Metaphor in Cognitive Behaviour Therapy

Metaphors are common in psychotherapy. Over the last decade, there has been increasing interest in the use of metaphor in cognitive behaviour therapy (CBT), with attention to client metaphors being asserted as a way of CBT. However, to date there has been very little research on the use of metaphor in CBT sessions, and no studies which have examined how to train therapists in this skill. Empirical study of metaphors in cognitive behaviour therapy has tended to be put in the ‘too hard basket’, confined to being part of the art rather than the science of therapy. The lack of research is largely due to problems with definition, lack of a consistent, reliable approach to metaphor identification and the challenges of finding appropriate methodology to study this language-based activity. This thesis will describe four studies exploring metaphor use in CBT. The first study used the discourse dynamics approach to assess the frequency of metaphors in CBT in a large sample of therapy sessions and to evaluate the reliability and utility of the discourse dynamics approach. The second study explored metaphor co-construction in early therapy sessions. It looked at what responses therapists and clients make to each other’s metaphors during bursts of metaphoric exchange and whether these were initiated by the therapist or the client. An iterative process led to the identification of a range of therapist and client responses to each other’s metaphors, and identification of whether therapists or clients initiated metaphoric exchanges. The third study explored the effect on therapy alliance of training CBT therapists to intentionally bring client metaphors into case conceptualisations, using video-recorded pre and post-training role played therapy sessions. Significant increases were found in some ratings of alliance, based on role play ‘client’ ratings and external ratings of role plays of therapy sessions before and after training. This study also explored whether working metaphorically suited some therapists and clients better than others. Correlations between ratings of preference for metaphoric language and alliance ratings suggested that working metaphorically may be most effective when the therapist and client have a similar degree of preference for speaking metaphorically. The fourth study describes the metaphor training provided and explores therapist ratings of the content and delivery of the workshops and the impact of the training provided, based on self-report ratings and reflections on their ongoing application of learning over a three-month period. These were compared to pre-training ratings. Therapists rated the workshops positively. They also reported significantly increased awareness of metaphors; increased confidence in responding intentionally to client metaphors and bringing them into shared conceptualisations; significant increases in reported time spent elaborating on client metaphors, and significantly increased use of metaphors when conceptualising with clients. Barriers and solutions to application of learning were identified