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CAT, Metaphor and Pictures: An exploration of the views of CAT therapists into the use of metaphor and pictorial metaphor

Turner, J., 2011. CAT, Metaphor and Pictures: An exploration of the views of CAT therapists into the use of metaphor and pictorial metaphor. Reformulation, Summer, pp.37-41.

This article is the first of two papers looking at metaphor and picture metaphors in Cognitive Analytic Therapy (CAT). It introduces preliminary findings from the first part of a four cycle action research project. The four cycles (Fig 1) have been used to enable a greater understanding of metaphor in CAT as well as to study the use of metaphor and pictorial metaphor in practice. Cycle 1, which is the main focus for this paper, entailed a series of preliminary workshops at a range of CAT conferences during 2008 to 2010. Cycle 2 is a Delphi study of expert opinion from the CAT community into the understandings and consensus relating to the use of metaphor and pictorial metaphor in CAT. Delphi is increasingly being utilised within health and scientific disciplines (Keeney et al 2001, Kennedy 2004), and in counselling and psychotherapy (Williams and Haverkamp 2010). Delphi is a proven research method (Williams and Haverkamp 2010) which employs a series of iterative questionnaires to organise opinions of a sample of expert individuals, enabling a decision-making process to occur (Delbecq and Van de Ven 1971). Cycle 3 concerns the development of a training programme, its pilot and then delivery based on the results. Finally a proof of concept cycle, Cycle 4, in which a sample of CAT Therapists will be asked to utilise the pictorial metaphor approach in their practice and evaluate this using a small ‘n’ methodology.

Fig 1 – Action Research Cycles

Action Research Cycles

Undertaking psychological therapies research, in particular practice based evidence rather than evidence based practice, is seen as an important focus of health and related services research (Pettifer 2003). This four cycle study aims to do this by investigating the following hypotheses:

That focussing on metaphor and pictorial metaphor can be considered a positive therapeutic step for CAT Therapists (which is the focus of this article)
That a ‘toolkit’ can be developed from the three main data gathering exercises (workshops, literature review and Delphi) to inform a training programme and subsequent evaluation of the effectiveness of the ‘pictorial metaphor technique’ in clinical practice (I shall report on this at a later date).

As I have been thinking about this subject, I have made a point of having conversations with ‘leaders’ in psychotherapy and CAT - conversations that supported the direction of this proposed study, and that helped me think more widely about the issues. I recognise that CAT therapists come from cognitive, analytic, and other backgrounds, so not all therapists will feel comfortable with using pictures and other more ‘creative’ approaches. Recognising that not all CAT therapists will be comfortable with pictorial metaphors has had a big influence on the design of this study. I have been told on a number of occasions that some therapists find it difficult to introduce use creative approaches. I hope that this research will go some way to enable colleagues to use this approach should they wish to do so.

The use of metaphor in CAT

Tony Ryle has said that CAT is developing from its initial integration and differentiation, and could now be described as being in the process of elaboration. Innovative ways of using CAT with different groups are being developed and evaluated across the CAT community. My observations and practice could be seen as an elaboration of the CAT model using a specific approach - the use of a pictorial metaphor by the therapist - see fig 2).

Fig 2

The left side of this picture represents the client's initial state on the left (‘in a dark place’ with no colour and limited hope), whilst the right hand side shows her preferred place, where there is the metaphor of the ‘yellow brick road’, there is colour and she is outside, viewing the world and herself differently. In fact the right hand image became a reality as during therapy she cleared up and planted out her small garden with lots of colourful plants.

Metaphors, and indeed pictures, are present in CAT practice and literature. What is important to differentiate is the specific focus in this study on metaphor, then the drawing out of the client’s metaphor(s) into a picture by the therapist, in collaboration with the client, to create what is in effect another form of reformulation. I have been focussing on and thinking about the usefulness of metaphor and the client’s ‘metaphorical’ language, drawing out a ‘picture metaphor’ usually following the Reformulation, then developing this picture as therapy progresses. By this stage of therapy, clients are familiar with an already discussed pictorial form (the SDR), and if a ‘metaphorical picture’, this can then offer a new link to the SDR and to the TPP’s.

