Revised, August 11, 2009
Is psychotherapy a science or an art? It is a complex process that partakes of many sub-processes. These are (ideally) adapted to the individual needs of each client (or patient, or analysand– the words themselves hint at the subtle shifts of metaphor.)
A metaphor is something relatively more concrete or conceivable which stands for something more elusive (Lakoff & Johnson, 1980). To say that life is just a bowl of cherries; America is a melting-pot; or the sun at sundown is a big red rubber ball is to evoke a complexes of sensory associations. Not only can metaphors be used in therapy--both the patient's spontaneous productions or the therapist's choice of words--but the process of psychotherapy can itself be explained metaphorically, in the interests of developing the treatment alliance.
Metaphors for Life and Mind
Complex phenomena can be elusive, and we tend to describe them in terms of other phenomena that are a bit more familiar. One of the more obvious targets is the immensity of complexity we call life. Ursula LeGuin, (1985: 483-485), describes some particularly generative metaphors in speaking about life, mind, philosophy, theology, and so forth:
* the war--struggle, triumph, courage, mind as warrior, language as control, winlose
* the lord, hierarchy, mind as control, law, place, responsibility
* animal, life, organic, indivisible wholeness, kinship, mind as animal, discovery, language as relationship
* the machine, work, clockmaker, use, function, medicine as repair, mind as machine, information, communication language, exploitation, progress
* the dance, music, harmony, creation/destruction, participation, cooperation, medicine as art, mind as dance, rhythm, language as connection, horizontal link
* the house, stability, division within unity, person as householder, selfhood; medicine as protection, mind as belonging, language as self-omestication, inside/outsidee
* the way, change, mystery, balance in movement, imitation of animal, water, etc. inaction, receptivity, medicine as balance, mind as spontenatity, language as inadequate, unity, return
The Dramaturgical Metaphor
Another well known metaphor, and one I find particularly useful, is the "dramaturgical model," speaking of events in life as if they were scenes in a theatrical production. William Shakespeare, through a speech given
by one of his charcters in As You Like It (Act 2, Scene 7), puts it in a fairly well-known way: "All the world's a stage, and all the men and women in it, merely players." Shakespeare then goes on to note seven ages of man as if they were character parts. Psychodrama builds on this, noting that we are not merely (or only) players, but also, with reflective consciousness, potentially the co-directors and co-playwrights of the dramas of our lives. In another paper on this website, I discuss the metaphor of self as chief executive officer of a system, ann organization, a collective of many different roles, the choosing self being the "meta-role."
Metaphors of Psychotherapy
The process of psychotherapy is also complex and can be described in a variety of ways, and at different times in the course of clinical work it's often appropriate to change the choice of metaphor. At one point, psychotherapy can be like agriculture or gardening, or like historical research, like a process of education or re-programming a computer, and even like being treated for an illness--especially the kind of treatment in which the patient has to struggle, to practice, to be willing to work at getting better, like recovering from a burn or a stroke. Psychotherapy can be a process of exploration, or like detectives solving a mystery. It can include activities that are more like drama or art than science. Psychotherapy also involves elements of philosophy, friendship, and meditation. Thus, it's useful for both the therapist and the client to be flexible enough to use whatever metaphor is most helpful at a given stage in the process.
Is psychotherapy a science, with the subject matter being the dynamics of the client's life, objectively assessed through a variety of replicable procedures, and the treatment administered, chosen rationally based on clear criteria? And are these treatments themselves clearly laid out, and determined to be effective according to objective criteria?
Well, sometimes, a little. The whole question of psychotherapy research is beyond the scope of this paper, but efforts are being made to clarify which approaches are better, and for which kinds of patients, which kinds of problems, etc.
On the other hand, some might call therapy more of an art, an interweaving of elusive and unique blends of style, preference, the personality of the therapist, along with an intuitive application of various approaches. This, too, occurs in most cases, and accounts for therapy's not being all that scientific.
