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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
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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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