This study aimed to explore which metaphors patients use to describe their experience of therapy and their improvement from depression. Our results show that patients use many different metaphors, but that there are some conceptual metaphors that are used by most patients. We will now discuss these metaphors individually.
4.1 Surface and depth: what patients need to explore in therapy
In an article about the metaphor of depth and the ways in which it can mislead, Wachtel makes the point that we are sometimes taken prisoners by our therapeutic metaphors (36). The metaphor of surface and depth may be considered a conceptual metaphor. This metaphor has become so common and compelling that one may tend to forget that it is a metaphor, and thereby forget that there can be alternative ways of conceptualizing therapy.
We find that most patients believe it is important to go deep in therapy. At the same time, there seems to be less consensus on what it really means to go deep. While some patients think that depth equals painful emotions, others believe you go deep by talking about past experiences or by exploring unconscious processes.
It seems that many patients believe that the exploration of present issues in CBT is “shallow”, and that they only scratch the surface of their problems in therapy – even though they improve. Many patients were dissatisfied because they felt they hadn’t dug deep enough into the depth of their psyche. Our impression is supported by a qualitative comparison of CBT and PDT by Nilsson et al. (37). They found that the statement “getting to the root of things” was used by 73 % of the satisfied PDT-patients, while none of the satisfied CBT patients used this metaphor. The same was pointed out by De Smet et al. in a qualitative analysis of depressed patients receiving CBT and PDT, where they found that many patients think that CBT is too superficial (38). This is a critique of CBT that we believe is of great clinical importance, especially because it may be avoided by exploring the patient’s metaphorical understanding of therapy.
It seems vital to step into the patient’s conceptual metaphors of therapy to understand what surface and depth means to the patient. What does the patient mean when she says that the therapy is not deep enough? Does the patient think that something important has been avoided, or overlooked? Has the emphasis on present issues, which is a crucial part of CBT, been conceptualized as “scratching the surface” by the patient? Or has the therapy been too cognitive and with too little emphasis on painful emotions? These are just some interpretations based on our results. This is important because even though the therapy is effective, our results indicate that many patients are still not satisfied if their wish to “go deep” has not been sufficiently met. Therapists may take time to explain the theoretical rationale and the conceptual metaphors behind their therapeutic approach when starting therapy, or whenever needed. It may also help therapists to broaden their horizon by studying alternative metaphors. Some alternative metaphors, like horizontal depth instead of vertical depth, or going from depth to breadth, are discussed in an article by Wachtel (36).
4.2 Tools: what patients need to improve
We identified that patients in both groups had the same expectation of therapy and used the same metaphor describing it: to get a mental tool to solve their problems. This may or may not be possible and feasible, depending on the definition of a “tool”. It seems to us that many patients are unsure of what really constitutes a mental tool; all they know is that they want one. We think it may be important that the therapist engages in this metaphor in the same way as mentioned above. Does the patient want gardening tools to clean her mental weeds and fertilize the soil of her soul? A mental wrench or screwdriver to tighten or loosen parts of her mind? A cerebral knife to cut some of her thoughts out of her mind? Or does she dream of a psychological multitool that does all of the above?
In two previous articles on the same patient material we found that both patients who had received CBT and PDT wanted tools to help them out of the depression (39, 40). By exploring the metaphor of tools more closely when it is used by the patient, the therapist may get a better understanding of what the patient actually needs. In addition, by being asked to elaborate the metaphor, the patient may increase her own understanding of what she is actually seeking in therapy when she is asking for a tool. If the therapist manages to explore this metaphor with the patient and re-imagine her metaphorical concept of a tool so that it fits with the therapy, we think the patient satisfaction will increase.
4.3 Openness, chemistry and temperature: what patients need from the therapist
Openness, chemistry and warmth seem to be the most important metaphors concerning the therapeutic relationship. It may not be obvious at first that these terms are in fact metaphors because they may represent what are often labeled as “dead metaphors”. Dead metaphors are particular words or phrases that have become linguistically attached to a particular meaning (4). They may be dead, but this does not mean they should go unrecognized. As suggested by Witztum & van der Hart, dead metaphors may be brought back to life and become excellent points of departure for therapy (41).