Let's consider, then, some other metaphors for this complex process:
Parenting: This role involves a host of helping behaviors, primarily in the area of emotional nurturance, containment, empathic validation, encouragement, at times substantive help.
Educating: Not only didactic provision of information is implied here, but a whole range of interactive and experiential approaches. Opportunities for seeing others perform the desired behavior (modeling); opportunities for practice in a fail-safe context; helping patients to review, reconsider, discover for themselves, re-evaluate old cognitions, make discriminations, etc.
Friendship: Discovering a more mutual relationship, an "encounter" with another person, getting realistic feedback. The idea of constructing a disciplined, authentic meeting appealed especially to the existential psychotherapists.
Erotic Love: Please do not overreact to this idea; it is not an apology for sexual misconduct between therapist and patient. Rather, it is a recognition of an underlying theme in human relations. James Hillman, in his mid-1970s book, Re-Visioning Psychology, pointed out that in mythological terms, "eros" awakens "psyche." And if you think of it, eros refers to something much deeper than mere sexuality: eros refers to the deep feelings of attraction and delight and pleasure which really gives romance its flavor. The most delicious aspect of romance isn't the physical sexuality, but the sense of discovery of self which comes through reflected admiration. It's incredible that someone else admires or enjoys or celebrates aspects of your personality which you had taken for granted or perhaps even devalued. This kind of love profoundly reorganizes the sense of self, expands it, establishes a stronger and more positive self-representation.
In the sense that therapists help patients discover their own value as persons, psychotherapy is erotic, and indeed it works best when the therapist can, as Carl Rogers noted, communicate a feeling of unconditional positive regard. I suspect that the stronger the genuine feeling of liking of the therapist the more effective the therapy, all other factors being equal. (That is, a foolish, shallow, or fawning therapist may not be very effective, and we know that becoming erotically or sexually involved with a patient is actually very counter-therapeutic!)
This model also partakes of Heinz Kohut's theories of "mirroring" that are part of that school of psychoanalysis called "self psychology." He noted the need for the developing ego–and continuing in everyday life even for mature people–of the function of having others reflect back some validation that one's self is valued.
Direct Authority: Closer to the old time Herr Professor Doktor role, also drill sergeant, just tell the patient what to do, lay out rules. Related to this on a more subtle level is the recognition of the power of suggestion, whether formalized in hypnotherapy, disguised as education, or integral to the role of the healer. Therapists must not deny their power in the minds of their patients, and they do better when they use it carefully and consciously. Even if a therapist seeks a more egalitarian relationship, seeks to promote the empowerment of the client, still at least at the outset, clients tend to confer on the therapist many subtle elements of authority.
Salesperson: In fact a good deal of therapy involves the act of persuasion, in gently, sometimes directly, often indirectly, encourages, cajoles, sympathizes, and in many other ways manipulates a patient to think about other alternatives to their problems, to continue to work on issues, to take the prescribed medicine, etc.
Management: Coordinating care, maneuvering in family therapy, dealing with other care providers, these and a host of other activities often occupy part of the therapist's time. Teaching patients principles of self-management, using an associated metaphor of helping them to become the manager of the many semi-autonomous parts of themselves, is also a relevant task. The metaphor of management involves a mediating quality, as modern management has come to eschew the earlier authoritarian, "boss" role.
A related management metaphor is "Quality Assurance," or "preventive maintenance," an idea that anticipates the needs for active self-assessment and pro-active behavior. People, like highly complex organizations, are constantly dealing with change, and thus it is useful to anticipate the need to revise obsolete elements in the attitudinal system and behavioral repertoire even before they become highly problematical. Patients are taught to seek areas which might be sources of future difficulty rather than to wait until they become compounded and far harder to repair.Added 8/09: A related metaphor I like is the idea that therapy might be imagined to be closer to teaching the client's inner manager how to do a better job, rather than the therapist taking on the role of one who has answers or techniques that the client can’t understand. Without intending to oversimplify, for most problems, I envision the situation as follows. In the individual personality, as in a large organization, there are multiple participating roles with various issues, often in conflict with each other. There is a “meta-role” whose job it is to monitor, assess, modulate, balance, and coordinate the role demands of the component roles. Most people slip into this management role without ever thinking of themselves explicitly as doing so. They do what they can based on past learning, and often slipping and identifying more with one of the sub-roles over and against the other sub-role, which then complicates matters. (In dissociative disorders such as Multiple Personality Disorder the inner manager effectively abdicates, allowing the sub-personalities to operate autonomously, with little or no conscious coordination.)
