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malkomsen et al bmc psychiatry 2021 21 533 https doi org 10 1186 s12888 021 03551 1 research open access digging down or scratching the surface howpatients use metaphors to ...

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                Malkomsen et al. BMC Psychiatry          (2021) 21:533 
                https://doi.org/10.1186/s12888-021-03551-1
                 RESEARCH                                                                                                   Open Access
                Digging down or scratching the surface:
                howpatients use metaphors to describe
                their experiences of psychotherapy
                               1*                1,2             3             1,2             1           2,4                 5
                A. Malkomsen , J. I. Røssberg      , T. Dammen , T. Wilberg      , A. Løvgren , R. Ulberg     and J. Evensen
                 Abstract
                 Background: In the present study, we wanted to explore which metaphors patients suffering from major
                 depressive disorder (MDD) use to explain their experience of being in therapy and their improvement from
                 depression.
                 Methods: Patients with MDD (N=22) received either psychodynamic therapy (PDT) or cognitive behavioral therapy
                 (CBT). They were interviewed with semi-structured qualitative interviews after ending therapy. The transcripts were
                 analyzed using a method based on metaphor-led discourse analysis.
                 Results: Metaphors were organized into three different categories concerning the process of therapy, the
                 therapeutic relationship and of improvement from depression. Most frequent were the metaphorical concepts of
                 surface and depth, being open and closed, chemistry, tools, improvement as a journey from darkness to light and
                 depression as a disease or opponent.
                 Conclusions: Patient metaphors concerning the therapeutic experience may provide clinicians and researchers
                 valuable information about the process of therapy. Metaphors offer an opportunity for patients to communicate
                 nuances about their therapeutic experience that are difficult to express in literal language. However, if not
                 sufficiently explored and understood, metaphors may be misinterpreted and become a barrier for therapeutic
                 change.
                 Trial registration: Clinical Trial gov. Identifier: NCT03022071. Date of registration: 16/01/2017.
                 Keywords: Major depressive disorder, Cognitive behavioral therapy, Psychodynamic therapy, Metaphor
                Background                                                        of AIDS and cancer, and the damaging implications of
                “My point is that illness is not a metaphor, and that the         the conceptual metaphors she identified [1].
                most truthful way of regarding illness—and the healthi-             The linguists Lakoff and Johnson introduced the idea
                est way of being ill—is the one most purified of, most re-        of conceptual metaphors in their book Metaphors We
                sistant to, metaphoric thinking.” This statement is made          Live By [2]. According to the Conceptual Metaphor The-
                by Susan Sontag in her book Illness as Metaphor from              ory (CMT), the meaning we ascribe to abstract concepts
                1978, in which she examined the metaphorical language             depends not only on the knowledge we get from culture
                                                                                  and experience, but also on the way our abstract thought
                                                                                  is structured in terms of concrete metaphorical concepts
                * Correspondence: anders.malkomsen@gmail.com                      [3]. Since people suffering from mental illness are often
                1                                                                 wrestling with abstract, existential concepts, metaphors
                Division of Mental Health and Addiction, Oslo University Hospital, P.O. box
                4959, Nydalen, N-0424 Oslo, Norway                                may act as a bridge between the abstract and the
                Full list of author information is available at the end of the article
                                                 ©The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
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                   Malkomsen et al. BMC Psychiatry          (2021) 21:533                                                                                      Page 2 of 12
                   concrete. Stott et al. point out that emotion is a proto-                      did this by training 12 therapists to better attend to pa-
                   typical example of an abstract concept exceedingly diffi-                      tient metaphors and bring metaphors into case concep-
                   cult to express without using metaphors [4]. One                               tualizations, which resulted in a significant increase in
                   example of a concrete conceptual metaphor is anger.                            ratings of therapeutic collaboration, session satisfaction
                   Anger is often viewed as a hot fluid in a container inside                     (measured by Session Rating Scale) and a non-significant
                   our bodies, evidenced by expressions like “keeping a lid                       increase on the working alliance (measured by Working
                   on” or “boiling with rage” [4]. Metaphorical concepts                          Alliance Inventory). By testing patients’ and therapists’
                   shape the way we perceive the world by highlighting cer-                       preference of figurative language they found that work-
                   tain aspects and hiding others, in turn affecting how we                       ing metaphorically may be most effective when both the
                   interpret situations and ultimately how we behave [2].                         therapist and the patient enjoy speaking metaphorically.