As an example, imagine that the patient says to the therapist that she is struggling to “open up” in therapy. How can the therapist unwrap and re-awaken this metaphor? To unwrap its literal meaning, the therapist may ask questions about what this metaphor really means to the patient: it may mean she is holding back particular parts of her story; it may mean that she is not being honest about what she is feeling; or it may mean that she is not showing her true feelings. To re-awaken the metaphor, the therapist may need to use the same metaphorical concept and try to make sense of how this metaphor of openness affects the patient. Does it feel vulnerable to be open because she associates openness with an open door – where a burglar may sneak in – or does openness make her afraid like the open door of a lion’s cage or the way an open door of the freezer will make the ice melt and destroy the food inside? The point of “stepping into” the patient’s own metaphor in this matter is ultimately to build a cognitive bridge and to change the way the patient thinks and feels within the metaphoric realm (4). Working with metaphors may make it easier for therapists to understand the patient’s experience (of existing, being depressed, being in therapy). In turn, this may give the therapist a better understanding of what the patient needs, creating more empathy and strengthening the working alliance. The importance of a discovery-oriented, collaborative style of metaphorical elaboration is shown in a study by Angus and Rennie (42). In an in-depth analysis of four dyads they found that a mutually shared understanding of metaphors was important to avoid misunderstandings. They found that a shared understanding could be achieved by attentive listening strategies that encouraged patients to present their particular associations to a metaphor.
Most patients value openness in therapy, but it seems that many patients find openness in the therapeutic setting to be difficult, especially if they feel a lack of chemistry with the therapist. Landau et al. studied the fear of exposing oneself by exploring the common conceptual metaphor of a “true self” as a physical entity that must be protected from external threats (43). While they do not discuss openness specifically, it would make sense that being open will expose this “true self” to danger, which may partly explain the patients’ reluctance.
Some patients in our material used yet another metaphorical concept to explain why they hesitated to open up: the temperature of the therapist. One patient said he did not feel any warmth from the therapist and suggested it would have helped if the therapist had offered him a cup of coffee. Interestingly, Williams and Bargh have found that experiencing physical warmth – e.g. by holding a warm cup of coffee – promotes interpersonal warmth (44).
4.4 Improving from depression: darkness and light
We find that our patients use the same conceptual metaphors that are found by other researchers in other countries (10). This supports the idea that conceptual metaphors can cross barriers of culture and language. For example, the conceptual metaphor of light and darkness as a way of experiencing depression is not unique for our patients – it is part of our culture. A metaphorical analysis by Forceville of nine short, wordless animation movies concluded that the films featured two dominant metaphors: depression as dark monster and depression as a dark confining space (45). The metaphors of darkness and light are also found by El Refaie in two graphic memoirs, and Schoeneman et al. show that this conceptual metaphor of depression as a struggle in darkness is by no means new, as it is also found – for example – in the The book of Job (46, 47).
While the connection between depression and darkness seem to be manifest in western culture, one could wonder whether the connection between depression and darkness is universal. Interestingly, the same metaphors of depression as darkness and being confined in a dark space was also found to be dominating in the Iranian society (48). In a study by Schwartz et al. they found that people who prefer darkness to light are more prone to negative emotional experiences and symptoms (49). It also seems that darkness and light actually have a biological influence on depression, although the mechanisms are still largely unknown (50, 51).
Conceptualizing depression as being confined in a tight space, way down, alone in a void-like darkness has the potential to enhance the patient’s feeling of being isolated, abandoned and exposed to horror. Exploring such metaphors may however clarify, expand and validate the patient’s experience. It may capture the patient’s current feelings, but it may need to be counterbalanced by the therapist’s metaphors – perhaps metaphors of expansion, elevation and light.