Therapy, as I see it, ideally should involve the therapist-as-coach teaching the client to be a better inner self-manager. (Dr. Richard Schwartz, who developed “Internal Family Systems Therapy,” uses a similar metaphor. Mine operates more from a role theory basis, but there is much in common.) I think few therapists operate this way, but the challenge is not only to help clients address their problems, but also to teach them how to do the various steps in doing so.
Thus, the therapist might say, “The next step is to assess the roles in the situation, and here are some ways to do this. You might want to learn how we do this so you can do it for yourself in the future.” Such a statement might be thrown in a couple times a session as the therapist demystifies the process of analysis of the problem, breaking it down into manageable components, getting more history or current information, identifying sub-roles and their component attitudes, helping them express their needs and helping in the negotiation with other parts of the self that might be in conflict, and so forth.
The "Sports Analyst": Just as these sportscasters or newsmen reflect on replays of the incidents they describe, so it becomes useful to teach the patient to join with the therapist on pausing intermittently and reflecting on the therapeutic interaction itself. Freud's emphasis on the importance of analyzing the "transference" forshadowed this idea, and the use of video-playback simply makes the process more available and vivid. One doesn't need technology, though. I say to patients, "Let's pretend that we have some observers, something like sportscasters, up in the corner, watching our interaction. Every once in a while we'll go up there and ask them what they observe. Okay?" Patients like this idea, for they sense the integrity involved in the therapist's wilingness to be subject to an investigation of the interpersonal process and the relationship itself. This is a rather unique dimension of psychotherapy.
The “Woods Elf” Metaphor
Here the therapist emphasizes a different aspect of the coaching process: the need for the client to share perceptions of the various aspects of the problem (including somatic reactions). The therapist might say something like, “My role is more like that of a kind of woods elf, one who has been in many forests and knows a fair amount of forest lore; yet I’ve never been in your forest. I’m quite near-sighted, so you will have to see what’s in the forest and report to me. And being an elf, I can fit in your front coat pocket and talk to you, but I can’t deal directly with whatever you encounter in your forest.”The point of this metaphor is to lay out the various elements of “helping,” so as to minimize unrealistic expectations—especially the tendency of clients to idealize the therapist by expecting them to be able to read one’s mind. This expectation is unconscious in most cases, but clients feel angry when the therapist fails to appreciate what’s going on “behind the mask.”
Teenagers do this a lot: They want to retain their persona or mask of independence, coolness, invulnerability, but also want to be understood regarding their vulnerability without having to explicitly admit such feelings, or related feelings of confusion, ambivalence, and so forth. To allude to the computer metaphor mentioned above, people often continue to use the “programs” they learn in childhood or adolescence on into adulthood, and these programs don’t change unless the change is done intentionally, carefully, and in explicit consciousness.
Spiritual Direction: As people in our postmodern culture experience the alienating influences of this environment from a host of sources, becoming re-grounded in a framework within one can operate meaningfully becomes a significant underlying theme within every change, growth, and reconstructive process. Spirituality is the activity of developing a relationship with the bigger picture, the larger, living framework within which we all operate. It's an activity, and most people don't take it on consciously. They've learned their philosophy of life, their religious beliefs, and these operate as residues– they need to be rejected, revised, or revitalized, and this process has in it a component also of philosophy.
