Blinders and dark glasses – metaphors to educate clients about depression

An important objective of psycho-education in the first CBT session with clients is helping them begin to understand that, due to their illness, their minds automatically process their experiences (both external and internal) in a distorted way. We want them to begin to distance themselves from their inaccurate, depressive thoughts, seeing them as ‘ideas’, not necessarily truths (as a prelude to evaluating their cognitions and/or refocusing their attention elsewhere).

Two metaphors can be particularly useful: ‘black glasses’ and ‘blinders’ (or ‘blinkers’) that are put on a horse to limit its range of vision.

I explain to clients that when people are depressed, it is as if they are wearing glasses whose lenses are covered with black paint. The information they receive from their environment passes through these lenses. So they tend to view their experiences in a very dark, negative way. It is not their fault; in fact, they probably do not even realize that they have glasses on. I then explain, in metaphorical terms, one part of the treatment plan. Together we will evaluate their thinking, scraping off the dark paint on their lenses, so they can see reality more clearly. Doing this helps them feel better. Then I ask them for feedback about this concept.

Later, when clients express unrealistically distorted interpretations about their internal experiences (physiological or mental or emotional sensations), I extend the metaphor. It is as if they have internal black glasses, too, which influence the way they think about feeling tired, sad, lonely, mentally slowed down, apathetic, distant from others, in pain, and so on.

I use another metaphor in the first session as well. Holding my hands up on either side of my eyes, I explain, ‘When people are depressed, it's also as if they're wearing blinders, like you might see on a horse that is pulling a carriage. All it can see is what is straight ahead. Depression leads people to see only what is straight ahead of them, too – all of which seems negative and distressing.’ I tell them that we will take off the blinders, so they can see all of the information that's out there, all of reality, not just the negative.’

Again, I ask the client for feedback. If these metaphors are meaningful to the client, I will ask him/her to summarize the messages in writing, to refer to throughout the day. One client, for example, drew a rough sketch of dark glasses and blinders and wrote: ‘Because I'm depressed, everything looks black. But I'll learn to see reality more clearly, and when I do, I'll feel better.’

JUDITH BECK

The burdened camel – a metaphor for stress

A simple but useful metaphor that I often share with clients involves the idea of a camel with a huge pack of straw on its back. As I describe it, the camel's load really is unbearably heavy and the poor animal is close to breaking down (or breaking its back, or being brought to its knees).

I use this metaphor when it has become clear that there is a lot going on in the person's life and that it is all getting to be too much. In this situation, to use alternative metaphors – ‘they have a lot on their plate’ and ‘it's all getting on top of them’. Using the camel metaphor shows that I have a grasp of this aspect of the client's situation and also that I feel compassion towards ‘the camel's predicament’. There is also an acknowledgement that things are critical and that something needs to be done fairly urgently.

It is clear that what is needed is to reduce the load. This does not mean that all of the straw needs to be removed, but it does mean that some straw needs to be removed quickly in order for the load to be bearable and for the threat of collapse to be removed.

This suggests that there may be many alternative ways of achieving the necessary change and that a thoughtful consideration of the situation may generate useful ideas. Would it be best to tackle the anger issue first, for example, or to focus on the underlying tension in the relationship, or on certain childhood experiences? Together, therapist and client may identify various bundles of straw that are contributing to the overall load and consider which issues would best be addressed. The idea is that addressing any key issue effectively will have a holistic beneficial effect, reducing the overall burden or pressure.

This model suggests that in helping people with complex problems the issue of which aspects to work with, and in which order, can be addressed strategically with an appreciation of the overall benefits likely to come from any specific focus. It is clear that therapy is not a matter of identifying and removing a specific bundle of straw. The situation (in those cases for which this metaphor best applies) is not akin to a lock that can only be opened with a specific key.

The issue is thus one of strategic choice of the problem to be addressed (or the order in which to address a number of problem issues). Some bundles of straw are clearly more accessible than others; some will be relatively easy to shift, others not. And whereas some are relatively independent of others, some are linked in such a way that the overall impact of removal might make the structure unstable, for example by making the load unbalanced). Removing some lower level bundles (‘the low-hanging fruit’) may increase the accessibility of bundles of straw that were initially at a higher level and beyond reach.

The burdened camel metaphor is not universally applicable, but in many cases it can provide a useful tool for therapist and client to think together in a creative way about how the camel can lose some of its burden and thus become more comfortable, more mobile and less vulnerable to collapse.