Metaphors are enmeshed with individual and also collective meaning (Angus 1996 and McMullen 1985 in Levit et al 2000, Abbatielo 2006). They have a long tradition in psychotherapy (Palmer 2006) and can be a guide in the consulting room. Although CAT and other psychotherapists have been aware of metaphor as an approach in therapy, and some focus on and use metaphor in their practice, there has been no systematic study of the development and effects of working with metaphor and pictorial metaphor in CAT. The literature in counselling and psychotherapy suggests a focus on case studies and speculation (Bayne and Thompson 2000) whilst recognising that ‘therapists in good outcome studies develop and carry forward metaphor phrases initially generated by their clients’ (Mio and Katz 1996). Levit et al (2000) found that, although little is known about how metaphors evolve over the course of therapy, clients in successful therapies develop a core metaphorical theme in relation to the main issues of therapy. However, little is known about the process entailed in generating and elaborating metaphor themes (Mio and Katz 1996).

Therapy itself has been described in metaphoric terms. For example, Kopp (1995) sees psychotherapy as a ‘pilgrimage involving the “guru” (or therapist) and client as “disciple”.’ I feel that CAT - as a collaborative therapy - lessens the “guru” effect of the therapist. Issues of power and metaphor have been helpfully explored recently by Kirkland (2010). Collaboratively developed metaphors seem much more useful, are found to be used extensively, and when expressed can facilitate insight, providing new solutions and enhancing communication and the working alliance (Angus 1996 and McMullen 1985 in Levit et al 2000).

Is it reasonable to suggest a case for pictures as metaphor? Strong (in Bayne and Thompson 2000) argues this is so, suggesting three possible responses for the therapist: explicating what is implicit in a client’s metaphor, therapeutically extending or modifying it, and the counsellor creating and delivering a ‘therapeutic metaphor’. The latter could apply to pictorial metaphors produced primarily by the therapist. A picture, like the prose Reformulation, may be “delivered” by the therapist, but is in fact co-constructed from the “raw material” offered by the client.

With this in mind the Preliminary Work (Cycle 1) was done at a series of workshops/focus groups across the CAT community in order to:

generate data in order to establish support (or lack of it) for the continuation of this research
seek initial ‘expert’ guidance regarding the use of metaphor in CAT
seek initial ‘expert’ guidance regarding the use of pictorial metaphor in CAT
consult regarding the study design.
Preliminary Workshop data (Cycle 1)

Preliminary data collection for this action research study was undertaken at four workshops during 2008 to 2010: two workshops at a CAT International conference, one at a National CAT Conference, and one at a regional CAT North (CATALYSE) Conference. This preliminary information has been important in formulating the overall study as the researcher was seeking guidance from CAT Therapists regarding the direction of travel for the study and generating an initial understanding of current perspectives.

Sampling strategy

Denzin (1970) comments that a researcher should ‘attempt to locate as many data sources as possible, thus increasing the probability that his/her theories will be fully tested.’ This preliminary ‘data’ can be seen to constitute and derive from ‘expert focus groups’ in the CAT community.

For Cycle 1 a sample, or subset of the target population (Parahoo 1997), consisted of the workshop participants. These were both heterogeneous and homogenous; they had a shared experience as CAT therapists, but were from differing backgrounds and locations. Therefore they may be said to represent an appropriate sample of the target population (Hek et al 2002). The sample technique was therefore a combination of an ‘opportunistic’ and a ‘purposive’ sample (Honigman 1994). Opportunistic because I used therapists attending CAT conferences and conversations with CAT therapists in other situations, purposive because the data needed to be collected from CAT and other psychotherapists. Overall, the views and comments of about 60 CAT therapists, representing about 8% of CAT trained Therapists, have been included either from workshops or individual dialogue.

