Yesterday I wrote about David Clark's inspiring conference talk on "IAPT: achievements, lessons and the future".  The lecture was followed by a rather poor conference lunch - I had an image of us all dipping our heads into the brown paper bags of sandwiches we were given, like feedbags for horses.  A good conversation with neighbours over lunch, then wandering to a different building to get to the "Metaphors and stories in CBT" panel discussion with Richard Stott and Ann Hackmann.  Paul Blenkiron had been billed to contribute too, but apparently his wife had had a baby this morning - I hope they're doing well.  Richard Stott is one of five contributors to the "Oxford guide to metaphors in CBT: building cognitive bridges" published this year.  The description on the book's back cover states: "The business of cognitive therapy is to transform meanings. What better way to achieve this than through a metaphor? Metaphors straddle two different domains at once, providing a conceptual bridge from a problematic interpretation to a fresh new perspective that can cast one's experiences in a new light ... One such example is the 'broken leg' metaphor for depression. Clients with depression are understandably frustrated with their symptoms. They may often push themselves to get better or tell themselves that they should be better by now. As a therapist, it is fair to ask, would the client be so harsh and demanding on herself after getting a broken leg? A broken leg needs time to heal and you need to begin to walk on it gradually as it builds up in strength. "You can't run before you can walk", and if you try, you are likely to make it worse. For many clients this simple metaphor is enlightening, changing their view of their symptoms as a sign of their own laziness and worthlessness, to a view of them as part of an understandable illness that, while open to improvement, cannot get better over night. This book shows just how metaphors can be used productively in CBT as an integral part of the treatment ... ".  Richard kicked off the discussion with a short presentation.  He mentioned with approval Lakoff & Johnson's book "Metaphors we live by" with its argument that: "People use metaphors every time they speak. Some of those metaphors are literary - devices for making thoughts more vivid or entertaining. But most are much more basic than that - they're ‘metaphors we live by', metaphors we use without even realizing we're using them. In this book, George Lakoff and Mark Johnson suggest that these basic metaphors not only affect the way we communicate ideas, but actually structure our perceptions and understandings from the beginning ...".  So we use metaphors whether we choose to or not, and the metaphors profoundly affect how we experience ourselves and our lives.  Sounds like an important subject to look at!

Richard went on to make a series of thoughtful points - for example, the importance of checking understanding and "fit" of a metaphor with a client.  How useful it can be to discuss the metaphor with the client and possibly adapt it.  He talked about capitalizing on the mnemonic power of metaphor.  They certainly can be memorable.  I remember seeing a woman client in her thirties after a gap of twenty or so years - she had been to see me before as a teenager.  It seemed maybe the one thing she remembered about our work together was a metaphor I had shared with her about humans being like trees.  One doesn't typically criticise a tree for not being perfectly symmetrical.  In fact the glory of trees is partly because they're so amazingly individual in their growth and shapes. And different types of tree are so different.  A rowan tree isn't meant to become an oak, and a Scots pine shouldn't try to mimic a banana tree!  A metaphor can obviously be memorable.  It can also allow "distance", Richard Stott suggested, and there can be value in both "off-the-shelf" metaphors (for example, I sometimes say a compulsive response to an obsessive thought is a bit like an alcoholic reaching for another drink when they feel upset - maybe "relieving" in the short term but actually simply making the problem even more entrenched in the longer term), and in metaphors where the client has largely generated it themselves. 

Ann Hackmann gave the second talk and she further developed this theme of client-generated metaphors.  In fact she picked up the ball and ran right off the pitch with it!  Happily where she ran to was fascinating and, for me, helpful.  So she described a technique with clients that went something like: "Bring to mind a problem situation or symptom.  Notice the associated emotions and bodily sensations that come up.  Let a metaphorical image emerge.  Stay with it, even if it seems strange.  Explore the feelings and image.  Maybe look at it up close and from further away; look at it from different angles.  Maybe touch it.  What does it seem to mean about oneself, others, the world?  Notice any spontaneous changes that occur in the feelings and image."  Ann commented that sometimes working in this way allowed clients to approach their problems when previously maybe their emotions had felt overwhelming - that it could allow meaning to emerge where before there had been avoidance.  She talked too about the spontaneous changes that sometimes occur when such images/metaphors/felt-sense are simply held in awareness.  She quoted Carl Jung (brave at a CBT conference!) "When you concentrate on a mental picture, it begins to stir, the image becomes enriched by details, it moves and develops".  The quote actually goes on "Each time, naturally, you mistrust it and have the idea that you have just made it up, that it is merely you own invention. But you have to overcome that doubt, because it is not true".  Ann also mentioned with approval the wonderful story telling of Clarissa Pinkola Estes who wrote both the classic "Women who run with the wolves" and also many other works that can be a rich source of healing metaphors.  One of the many great quotes from "Women who run with the wolves" goes ''If you have never been called a defiant, incorrigible, impossible woman... have faith... there is yet time."  Good!  Thank you, Ann.   

In the question time I linked this work with Gendlin's Focusing and Ann agreed.  I have tended to follow the Emotion-Focused therapists in keeping focusing more for situations where there is a lack of clarity.  I can see though that using this kind of metaphor/image/felt-sense exploration with more clients could provide a potentially very helpful theme that we could build on during therapy.  Possibly this might be particularly useful for clients high in rumination and worry.  Teaching worriers to think more in imagery can reduce verbal worry and negative intrusions - see Stokes & Hirsch's paper  "Engaging in imagery versus verbal processing of worry: Impact on negative intrusions in high worriers".  In a somewhat similar way, Harvey and colleagues found that people suffering from insomnia experienced fewer images in the pre-sleep period than good sleepers - although the images they experienced tended to have a higher unpleasant-pleasant ratio.  In their paper "The differential functions of imagery and verbal thought in insomnia" they described the benefits of encouraging worriers to think more in images than verbal thought.  This overlaps into the expressive writing literature.  Expressive writing very much encourages dipping down into feelings rather than just staying up in one's head analysing.  Feelings and imagery are often entwined.  Relevant papers include Gortner et al's "Benefits of expressive writing in lowering rumination and depressive symptoms" and Sloan et al's "Expressive writing buffers against maladaptive rumination".  I find this a very interesting idea to follow.  For example, how would it be for people who are often distressed by worry and/or rumination to be helped to explore image/sensation/felt-sense of this state.  How would it be if, when they found themselves caught in worry/rumination loops, they deliberately shifted down into image/sensation/felt-sense in a way that they had already explored in therapy sessions - and that they had learned to be less frightened of, more compassionate towards, and possibly had developed ways of working with using further imagery, posture, and other changes.  This links with the bottom half of the diagram "Working with past & future images" that I illustrated in the blog on Emily Holmes's lecture a few days ago - with "over general memories" and "avoided negative futures".  Worth exploring.

Next month I'll write about "Manchester BABCP conference: agreeing & disagreeing with Jamie Pennebaker (sixth post)".