NEIL FRUDE

Rowing upstream – a metaphor for eating disorders

Young people with anorexia nervosa often describe vividly in metaphorical language what it is like to experience an eating disorder. They may talk about the gremlin on their shoulder telling them what to do, the experience of being in a cage or a deep pit, or the arduous task of climbing the mountain of recovery.

One of my favourite metaphors in working with a young person with anorexia nervosa is the simple concept of rowing upstream against a strong current. This acknowledges the great difficulty young people have in making progress even when they are trying hard. It also helps parents to understand that it is no easy task recovering from an eating disorder. There is always a strong force keeping the young person back. The metaphor works well in situations when the young person wants to stop gaining weight and have a break in treatment. If you stop rowing when your boat is facing upstream you get carried back again by the current until you reach the place where you started. In the same way, if you take a break in the treatment for an eating disorder you can easily slip back into old habits and lose the new strategies that you have begun to develop. It is hard work keeping on going but this is the only way to recover from anorexia.

In working with the young person, the metaphor can be elaborated to describe how there may be people on the bank who are willing to give a hand pushing the boat when the current is strong, or fixing a rope to the boat and pulling it along the river for a while. This can lead to a discussion with the young person on what would help when the going is tough and the desire to stop is strong. You can find out what sort of help they would like and who should provide it. For some young people, perhaps just encouragement from the bank is enough. If they can just keep on going they will eventually arrive at their destination and be able to get out of the boat onto dry land again.

ANNE STEWART

The orchid and the dandelion – individual differences

Anxiety tends to run in families and one of the concerns that many parents raise with us clinically is that they are responsible for their child's anxiety, most commonly, through the genes their child has inherited from them. Parents can feel anxiety, hopelessness and guilt, and may question whether a psychological treatment can really change something that may be ‘hard-wired’. It appears that some of us will indeed have particular variants of genes that may make us more vulnerable to developing anxiety or other difficulties (e.g. Karg et al. Reference Karg, Burmeister, Shedden and Sen2011). However, more recently, researchers have recognized that those of us with these same genotypes may also show the largest benefit in response to low stress or enriching environments (the differential susceptibility hypothesis; for a review see Caspi et al. Reference Caspi, Hariri, Holmes, Uher and Moffitt2010).

A metaphor that we find particularly helpful to help explain the differences in temperamental sensitivity that these genes appear to create is that of the orchid and the dandelion (Boyce & Ellis, Reference Boyce and Ellis2005). While dandelions are able to thrive in most conditions, orchids tend to be more sensitive to their environment. This can mean that in challenging environments they can struggle (e.g. too much or too little water, the wrong temperature), but with the optimal environment (e.g. a particular windowsill, a non-draughty room), they can flourish. Thus the same genotype can yield very different results in different circumstances. The strategies that children (and their parents) learn through CBT (e.g. using exposure to challenge unhelpful beliefs and develop self-efficacy) can be viewed as creating a more enriching environment. Consistent with this, studies have found that groups of individuals with ‘orchid’ genotypes do just as well in treatment and may respond particularly well to intervention (e.g. Eley et al. Reference Eley, Hudson, Creswell, Tropeano, Lester, Cooper, Farmer, Lewis, Lyneham, Rapee, Uher, Zavos and Collier2012). In this circumstance, the genotype appears to enable individuals to be more sensitive and responsive, but in an adaptive way. Reframing genes in this way, can allow parents to let go of unhelpful beliefs and enable them to see that with the help of therapy, their child may truly flourish.

POLLY WAITE

The coach: a reaction to perceived failure with self-criticism

Many of our clients are self-critical and it is very common amongst those with dysfunctional perfectionism. Such clients tend to believe that such self-criticism has a positive function, often explaining ‘it keeps me on my toes’ or ‘it stops me from getting big-headed’ and, ultimately, ‘it helps me to achieve my goals’. We use a variety of techniques to address this but one of this is the adaptation of the ‘coach’ analogy that was first described by Hoffmann & Otto (Reference Hoffman and Otto2008) in the treatment of social anxiety disorder. Like other aspects of my work, I tend to personalize the analogy to make it as relevant to the client as possible. So, if my client is interested in football, I would use that analogy. If the client had an interest in music, I might adapt it for that situation – often stretching plausibility but clients do not seem to mind that! I typically get out of my seat and act out the scenario and encourage the client to join in by giving sympathetic ‘aahs’ when required.

The analogy is as follows: Little Jonny is playing in a baseball match. It is a very important match and everyone is watching in a stadium as big as Wembley. In this match, the rules are ‘three strikes and you're out’.