Data Collection

Each workshop was considered to be both a subjective and objective experience. Recognising this is important because one cannot expect the same answers to emerge and replicate another’s as they ‘come out of different circumstances of production and reality’ (Holstein and Gubrium 1997). Interviews/focus groups are among the most widely used methods of investigation in the social sciences (Baker 1997) and are deeply and unavoidably implicated in creating meanings that ostensibly reside within respondents (Silverman 1993). Therefore data collection and analysis was in the form of a mixed qualitative and quantitative questionnaire.

Questionnaires were useful, as keeping to similar questions can help manage the data. However, it felt important to work within the collaborative nature of CAT and be ‘pushed where it moved,’ so to speak, in response to the wishes of the group. In doing this, data collection became richer, but more complex to capture. This change can be supported in methodological literature, as both Baker (1997) and Silverman (1993) observe. Baker (1997) notes that interviews move ‘from thought to language to themes’ and are understood to be an ‘interactional’ event.

Even if one tries to control an interview through a structure, active interviewing is ‘contamination everywhere’, but if interview responses are seen as products of interpretative practice, they are neither performed, nor ever pure. Any interview situation - no matter how formalised - relies upon the interaction between participants. As meaning construction is unavoidably collaborative (Garfinkel 1967), it is virtually impossible to free any interaction from factors that could be construed as contaminants (Holstein and Gubrium 1997). Nevertheless, reliability and validity are important because in them the objectivity of social research is at stake (Perakyla 1997). By using the same semi-structured questionnaire at the beginning of each workshop, some reliability of data generation was achieved but, as noted, because the workshops were fluid and responsive validity and reliability are reduced. However, the aim was to capture views rather than to research consensus at this stage, so this seemed an acceptable methodology.

Data analysis

Data measurement and assessment used both qualitative and quantitative techniques. Quantitative analysis was relatively straightforward. It involved a simple scoring system as part of the questionnaire utilised in each International workshop (n = 22 therapists), and a reflective exercise using the pictorial metaphor in role play at a National CAT workshop (n = 6 therapists). Some qualitative comments from the regional workshop are included in the analysis (n = 18).

Ethical issues were fully considered, and approval was obtained from the Clinical Governance group of ACAT. ACAT ethical principles (ACAT 1995 and 2010) have applied at all stages of the process. All results are anonymous, and confidentiality was guaranteed for all participants. Each workshop had clear ethical consent forms and information provided, and all responses were coded to ensure confidentiality. With hindsight, this should also have been made explicit in the Conference literature, as feedback from one workshop was that the ‘focus group’ aspect of the workshop had not been as clear beforehand as I had believed it to be.

Results, Analysis and Discussion

Exercise 1 – Collective words that associate with use of metaphors in practice

Participants were asked to generate a list of words that related to their thinking around metaphor and pictorial metaphor in CAT.

Table 1 -

There are a number of words that speak of the resonance and influence of metaphors in clinical work, the way metaphors illuminate problems and get under the story and as such become healing in the clinical encounter. I think that even the small list generated above is a start towards clarity on this area.

Question 1 - What has been your experience of metaphor in CAT?

86% of participants noticed metaphors in their work, with 72% often or always noticing/working with them. Qualitative comments were recorded as:

I do not use metaphor unless it comes from the client then I might adopt what they suggest
I like metaphors and find them very useful but at the same time I am sometimes concerned that my lack of expertise means that I am likely to impose them rather than develop them collaboratively
It feels like a fundamental part of finding a shared language
I am trained in a method that utilises metaphor – positive psychotherapy

Question 2- What types of metaphor do you use/work with in practice (n=21)

One of the participants did not score this question, hence n = 21. Nearly all of them regularly use and recognise word metaphors, with others utilising stories and some utilising pictures. This was encouraging, as the use of client-derived metaphors has been found to correlate with positive outcomes in psychotherapy. A small numbers of these workshop participants never used metaphor or stories, and about 25% did not use pictures. It may be that cycle 2 of this research project may shed light on why this is. Concerns expressed at the workshops were about technical competence in drawing and in capturing complex experience in a picture.

Question 3 - How useful is Metaphor in CAT?

