Le Magazine ACT: One of the goals of ACT is to undermine the control of plys over the patient behaviours. Could you tell us how the use of metaphors can be part of that process?

Yvonne Barnes-Holmes: This is one of those occasions where we have abstracted an idea from basic behavioural research and applied it to therapy without empirical evidence to support it, but the little that we do know about rule-following as verbal behaviour generally suggests that this is a good idea. Pliance is implicit in all forms of therapy and of course a certain amount of pliance is required (e.g. to get clients to do homework). But some psychological conditions (e.g. depression) are characterised by rather extreme levels of pliance (usually excessive), which functions as a generic rule along the lines of ‘I must do everything I can to keep the therapist happy and then I’ll get better’. Of course, this wouldn’t work because there should really be no causal and complete relationship between the therapist being happy and the client getting better. And of course this is indicative of the type of over-arching ‘keep everyone happy’ strategy that is indeed common in depression. For ACT, we want them to learn to manage their lives by making experiential contact with their situation and assessing the overlap between this and what they value and rules such as the one above just don’t seem to help them do that. Also if you give clients rules, you are likely to reinforce rule-following and if rule-following is the problem, then the problem will only get worse. As with all verbally sophisticated human beings anyway, we often construct rules mistakenly and because they are mistaken as solutions, they don’t work for very long in the first place and then we just come up with another rule and so on. In order to do values and acceptance, tracking is a much better strategy and likely to be more informative and we are less likely to get sucked into details of tracking as is the case with pliance. It’s a bit like tracking is more realistic and even more honest and reliable than pliance, almost less verbally fraught, if you know what I mean. All you have to do is to keep your eye on your experience as it is not as what you say it is and let that be your guide.

            Because metaphors are metaphors, they alter verbal functions in novel ways and so when a problem is a verbal one, metaphors offer a perspective on it than is not really available in any other verbal format. If you instruct a client directly you will perhaps just add to the existing relational network that contains the problem. But if you put a new slant on it with a metaphor, you can start to change verbal functions that already exist. It is also hard to get pliance with metaphors because they are not instructions, it’s like they inform but don’t instruct. They encourage you to see something differently and there is often room for you to see two or three new things in a metaphor (which would otherwise take a lot of instructing). So in a way, metaphors are naturally more attuned to tracking than pliance. In fact, metaphor is a way around pliance, because there is no accurate way to interpret a metaphor and it does not require you to given a pliant response. Interestingly, I have found that clients rarely think of their problems in metaphor, but instead just keep giving themselves new rules when old ones fail. This suggests that pliance is a problem. But clients often think that they just keep coming up with the wrong rule, not that coming up with rules per se is a problem. So in a sense, there is nearly always an issue with pliance at the beginning of therapy. So we begin to use a metaphorical style with clients from the beginning.

           
LMA: In a clinical setting, how should a metaphor be presented to a client? Should the frame of coordination that relates the vehicle and the target be established under the control of an arbitrary or a non-arbitrary Crel? In other words, should the therapist explain explicitly this relation (for example, by saying that struggling with anxiety is like struggling in quicksand) or is it better to tell the metaphor and let the client feel the similar nature of the two relational networks? What outcome can be expected from these two different methods?

 YBH: Of course, these are empirical issues and ultimately that is the best way we will learn how to proceed with these issues in therapy. But for what it is worth in advance, I would suggest the following. Sometimes you can explain a metaphor but I generally don’t. If a client hasn’t got the point (usually metaphors have several), then add a layer to the metaphor or use another one. Even try to get the client to give you another metaphor along similar lines. That way you will be able to assess the coordination relation that you are trying to get to with the metaphor. If you explain the metaphor you will not only kill the effect but you will just add to the existing verbal network that is the problem in the first place. This is a poorer outcome and might even be problematic, so metaphors are best left to work for themselves. Almost by definition metaphors contain at least one non-arbitrary element that is highlighted and verbal sophisticated humans are excellent at abstracting this. We have good empirical data to suggest that when adults can’t derive arbitrary relations, they look immediately to non-arbitrary relations and derive them instead. So even if parts of your metaphor don’t work as you hoped, clients will get something out of it. They are not stupid, often it is the contrary. Clients are very verbally sophisticated individuals, so more contact with the non-arbitrary world is better for them. Imagine for example that a client has a problematic relationship with her husband. And what you have learned so far is that the problem in large part is that the client has low tolerance of her husband’s efforts to be jovial around her (as in the earlier part of their relationship). So, you say “It seems a bit like cat and mouse in your house, where you’re the cat”. What the client can get is that no matter what the mouse does the cat is always waiting; they bicker but at times it is funny like in the Tom and Gerry cartoons; at times she can be vicious; the mouse is harmless really; she can be in charge too and so on. There are so many messages and you can work them to aid your cause. But if you began explaining to the client that she is the cat, she might feel defensive like you are categorising her as vicious and thus she will focus on that element over the others. And then you really are in trouble!