The first ball is thrown. Little Jonny misses it. The spectators gasp. Little Jonny's face crumples (I encourage an ‘aaah’ from the client). He prepares for the next ball.

The second ball is thrown, Little Jonny lunges, takes a swing but again, he misses it (‘aaah’ from the client again). The spectators are in silence. You can hear a pin drop. It all depends on this last ball.

Final ball and . . . Little Johnny misses it! (‘aaah’ from the client who is in the swing of it by now).

Coach A comes out. ‘you idiot’ he yells (and I yell). ‘you are utterly useless and pathetic. all that practice was for nothing. i can't stand the sight of you. i never want to see you again – get out of here – you never do anything right. you're too pathetic for words’. (Big ‘aaah’ from the client now.)

Coach B comes out. He says ‘Oh Jonny, bad luck. I could tell you were trying really hard. I guess that you might have been standing a bit far back and not quite at the right angle. How about you come out and practice with me during the week.’

Then I tell the client that I have two questions for him/her.

First, which coach is likely to get a better performance out of Little Jonny?

Clients almost invariably say ‘Coach B’ will get a better performance.

Second, which coach are you to yourself?

After a pause, clients typically respond ‘Coach A’.

I then react with puzzlement given that we have discussed how important performance is to the client. After further discussion, we then go on to devise behavioural experiments in which they alternate acting as coach A and coach B in response to perceived failure and gather data about the functionality (or otherwise) of responding to perceived failure with self-criticism.

At the end of therapy, clients often feedback that this analogy was one of the most helpful and memorable components of the intervention.

ROZ SHAFRAN

Traffic lights – a metaphor for children

The use of metaphors with children provides a way of making the ideas and techniques of CBT accessible in a simple and familiar way. They are particularly helpful with children who developmentally may lack the cognitive, linguistic and reasoning skills required to engage in more abstract and complex reasoning processes. Good metaphors should be simple, concrete, relevant to the focus of the therapeutic work, and, relate to objects or events that the child is familiar with. Within CBT, metaphors can provide both a way of increasing the child's understanding of their current difficulties as well as providing a process for helping them to re-evaluate and develop alternative perspectives and behaviours.

A common and familiar metaphor which can be used with young children and adolescents is the traffic light. From an early age children learn that the red light means stop, amber is to get ready and green means go. This simple and familiar metaphor can be used with children to help them understand that there are different ways of thinking. Some ways are unhelpful (red thoughts) because they stop them from doing things or make them feel uncomfortable. Other ways of thinking are more helpful (green thoughts) because they encourage the child to go and do the things they would like to do or which make them feel better.

The traffic light sequence also provides a simple three-step process for developing alternative more helpful (green) thoughts. At the red light the child is encouraged to stop and catch the red (stop) thoughts that are tumbling around in their heads. As the light changes to amber the child is helped to get ready and to identify alternative, more helpful, ways of thinking. The final stage is the green light where the child is encouraged to go and use their new (green) ways of thinking to test whether these are more or less helpful.

The traffic light can be used in different ways and can, for example, provide a simple sequence to help children develop problem solving skills. Red means stop and define the problem. Amber means get ready and explore alternative solutions with green being the time to choose a solution and to go and try it out and see what happens.

PAUL STALLARD

The seeds of change – a metaphor to help clients contemplate the nature of change

One of my favourite metaphors – especially for gardeners – is the ‘seeds of change’. Seeds need to be chosen which ‘fit’ the environment. There is no point in planting seeds which are alien. So first we need to understand the environment, characterize it, measure elements of the soil, and in CBT terms, conceptualize it. It is the client's garden – the client will provide us with the best description. But we might have some conceptual and technical knowledge which might help in formulating that description.

Next, now that we have understood the environment, we need to determine which seeds are going to grow best, and what the client would like the garden to look like. We need to decide whether we are planting rapid growing flowers or bushes or trees which might grow slower but play a key role in shaping the garden in the long term. We need to determine where to do the planting – in full sun, part sun or shade? How should the ground be prepared? Any other materials (straw, fertilizer, etc.) needed? We discuss, and make these decisions together. Either way, the flora will require watering, especially in the first weeks and months.

The planting is only the first part of the process. Without regular watering, the plants wither and die. So we discuss what watering might involve, how much watering is needed, whether fertilizers could be helpful and if so which. We continue to use the watering/growth metaphor, linking this as we develop the metaphor further to the development and growth of neural pathways. We may go on to expand the metaphor, discussing the difference between knowing at a head level (selecting the seeds) and experiencing at a heart or gut level (the need for regular watering, fertilizer, sun, etc.).