4.5 Improving from depression: depression as opponent or disease
A few patients seemed to think and feel their depression had its own unique character that somehow had occupied their body and/or mind. Some even said that the depression had its own voice that they could argue with or force to silence. The metaphorical concept of the depression as an opponent and a disease is not a new one, and has gained popularity over the years, as found by a multinational Latin American study by Reali et al. (52). Susan Sontag emphasized the negative effects of looking at a disease as an opponent in her book, a point that has later been followed up by others later (1, 4, 53). Heide calls the opponent-metaphor “the agonistic metaphor” and points out that while the metaphor may motivate patients to “fight their depression”, it also has several potential negative consequences, like making the patient more hostile to herself and her own thoughts and feeling. It has also been shown that trying to suppress and remove thoughts and feelings, as one would try to do in a battle, often is counterproductive (53). Whether a biogenetic disease-framing of depression is helpful is an empirical question, and in a quantitative synthesis by Kvaale et al. they found that biogenetic explanations for mental disorders are negatively associated with blame, but positively associated with perceived dangerousness (for schizophrenia) and with desire for distance (54). Reali et al. found that people who conceptualized depression as a place-in-space (e.g. “a dark place”) favored social-related causal explanations, while the opposite was true when depression was framed as a disease, indicating that metaphorical framing of depression as a disease may also affect the way patients look for solutions (52).
When patients frame their depression as a disease, and this framing make them believe that nothing can be done except using medication, it may be wise to explore what kind of physical disease might be the best analogy for their depression (4). If a patient views her depression as a viral infection – comparable to the flu – it may be tempting to stay in bed and wait for it to pass, an approach seldom effective in the treatment of depression. Rather, if viewed as a systemic disease of multifactorial etiology – comparable to type 2 diabetes – the analogy might stimulate exercise, a healthy diet and an active life – in addition to the use of medication.
Another challenge when dealing with patients who are using medication as well as receiving psychotherapy is that this combination may send out a mixed message. The use of medication sends out the message that this is a physical disease, requiring pharmacological treatment. At the same time, the therapist communicates that the problem is psychological by offering psychotherapy. Combining medication and psychotherapy is shown to be more effective than pharmacotherapy alone (55), so this mixed message should not stop therapists from suggesting this combination. Stott et al. provide therapists with a possible solution to the problem in the form of a metaphor: medication as training wheels (4). Using this metaphor, medication may help to reduce symptoms and thereby make it easier for patients to engage in therapy. Nonetheless, it is impossible to learn how to ride a bike simply by attaching training wheels. The aim of psychotherapy might be to learn the patient how to ride – or live – so that they may be less reliant on training wheels – or medication – in the future.
4.7 Strengths and limitations
Interviews were performed without questioning the patients specifically about their use of metaphors, as we did not plan to investigate the use of metaphors at the time interviews were conducted. The idea for this article came later, when we recognized the patients’ extensive use of metaphors during the interviews and the importance of what was being said through their use of metaphors. As the interview was not specifically designed to explore metaphors, a few common metaphors were introduced by the interviewer during the interview. These metaphors have been excluded from the analyzed material. As these occurred in small numbers and were of a common nature, their exclusion should not impact the results. The fact that the interviewer did not focus on metaphors gives us a great opportunity to analyze the use of metaphors in a “natural” conversation.
This study was not designed to differentiate the use of metaphors between patients who got PDT and CBT. We can therefore only speculate on how the two groups differ. Interestingly, we cannot find any major differences between the two groups concerning which metaphors they use to describe their therapy or improvement. Neither did we find clear differences between the groups in the way they interpret and use these metaphors. There is not much research on how the therapists in CBT and PDT differ regarding their use of metaphors. Thus, it is difficult to say how the therapeutic approach impacts the patients’ conceptual metaphors. Further research is needed to answer this question.
None of the authors have any formal linguistic training. To increase reliability, the first and last author read the transcripts independently and agreed on the identification of metaphors. We believe this method served our purpose for this article. It is a considerable strength for the analysis that the authors have such varied therapeutic orientations, as this decreases the risk of bias.
Obviously, these results do not apply directly to other patients. We suspect that additional caution of generalization is advised when studying metaphors. Nonetheless, as we read the current research, we are struck by the metaphorical similarities across different cultures and languages.