LMA:  In their review of the literature on metaphors, McCurry and Hayes (1992) explained that a good therapeutic metaphor should have “multiple interpretations if the client’s problems are diffuse, but fewer meanings if the client’s problem is more constrained”. Could you explain us this rule from an RFT view? How can a therapist vary the number of interpretations of a metaphor?

 YBH:  Again, this is an empirical issue. This is a difficult one because it is hard to predict whether a client’s problems in simple terms reflect constrained relational networks or excessively large ones. My inclination is that they are often constrained in some respects, which is why they can only see one or two solutions as a way out. In simple terms, we might say that they don’t see the bigger picture, like worrying over things that aren’t relatively important in the fullness of their lives (like having clean hands or a tidy garden). The metaphor should fit the problem, that is the key. So, if the problematic network is constrained, then the metaphor should open it out. But if the problem is that the network is too broad and everything is in there (like the self, for example) then the aim of the metaphor is to reduce it and highlight one or two features that will shift the perspective or even just give the client something to focus on initially. Alternatively, you could think of it the other way and suggest that if a client’s problematic network is broad, then the metaphor should be broad to give them a view on the breadth of the problem and if it is constrained, then the metaphor should be specific so as to hit the target. That’s why this is a complicated issue. e to think through the metaphors clearly before using them. The question is what is the problem and what do you want them too see about that problem (not do, just see) that they can’t see already. Put simply, how come the therapist doesn’t have that as a problem, so what do you see that they don’t, and how can you make a metaphor out of that. So, if each problem has about three key elements, what type of metaphor has all three and has them linked together in a coherent story. So for RFT, the metaphor should match the network in breadth and add something new into it, likely by changing some of the existing functions. In training, we often draw the metaphor on the board and try to come up with every possible derivation and how much weight each gets in that metaphor. And when we are struggling with a client, we derive the problem and work out all the possible metaphorical hits we need to address it and then we construct the metaphor that tells the best story around that.

  YBH: The simple answer to this is that no therapist can feel what a client feels, even if they have struggled with the same problem and there is no point in pretending that you can. So, I tell clients from the outset that I can’t feel it, and that’s probably a good thing because if I did I would almost certainly end up having the same problem with it as they do (this is very empathic). So, it is an advantage that I don’t in fact because then I might have an insight into it that is not on view yet to the client. But what I emphasise is that I do feel and I am human and in similar circumstances I would like do what they are doing right now. And if I was to get help, I wouldn’t want to go to someone who had the same problem or to someone who had no problems. That’s why humans can make good therapists (and not so good ones too). Clients often have little perspective on their problems, because for them they are the problem and there is a coordination between the problem and the self. They will often say, I know having dirty hands is not really a problem, so the problem is me because I worry too much about having dirty hands. So, the coordination among dirty hands, the anxiety that comes with it and a low sense of self overall is problematic. What you want the client to see is that having dirty hands does not make you a bad person even if you get anxious about it. So the way they see it is that you can’t be a whole person and have anxiety and dirty hands, so there is distinction here that is the flip side of that coordination which has a whole human being distinct from minor things like dirty hands. This is problematic, because at one level there is hardly a comparison between whole people and dirty hands. It’s like they can’t be whole while dirty hands is a part of them, so that the self and the hands are coordinated when really one should only be the  most minute part of the other in a tall hierarchical relation. But if you tried to explain this to a client, they would just get more anxious about being anxious about nothing, because you just added to the network. But you can use metaphors and other verbal styles that basically question “As a human being, are you not worth more than your hands. When you were a young girl, did you dream of clean hands, rather than romantic relationships and children?” This begins to alter the existing network and put lots of things higher up the network and closer to the self than hands. So in empathy it is the perspective on the problem that is to be shared, not the problem. And the empathy comes when you start to shift their perspective, not when you take on their problem. Empathy also comes when you indicate to clients that they are better than their problems and that they are worth fighting for. When they come into therapy, they are focused overtly on key problems but actually they are really sick of being who they are right now. So initially de-focus on the problem and focus on the self and automatically they begin to think about who they are and now what is wrong with them. This is also empathic. It’s like you see the person underneath the verbal system that is attacking them, so together you go to war on the problem and not that you go to war on the person. That way they will feel like you are on their side against their verbal system. What we know about relations and perspective-taking can help ACT immensely (although I would say that) because empathy is a target, it is not a feeling. And the target comes when we shift their perspective and we can only do that when we see what relational networks are problematic. And RFT helps us do all this, especially because I think that the sense of self and the hierarchical perspective that goes with that are problematic in most clients that I have known. RFT also helps immensely with metaphors that allow you to see the problem, see the client’s perspective and give them a new perspective on who they are and who they can be and who they want to be.