the final 37-item CCCMII provides a general index of CC as well as assesses CC associated with sexism and ableism above and beyond the general factor. Results support the internal consistency and factor structure of the measure. Expected relationships between the CCCMII and existing measures of sexism, cissexism, and ableism provide evidence for the validity of the instrument. Limitations, future directions for research, and counseling implications are discussed. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
Gendered Racism Scales for Asian American Men: Scale development and psychometric properties. - July 23, 2018
The Gendered Racism Scales for Asian American Men (GRSAM) was developed to assess the frequency and stress level of gendered racism perceived by Asian American men. The development of the new measure was grounded in the Intersectional Fusion Paradigm. This paradigm explains individuals’ experiences of discrimination based on unique combinations of multiple interlocking identities that individuals experience simultaneously. In mixed samples of college students and community adults, GRSAM’s factor structure as well as evidence of convergent validity, criterion-related validity, discriminant validity, incremental validity, internal consistency, and test–retest reliability was examined. Exploratory factor analyses revealed three dimensions of GRSAM: Psychological Emasculation, Perceived Undesirable Partner, and Perceived Lack of Leadership. Confirmatory factor analyses demonstrated that a bifactor model was a better fit to the data than a correlated three-factor model and a higher-order model. Results of correlation and regression analyses further provided evidence for different aspects of construct validity and internal consistency. Both the Frequency and Stress versions of GRSAM positively predicted psychological distress and somatic symptoms above and beyond the effects of general racism experienced by Asian Americans and masculine gender role stress. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
Gendered Racial Microaggressions Scale for Asian American Women: Development and initial validation. - July 30, 2018
Asian American women’s (AAW’s) mental health issues have received growing public attention; recent statistics suggest alarmingly high suicide rates among AAW. Yet, little research has examined the nuanced oppression that AAW face and the daily effects of compounded racism and sexism contributing to their mental health issues. Applying the intersectionality and microaggressions framework, we developed the Gendered Racial Microaggressions Scale for Asian American Women (GRMSAAW) using data collected from 564 AAW. Items were developed via literature review, focus group, and expert review. Exploratory (N = 304) and confirmatory (N = 260) factor analyses suggested a 4-factor structure and produced 22-item scales of frequency and stress appraisal with the following subscales: (a) Ascription of Submissiveness, (b) Assumption of Universal Appearance, (c) Asian Fetishism, and (d) Media Invalidation. Internal consistency estimates were .80 and above for frequency and stress appraisal scales, and the scales accounted for 52% and 60% of variance, respectively. Examination of a bifactor model containing one general factor and four group factors suggested that GRMSAAW could be represented unidimensionally (total scale score) for the purpose of applied measurement. Initial construct validity was established as GRMSAAW scores were associated with sexism, racial microaggressions, depressive symptoms, and internalized racism in ways consistent with theory. Implications for research and practice are discussed. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
Experiences of transmasculine spectrum people who report nonsuicidal self-injury: A qualitative investigation. - August 02, 2018
Transgender populations experience mental and physical health disparities compared to nontransgender populations, including nonsuicidal self-injury (NSSI). Guided by the minority stress theory and Nock’s model of NSSI, this study explored perspectives of transmasculine spectrum people (i.e., people with a gender identity that is man, male, transgender man, genderqueer, or nonbinary and who were assigned female at birth) who engage in NSSI. Qualitative interviews were conducted with transmasculine spectrum people (N = 18) who reported a history of NSSI. Their mean age was 24.9 years old (SD = 5.43, range = 17–38). Participants reported that NSSI was influenced by a variety of factors including stress from gender nonconformity in childhood and adolescence. Stigma related to minority status and identity as well as proximal minority stress processes of concealment and expectations of rejection were identified as contributing to NSSI. Transgender identity development tasks such as coming out and identity exploration also appeared to affect NSSI. Finding a community of peers who engage in NSSI was helpful in mitigating social isolation, but at times reinforced NSSI. We discuss clinical implications at the individual and family levels. Interventions to reduce NSSI among transmasculine-spectrum people should include facilitating connections with gender minority peers and providing individual support and family interventions to facilitate transgender identity development. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
The relative importance of parent–child dynamics and minority stress on the psychological adjustment of LGBs in China. - July 12, 2018
This cross-sectional study examined how minority stress (i.e., internalized homonegativity, self-concealment, and rejection sensitivity) and positive parent–child relationship dynamics (i.e., respect for parents and perceived parental support for sexual orientation) were associated with the psychological adjustment of lesbian, gay, and bisexual (LGB) individuals in China. Based on survey responses from 277 self-identified Chinese LGB young adults, results from structural equation modeling showed that minority stress was not a significant predictor of psychological maladjustment, whereas respect for parents and perceived parental support for sexual orientation were associated with positive psychological adjustment. Tests of gender differences partially confirmed whether Confucian traditions may burden sexual minority men more than women. Gender differences were found in the correlations between minority stress and each measure of positive parent–child relationship dynamics. However, the associations between independent variables and psychological maladjustment were not different between men and women in the sample. Our results suggest that culture-specific variables, such as parent–child factors within the context of China, may be especially important when working with LGB individuals in research and clinical practice. (PsycINFO Database Record (c) 2018 APA, all rights reserved)

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