Shamanic Healing: The aura of the Herr Doktor of science also has roots in the more primal archetype of the healer, and in some non-technological cultures, this involves the healer's role in going into the heavenly or otherworldly realms, there to do battle with the spirits who may have invaded or kidnaped aspects of the patient's "soul."
Many aspects of healing have some resonance with a process of redemption, of recognizing that one's power, sexuality, spontaneity, innocence, self-confidence, or some other positive quality has been in a sense "lost." The image of being helped in redeeming these components can be enlivening. (The disadvantage of the role is that it may feed into the expectation that deep change can happen from the outside. However, in certain ways, it is true! Hypnotherapy often partakes of this operation, with changes happening without the client take responsibility. The problem is that it only works for some kinds of difficulties.)
The development of the skill of discriminating subtle inner perceptions also invites the use of a metaphor–that of learning to taste wines. This image can help people learn to become aware of their feelings, which is an innate part of the psychotherapeutic process.. People who seek counseling often have become somewhat numbed and unable to describe the feelings evoked by various situations--they are "out of touch," so to speak. Usually, these folks grew up in an environment where there wasn't much talk about emotions. By making the analogy to wine tasting, the process of re-learning is made into a mastery skill in a new area, so they can feel curious and as if they're taking on an interesting challenge rather than defensive about their ignorance.
I note that there are several levels of discrimination, several stages of the learning. The first step in wine tasting is to become aware that one is drinking wine and not water or beer. This is a way of gently communicating that feelings are different than mere sensations in the body or dry thoughts in the mind. If a person can only respond to a stressful situation with a rationalization such as, "Well, I guess they had to do it that way," he may have difficulty getting in touch with the idea that he did not like what happened. That approach, or the simple complaint, "It's my nerves, Doc" represent states of mind that have not yet learned to notice that they have emotional reactions.
The second step in wine tasting presents a useful lesson: There are three basic tastes--sweet, sour, and bitter, and wines are essentially varied mixtures of these three tastes. For the most part, there are four basic primary emotions, and most feelings are blendings of these emotional components--happiness and sadness, anger and fear. Happiness can include both joy and simple relief. Mixed with a trace of anger, it becomes triumph; with a trace of fear, anticipation. Like the primary colors, when blended, sometimes make up new colors, fear and sadness become depression, anger and sadness, suspiciosness. The point is to help people who are out of touch with their feelings (a condition known by the technical term, "alexithymia") to begin to have a vocabulary for describing these experiences.
The third step in wine tasting is more subtle, requires more intuition. It has to do with getting the more unique characteristics of the wine, the bouquet, the body, etc. This phase of learning is analogous to the next step in learning about the emotions: Once the person is able to notice that he is feeling, and what the basic qualities of the feeling are, then he can begin to discover what those feelings are about. This involves discovering the associations to the feelings--the memories, the beliefs, the significance. It's learning to know what your "buttons" are so that when someone or some event "pushes" them, you don't have to automatically react. You can build in some "circuit breakers." (Ah, but I'm changing the metaphor from learning how to "taste" the subtle feelings to how to "fix" the broken computer or machine.)
This process of learning to become increasingly sensitive applies not only to inner feelings, but also to making differentiations in interpersonal interactions. For example, some people have never learned to discriminate between conversation and arguing, encouraging and mocking challenge, gracious appreciation and self-effacement, or between cooperative play and teasing. Learning to, as it were, "taste" these differences in psycho-social states may also be framed as part of the re-learning process.
Enough people have hay fever or some similar allergy, or have family or friends with this common condition, so that the idea of treating people to help them become less sensitive to their allergies is well known. In psychology, certain conditions might be thought of as having become over-sensitized to certain emotions. For example, youngsters who have been raised in contexts in which a great fuss is made about making mistakes become allergic to shame. Every mistake becomes an occasion for an intolerable feeling of total humiliation, leading to rage, withdrawl, hysterical tears, and other exaggerated reaction patterns.