                     The use of metaphors in therapy is a topic that has                            It is important to remember that not only patients use
                   been addressed in psychodynamic therapy, cognitive                             metaphors to describe therapeutic processes – re-
                   therapy, narrative therapy, trauma therapy and many                            searchers and therapists are no exception. For example,
                   other therapeutic approaches [5–9]. Coll-Florit et al.                         Tay has presented a way of using the conceptual meta-
                   present a summary of the main English language studies                         phor of “present is past” as an alternative model to inter-
                   that explore the most used conceptual metaphors de-                            pret and explain transference in psychotherapy – thus
                   scribing the experience of suffering from depression                           providing an alternative and complementary way to
                   [10]. They find that conceptual metaphors of darkness,                         understand how patients construct the relationship be-
                   burden, descent, bounded space, journey and enemy are                          tween the past and present and the way this plays out in
                   among the most common.                                                         therapy [17]. This shows the potential of metaphor ana-
                     Mathieson et al. have shown that metaphors are fre-                          lysis in the development of psychotherapeutic theory
                   quent in cognitive behavioral therapy (CBT), counting a                        and technique. Furthermore, Stiles & Shapiro has cri-
                   total frequency of 31,5 per 1000 words of cognitive ther-                      tiqued process-outcome psychotherapy research for im-
                   apy sessions [11]. This study, however, only measured                          plicitly subscribing to a drug metaphor; a conceptual
                   the frequency of metaphors, and did not explore how                            metaphor implying that therapy consists of active ingre-
                   metaphors were used by either patients or therapists.                          dients supplied by the therapist, with an integrity com-
                   Levitt et al. closely examined two patients’ use of the                        parable      to    the     chemical       purity     of    drugs      and
                   “burden metaphor” related to depression [12]. Results                          presupposing a passive patient [18].
                   indicated that in the successful course of therapy the                           Several qualitative meta-analyses have shown that a
                   metaphor of “being burdened” had been transformed to                           better understanding of the therapeutic process from
                   a metaphor of “unloading the burden” over the course of                        the patients’ perspective is important to increase the
                   therapy, which did not happen in the other, less success-                      effectiveness of therapy [19–21]. Metaphors are often
                   ful course of therapy.                                                         used to describe what is otherwise difficult to express.
                     Sarpavaara and Koski-Jännes examined the use of met-                         Kauschke et al. found that depressed patients are able
                   aphors in the first two sessions of a motivational inter-                      to understand and produce metaphors for internal
                   view of 21 patients suffering from substance abuse [13].                       states similar to non-depressed controls, contradicting
                   They found several conceptual metaphors, the most                              earlier    assumptions that patients with depression
                   common being “change is a journey”, used by 12 partici-                        show a concreteness bias [22]. Neuroscientific re-
                   pants, and patients who framed themselves in a positive                        search shows that metaphors, even idiomatic expres-
                   way within this metaphor had better treatment out-                             sions, engage us stronger on an emotional level than
                   comes than those with a negative framing of themselves.                        literal expressions, resulting in stronger activation of
                   Although they do not claim to prove a causal relation-                         brain structures associated with processing emotional
                   ship between the conceptual metaphor and treatment                             stimuli [23, 24]. These are in sum important argu-
                   outcome, they conclude that patients often use meta-                           ments for studying which metaphors depressed pa-
                   phors when talking about change and that these meta-                           tients use to explain their experience of being in
                   phors     seem to be important. That metaphorical                              therapy. This may bring a new and important per-
                   restructuring can be effective to reduce mental stress                         spective on how patients engage with and improve
                   was also found to be true in a micro-counseling scenario                       from psychotherapy. To the best of our knowledge,
                   by Hu et al. [14].                                                             no other previous researchers have done this.
                     Mathieson et al. has developed a metaphor workshop                             In this study, we aim to explore which metaphors 22
                   shown to improve therapists’ metaphor awareness and                            patients suffering from major depressive disorder receiv-
                   confidence [15]. This research group also examined                             ing either cognitive behavioral therapy (CBT) or psycho-
                   whether better attention to metaphoric language by CBT                         dynamic therapy (PDT) use to explain their experience.
                   therapists increased client ratings of alliance [16]. They                     Our research question was: Which metaphors do
                   Malkomsen et al. BMC Psychiatry          (2021) 21:533                                                                                      Page 3 of 12
                   patients use to explain their experience of being in ther-                     interviews did not focus specifically on metaphors,
                   apy and their improvement from depression?                                     meaning the interviews were not conducted in order to
                                                                                                  do an analysis of the metaphors used be the patients. Pa-
                   Methods                                                                        tients   where, however, given time to explore and
                   Design, ethics and data collection                                             verbalize their experience of the therapeutic process.