Most participants felt that metaphor was useful or very useful. Comments included: ‘I feel metaphors can give us new ways to describe things/patterns’; their ‘Creative use can lead to expansion of understanding’; they can be ‘useful in facilitating “ah ha” moments’; the focus on metaphor could be ‘a “way in” that feels safer for the patient to tentatively find and tell own narrative’; metaphors can enhance a ‘client’s ability to become their own therapist and connect to the therapy’; and it was taken for granted that ‘metaphors emerge in the space between us’. I appreciate that participants at a workshop entitled ‘CAT and Metaphor’ might already be immersed in the topic but still this is a positive perception of the creativity present in CAT therapists.

Discussions on metaphor and pictorial metaphor

One of the issues raised was whether the drawing of the picture was to be ‘therapist-led or client-led.’ Where we got to was to recognise that the picture is developed collaboratively and in stages, and as such had a real sense of engagement in the here and now of therapy as well as engagement. By the end of the workshop, the consensus was that CAT therapists produce Reformulations and Diagrams based on what the clients bring, plus subsequent dialogue, so a similar process could result in therapists producing pictures for and with clients. This seemed a positive place to end up and one which could be enabling for therapists.

Another issue raised was that a ‘therapist-led drawing might lead to an enactment of client wanting to please the therapist’. I tend to think that, with clients where this sort of enactment is likely, it will also happen in relation to other CAT tools, and it needs to be noticed, named and worked with. The picture therefore can become another ‘gift’ of therapy, like the Reformulation and SDR.

A participant asked, ‘Is there some recognition of transference in the development of the picture?’ The answer is that often in the pictures the metaphor is representative of problem procedures, so transference may therefore be present. Siegelman (1990, p 99) observes that transference that the ‘therapist image is a valuable counter-transference tool’. The picture is whatever it needs to be, and can offer an enabler for clients to access their procedures and reformulation in a creative and imaginative way. One participant stated, ‘I feel metaphors can give us new ways to describe things/patterns’ and another said that their ‘creative use can lead to expansion of understanding’.

Finally, one comment related to the place of metaphor and pictures in CAT asking whether this is ‘a technique to call upon - not central to CAT’. This is certainly the case, as all therapists have a set of ‘tools’ in their ‘therapeutic toolbox’. Not all tools work for all problems, so it is important to have a range of tools. The pictorial metaphor is one such tool, to be used in appropriate cases, at the appropriate time, for the right reason and in the right way. Rubin notes that ‘imagery is one of the commonest tools used by [cognitive behavioural] therapists. Since the mental image is effective, the drawn image is a compelling addition to the array of CBT techniques’ (Rubin 2001, p 223). It seems to me to also apply to CAT practice.

Conclusion

The workshops delivered rich understandings into ‘CAT and metaphor’ and ‘metaphor and pictures’. It seems from these workshops – admittedly a small sample of self-selected therapists - that the use of metaphor is established within CAT practice. Using metaphors – including pictorial metaphors – was viewed as positive by these workshop participants. Hopefully this brief review, though far from perfect, will enable the reader to explore metaphor in more detail in their practice. I am indebted to the openness and energy generated by participants at the workshops, and I wish to convey my thanks for their warmth and generosity in giving of their time to help generate initial ideas for this study.

Corresponding author: James Turner james.turner@shu.ac.uk

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Full Reference

Turner, J., 2011. CAT, Metaphor and Pictures: An exploration of the views of CAT therapists into the use of metaphor and pictorial metaphor. Reformulation, Summer, pp.37-41.

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Comment on James Turnerâ€™s article on Verbal and Pictorial Metaphor in CAT
Hughes, R., 2011. Comment on James Turnerâ€™s article on Verbal and Pictorial Metaphor in CAT. Reformulation, Winter, pp.24-25.

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Turner, J., 2011. CAT, Metaphor and Pictures. Reformulation, Winter, pp.39-43.

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Lloyd, J., Ryle, A., Hepple, J. and Nehmad, A., 2011. Letter from the Editors. Reformulation, Winter, p.3.

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