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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.
Critical consciousness moderates the relationship between transphobia and “bathroom bill” voting. - July 12, 2018
In recent years, antitransgender legislation that focuses on gender and the use of public restrooms—so-called bathroom bills—has been considered in many states in the United States. The present study was designed to extend research on transphobic attitudes and elucidate links between religious fundamentalism, social dominance orientation, transphobia, and voting for bathroom bills. Further, we examined the moderating influence of critical consciousness on the relationship between transphobic attitudes and voting on a hypothetical bathroom bill. Results of a moderated mediation multinomial logistic regression path analysis using data from a sample of 282 college students (154 women and 128 men) indicated that religious fundamentalism and social dominance orientation were associated with transphobic attitudes. Transphobia was associated with lower likelihood to vote against or abstain from voting on the bill, compared to voting for it. Critical consciousness was also associated with greater likelihood of voting against the bill rather than for it. The interaction between transphobia and critical consciousness was associated with voting against rather than for the bill, such that at higher levels of transphobia, those higher in critical consciousness were more likely to vote against the bill rather than for it. Implications for incorporating critical consciousness into advocacy efforts to promote transgender rights are discussed. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
Socialization and well-being in multiracial individuals: A moderated mediation model of racial ambiguity and identity. - July 12, 2018
Scholarly interest in racial socialization is growing, but researchers’ understanding of how and when racial socialization relates to well-being is underdeveloped, particularly for multiracial populations. The present study investigated moderated mediation models to understand whether the indirect relations of egalitarian socialization to subjective well-being and self-esteem through integrated multiracial identification were conditional on phenotypic racial ambiguity among 383 multiracial adults. Tests of moderated mediation in primary analyses were significant for subjective well-being and self-esteem. Consistent with the hypotheses, egalitarian socialization was linked to a stronger multiracial integrated identity, which was positively associated with subjective well-being and self-esteem for those with moderate and high phenotypic racial ambiguity. This indirect effect was not significant for those reporting low phenotypic racial ambiguity. Results suggested a positive role of egalitarian socialization in relation to integrated identity and well-being for multiracial adults. This study highlights a culturally relevant pathway through which egalitarian socialization impacts well-being through racial identification for multiracial adults and the conditions of phenotypic racial ambiguity that contextualize this indirect effect. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
Work as a calling: A theoretical model. - July 12, 2018
Perceiving work as a calling has been positioned as a key pathway to enhancing work-related well-being. However, no formal theory exists attempting to explain predictors and outcomes of living a calling at work. To address this important gap, this article introduces a theoretical, empirically testable model of work as a calling - the Work as Calling Theory (WCT) - that is suitable for the contemporary world of work. Drawing from research and theory in counseling, vocational, multicultural, and industrial-organizational psychology, as well as dozens of quantitative and qualitative studies on calling, the WCT is presented in three parts: (a) predictors of living a calling, (b) variables that moderate and mediate the relation of perceiving a calling to living a calling, and (c) positive (job satisfaction, job performance) and potentially negative (burnout, workaholism, exploitation) outcomes that result from living a calling. Finally, practical implications are suggested for counselors and managers, who respectively may seek to help clients and employees live a calling. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
When in doubt, sit quietly: A qualitative investigation of experienced therapists’ perceptions of self-disclosure. - July 12, 2018
Using consensual qualitative research (CQR), we analyzed 13 interviews of experienced psychotherapists about general intentions for therapist self-disclosure (TSD), experiences with successful TSDs, experiences with unsuccessful TSDs, and instances of unmanifested urges to disclose. For TSD generally (i.e., not about a specific instance), typical intentions were to facilitate exploration and build and maintain the therapeutic relationship. Therapists typically reported becoming more comfortable using TSD over time. In successful TSDs, the typical content was accurate, relevant similarities between therapist and client; typical consequences were positive. In unsuccessful TSDs, the typical antecedent was countertransference reactions; the typical intention was to provide support; typical content involved therapists mistakenly perceiving similarities with clients; and the general consequences were negative. In instances when therapists repressed the urge to disclose, the typical antecedent was countertransference and the content typically seemed relevant to the client’s issues. We conclude that effective use of TSD requires general attunement to the client’s dynamics, attunement to the client’s readiness in the moment, ability to manage countertransference, and ability to use a specific TSD appropriately. Implications for practice, training, and research are discussed. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
Self-compassion buffers the link between self-criticism and depression in trauma-exposed firefighters. - June 21, 2018
Firefighters are frequently exposed to highly stressful, potentially traumatic events (PTEs). More than 50%, however, show no significant elevation in trauma-related symptomatology (e.g., depression). In the past, self-compassion has been discussed to promote psychological and behavioral flexibility that is vital to a successful adaptation to PTEs. The goal of this study was to understand whether and how self-compassion may alleviate personal suffering in the face of PTEs. We hypothesized that individuals who encounter their profession-related affective experiences with greater self-compassion, show lower levels of depressive symptoms because self-compassion buffers processes that perpetuate negative affectivity in response to PTEs (i.e., self-critical tendencies). Male firefighters (N = 123) completed self-report questionnaires about the severity of current depressive symptoms; prior traumatic, duty-related events; and the self-compassion scale that assesses two distinct factors: self-criticism and self-compassion. A stepwise regression model was employed to examine differential and interactive contributions of self-criticism and self-compassion to symptoms of depression across the cumulative range of exposure to PTEs. Our results indicate that the positive association between self-criticism and depression is buffered by enhanced levels of self-compassion. This moderation, however, only emerged for firefighters with substantial amounts of PTEs experience in the past. The present work provides insight into protective effects of self-compassion in the face of cumulative PTEs. It suggests that, particularly for severely trauma-exposed firefighters, self-compassion may confer resilience, that is, act as a protective factor from the development of depressive symptoms. Findings are discussed in light of counseling implications. (PsycINFO Database Record (c) 2018 APA, all rights reserved)

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