                   The present study took place at two public psychiatric                         Some examples of the questions asked were: How did
                   outpatient clinics in Oslo, in which patients suffering                        you experience being in therapy? What contributed to
                   from a wide range of mental illnesses are treated. These                       improvement in your therapy? Was there anything in
                   clinics are part of the specialist health care system and                      therapy that you experienced as not being helpful? How
                   require that patients are referred by a doctor, most often                     did therapy influence relationships and other important
                   a general practitioner. The study is part of the ongoing                       aspects of your life? Is there anything from therapy that
                   Norwegian project on Mechanism of Change in Psycho-                            you can use today or in the future? A research assistant
                   therapy (MOP) [25]. The aim of MOP is to examine                               transcribed the interviews and anonymized all the
                   moderators and mediators in CBT and PDT for patients                           transcriptions.
                   with MDD to develop a better understanding about what
                   works for whom and how. The participants were ran-                             Participants
                   domized to either CBT or PDT; the CBT consisted of 16                          A total of 22 participants were included in this qualita-
                   sessions and three monthly booster sessions, and the                           tive study, 15 females and seven males. Mean age at in-
                   PDT consisted of 28 sessions. Clinical assessments were                        clusion were 26years (range 22–48). The inclusion
                   conducted at baseline, during therapy, at the end of ther-                     criteria were fulfilling the criteria of MDD according to
                   apy and at follow-up investigations 1 and 3years after                         the DSM-IV (based on a clinical interview and MINI),
                   treatment termination. Inclusion and treatment in the                          age 18–65years, the ability to understand, write and
                   MOP-project is still ongoing, so outcome data for the                          speak a Scandinavian language, and willingness and abil-
                   participants are not yet available.                                            ity to give informed consent [26]. Exclusion criteria were
                     The Central Norway Regional Ethics Health Commit-                            current or past neurological illness, traumatic brain in-
                   tee (REC South East 2016/340) approved the MOP-                                jury, current alcohol and/or substance dependency dis-
                   study, including the qualitative interviews. Informed                          orders, psychotic disorders, bipolar disorder type 1,
                   consent was obtained from all participants.                                    developmental disorders, and mental retardation. The
                   The interview                                                                  level of depression was mean 24 (range 8–32) measured
                   All patients from the initial phase of the study were in-                      with the Hamilton depression rating scale, indicating a
                   vited to a qualitative in-depth interview after completing                     moderate level of depression [27]. A total of eight pa-
                   therapy. No selection criteria applied, and patients were                      tients were diagnosed with a personality disorder, ac-
                   invited to participate in the interview independent of                         cording to the Structured Clinical Interview for DSM-IV
                   sociodemographic factors, comorbid diagnosis or pro-                           Axis II [28]. Of the 22 interviewed participants, five
                   gress in therapy (factors that were all unknown to the                         dropped out of therapy due to dissatisfaction. The
                   interviewer). A few weeks after the end of therapy the                         remaining 17 participants completed the therapy.
                   second author conducted these interviews with a focus
                   on patients’ positive and negative experiences with treat-                     Therapists and treatment
                   ment, the therapeutic processes and therapeutic gains.                         The therapists, with the exception of one psychiatric
                   The interviews lasted 45 to 60min and took place at the                        nurse, were psychiatrists and psychologists. All thera-
                   outpatient      clinic    where the patients had received                      pists had a minimum of two years of training in CBT or
                   therapy.                                                                       PDT. In addition, they received one year of training on
                     The interviews were not designed to specifically ex-                         the principles of CBT or time-limited PDT before re-
                   plore the use of metaphors. In a few cases, the inter-                         ceiving patients for therapy. The principles of therapy in
                   viewer introduced a metaphor into the conversation.                            the CBT-group were based on the book Cognitive Ther-
                   These metaphors were excluded from the study. The                              apy of Depression by Aaron Beck et al. [29]. The therapy
                   interviewer aimed for an informal and supportive tone,                         in the PDT-group was based on the general psycho-
                   using semi-structured interviews and encouraging the                           dynamic principles as described in the book Long-term
                   participants to elaborate on themes of relevance. The pa-                      psychodynamic psychotherapy by Glen O. Gabbard [30].
                   tients were questioned about therapy in general, what                          Furthermore, the PDT-treatment was based on the
                   had been helpful and not helpful, how therapy affected                         short-term psychodynamic psychotherapy (STPP)-man-
                   their relationships and to what extent they could use                          ual    used      in   the     “First    Experimental         Study      of
                   something from therapy in their everyday life. The                             Transference-Interpretation” [31].