For instance, one of my clients well understood that she was deeply self-critical and that this was rooted in her family upbringing (the environment); she further understood the need for a compassionate way of dealing with her current and past distresses (selection of seeds); but she was blocked from applying these to herself (they did not get watered). She felt it would be incredibly self-indulgent to be self-compassionate. Going back to the metaphor, we asked whether it would be indulgent of the tree (especially a small fragile little tree) to require regular water. Working with this metaphor made it obvious to her that she needed to adopt a different approach – regular watering if the tree is to grow.

JAMES BENNETT-LEVY

Client-generated metaphors

Whereas metaphors are quite helpful for conveying educational information to clients regarding cognitive principles, our own preferred metaphors are risky for other uses in therapy. The most meaningful metaphors are highly idiosyncratic and culturally diverse. A metaphor that I find quite inspirational may fall quite flat for my client. Therefore, when we aim to inspire or create a metaphor for change it is likely to be more therapeutic to elicit a personal metaphor from the client. This is fairly easily done.

In our resilience protocol (Padesky & Mooney, Reference Padesky and Mooney2012), we ask clients to describe in detail positive interests or activities that they are motivated to do on a regular basis. The ways they manage obstacles that arise when they are doing the activities they identify are used to construct a personal model of resilience. In addition, any activity the client is motivated to do on a regular basis becomes a metaphor as well, offering a deep wellspring of creative ideas later in therapy.

For example, someone who loves to hike can use this expertise to manage difficult relations with co-workers. Begin by asking about an analogous situation in hiking. For example, ‘How do you handle inclement weather or roadblocks on a trail?’ After some discussion the therapist can then ask, ‘Are there any ideas your hiking self can offer for how to manage this difficult co-worker?’ Using a familiar and enjoyable activity as a springboard, clients are usually quick to develop their own metaphors for change. Our hiker client generated a metaphor of stopping to assess options and choosing the best path even if it is not an easy path. This metaphor and its accompanying familiar imagery inspired her to take difficult steps toward resolution of an interpersonal problem.

Personal metaphors are easier for clients to remember. When these link with experiences in which clients feel competent they also offer encouragement that the client is capable of taking steps required. Metaphors generated by our clients usually link to deeper emotions than will be evoked by metaphors we propose. For all these reasons, whenever possible, therapists can leave their own metaphors in the waiting room and enjoy the creative process of helping clients create their own metaphors in therapy.

CHRISTINE PADESKY

Folding up paper to put in the bin – Young people and trauma

I was working with a 14-year-old boy with PTSD following some very traumatic events. We were about to embark on our third session of trauma-focused CBT and I wanted to remind him why it could be helpful to go through what happened and talk about the very thing that he had avoided talking about for 18 months. I tried to explain that I wanted to help him to take the sensory information of the memories and ‘wrap them up in words’. I reminded him of two common metaphors that I had used in earlier sessions to explain how this processing of memories can lead to a reduction in symptoms: the wardrobe (Ehlers & Clark, Reference Ehlers and Clark2000) and the factory (Richards & Lovell, Reference Richards, Lovell and Yule1999). These two metaphors had been adapted and elaborated following the feedback from many clients (the revised versions are described in Trickey, Reference Trickey, Graham and Reynolds2013). The client listened patiently, nodding and encouraging me as I told him the stories. He then said ‘It's a bit like that David, but actually, it's more like this’. He filled up the waste paper bin with scrunched up pieces of paper until it was overflowing and said ‘These are all the bad things that have happened to me, and as I walk along the road to school [he made the bin walk along and bits of paper fell out of the top] they fall in front of my eyes. And as I go to sleep [he lay the bin down and more pieces of paper fell out] they fall into my dreams. But when I come here and talk to you, we take each piece of paper out [he took each of the pieces of paper out], un-scrunch them [he un-scrunched them], and we read them through carefully. Then we fold them up neatly and place them back in the bottom of the bin [he folded up each piece of paper neatly and placed it in the bottom of the bin]. This means that they don't fall out the top, and I have more room in my head to think of different things’.

Not only is this a remarkably helpful metaphor, I love using it because it came from a client in the middle of trauma-focused therapy to explain his own experience of how it was helping. I have used this story many times since, and because it comes from a ‘fellow-client’ it has much more credibility. I am so grateful to the client for his help.

DAVID TRICKEY