               Malkomsen et al. BMC Psychiatry          (2021) 21:533                                                              Page 4 of 12
                 Experienced clinicians monitored adherence to the              and A.M. have no specific therapeutic orientation. This
               treatment principles in both therapy groups in weekly            is made transparent in accordance with the checklist of
               group supervisions throughout the therapy period. Video          reporting qualitative research by Tong et al. [34].
               recordings from the therapy sessions were reviewed by
               the group with focus on the initial phase of treatment,          Results
               case formulation, individual treatment strategies and ter-       Our analysis resulted in the identification of several met-
               mination of therapy. Few other qualitative studies of this       aphors used by patients to make sense of their thera-
               kind run a similarly strict fidelity control.                    peutic experience. We organized the metaphors into
                                                                                three different categories concerning 1) the therapeutic
               Analysis                                                         process 2) the therapeutic relationship 3) the experience
               The object of our study was to explore which metaphors           of improvement from depression. All categories of meta-
               patients used to describe their experience of being in           phors are shown in Table 1.
               therapy and their improvement from depression. We an-              As suggested by Hill et al. we indicate the recurrence
               alyzed the transcripts using a method based on the               and representativeness of patients’ experiences by using
               metaphor-led discourse analysis presented by Cameron             the labels general, typical and variant [35]. When some-
               et al. [32]. We operationalized the analysis using a 4-step      thing is mentioned by all or all but one patient it is la-
               procedure, based on the method used by Mathieson                 beled as general, in the text referred to as all patients. A
               et al. [11].                                                     metaphor is considered typical when it is mentioned by
                 First, the first author read through all interviews to         more than half the cases, in the text referred to as most
               familiarize himself with the data. Second, the first and         patients. We use the expression some patients when the
               last author worked through the data looking for all pos-         metaphor is found to be a variant represented by less
               sible metaphors and collected them in a separate docu-           than half but more than two cases. The abbreviations
               ment. Third, each metaphor was analyzed to check if it           CBT and PDT will be used to specify which therapy the
               met the required criteria of metaphors. Our definition of        patient received. When, for example, the term “some pa-
               metaphor is “a figure of speech that implies a compari-          tients (PDT)” is used, this means less than half but more
               son between two unlike entities”–a broad definition              than two cases in the PDT-group. When no abbreviation
               that serves our purpose [4]. Lastly, the metaphors were          is used, it means that all patients in both groups are in-
               coded as metaphorical when there was a contrast or in-           cluded. All patient metaphors are written in italic.
               congruity between the meaning in the context and a
               more literal meaning [11, 33]. When all metaphors had            The therapeutic process
               been identified and collected by the first author, all au-       The patients conceptualized their experience of the
               thors read the collection of metaphors and gave feed-            therapeutic process in many different ways. The main
               back. Based on discussion of the material, we grouped            metaphors we discovered were: 1) metaphors of surface
               the metaphors into several categories. The authors have          and depth 2) metaphors of tools 3) metaphors of sorting
               different therapeutic orientations: J.E., T.D. and J.I.R. are    and organizing 4) metaphors of cleaning and emptying,
               CBT-therapists, T.W. and R.U. are PDT clinicians. A.L.           as presented in Table 1.
               Table 1 Conceptual metaphors used by patients to describe their experience of therapy and improvement from depression
               Category of Metaphors               Conceptual Metaphors        Examples of metaphors
               The therapeutic process             Surface and depth 2                     3
                                                                               Digging down , getting to the root, removing dental stones.
                                                       2                              2
                                                   Tools                       Get tools , build myself up.
                                                                      3                                                                      3
                                                   Sorting and organizing      Picking up pieces, finding a missing piece of the puzzle, untangle threads .
                                                                      3
                                                   Cleaning and emptying       Sweep the dirt, emptying the garbage, clean up, ventilate.
                                                           2                             3
               The therapeutic relationship        Openness                    Opening up , being closed.
                                                           3                                3
                                                   Chemistry                   Good chemistry .
                                                             3                                                         3
                                                   Temperature                 Cold relationship, cold therapist, warm therapist .
                                                         3                                    3
               Improvement from depression         Disease                     The disease talking , remove the megaphone.
                                                           3
                                                   Opponent                    Monsters inside me, a saboteur.
                                                                   3                            3
                                                   Stuck and loosened          Something loosened , being stuck, oiled the machinery.
                                                              3
                                                   Up and down                 Reduce the fall, raising the floor.
                                                                  2                          3
                                                   Darkness and light          Everything is dark , a spring morning.
               Metaphors used by all, most and some patients are numbered 1, 2 and 3 accordingly. If only one patient used the metaphor, there is no annotation
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...Malkomsen et al bmc psychiatry https doi org s research open access digging down or scratching the surface howpatients use metaphors to describe their experiences of psychotherapy a j i rossberg t dammen wilberg lovgren r ulberg and evensen abstract background in present study we wanted explore which patients suffering from major depressive disorder mdd explain experience being therapy improvement depression methods with n received either psychodynamic pdt cognitive behavioral cbt they were interviewed semi structured qualitative interviews after ending transcripts analyzed using method based on metaphor led discourse analysis results organized into three different categories concerning process therapeutic relationship most frequent metaphorical concepts depth closed chemistry tools as journey darkness light disease opponent conclusions patient may provide clinicians researchers valuable information about offer an opportunity for communicate nuances that are difficult express literal l...

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