Now, shame is a normal affect in ordinary circumstances–there's a slight wave of "oh-oh" when a mistake is made, with some slight feelings of embarrassment. This will happen even in the most loving and supportive environments. It's analogous to a slight immune response in the body to any foreign substance–but not an over-reaction. Allergies are over-reactions. People need to learn to take making mistakes in stride. Another metaphor I use is to think of the discomfort of going into the water and coming out–there's always a degree of wet-coldness at first, and then you get used to it.
But with people who have become allergic to shame, they subconsciously recall all the humiliations, all the ways others have "rubbed it in," – "Nyahh, nyahh, you made a mistake!–and this can be from peers as well as from parents or other grown-ups. So therapy can be framed in part as a way to learn not to be so upset.
Here's another metaphor: The "short circuit" in electrical systems. One form of residual neurosis is the process of reacting to a situation with an almost automatic behavior. There may or may not be a dim awareness of the feeling which fires the engines (another metaphor). Here is that over-reaction, that "allergy," that gets in the way of thinking rationally about a situation. So therapy then uses these metaphors to help people restore a sense of self-control.
Mind as Computer
As the sciences develop there is a tendency to describe natural phenomena in terms of the most advanced technology of the time. The cosmos and the body were described in mechanical and chemical terms in the late eighteenth century, and by the end of the nineteenth century electrical themes were brought into many types of explanations. More recently the technologies of holography and computer science have been applied as metaphors of the way the mind works. Recognizing the limitations of any metaphor, there's nevertheless some utility in thinking about psychiatry from the point of view of the mind as computer, as it helps define the way psychopharmacology and psychotherapy each have their domain of action.
Computers operate on three levels, "hardware," "firmware," and "software." Hardware consists of the actual physical parts of the computer, and it would be analogous to the physical nervous system. Major organic conditions such as abcesses, tumors, gross trauma, or other injuries affect the hardware. It is probable that most forms of retardation and dementia also are related to limitations of the central nervous system at the cellular level. There are a number of conditions in which the capacity of medications to reverse dysfunctions remains undecided.
The "firmware" is a kind of basic programming on which the thousands of available software programs are designed. "DOS" or "windows"-like systems have come to dominate the field, but in the 1970s and early 1980s there were a number of other systems. These overarching programs might be analogous to an individual's basic neurophysiological functioning, temperament, and to some extent, ability. In psychiatry we are finding that a number of these functions can be significantly modified by different drugs. This middle level, which a friend also termed "wetware" because it refers to the chemicals in solution which affect the neuronal processes, is the domain of psychopharmacology.
The third dimension of computer functioning is the software, the programs available for more specific usage. This would be analogous to a person's particular set of beliefs, expectations, memories, attitudes, desires, cultural and familial assumptions, etc. Distortions, deficiencies, and fixations in these systems account for a significant amount of psychopathology. People are to varying degrees ignorant, stupid, and foolish, misguided, stubborn, and prideful. Changing their chemicals won't change this.
However, we are finding that some attitudinal systems are fueled by basic emotional states of arousal, and tempering those feelings often leads to a significant diminution of the need to activate those pathological sets of attitudes or behaviors. As was found in the process of behavior therapy for specific phobias, their resolution was not followed by "symptom substitution." In other words, sets of cognitions which tend to complicate people's lives may not be the only determinant. If the basic affects shift, sometimes it seems that the cognitions are less influential.
On the other hand, sometimes those cognitions are sufficiently entrenched and maladaptive that changes in the individual's emotional inner environment cannot suffice to bring about a lasting change. Psychotherapy aimed at shifting those cognitions is needed. I am referring to a broader range of re-educational experiences than that described by cognitive therapy, therapeutic techniques which include the use of imagery, body work, interpersonal influences, etc. All these affect the kinds of "software" I'm referring to.
Added 8/09 The metaphor of the computer can be useful in thinking about how we need to become more psychologically-minded. We’ve come to a point where many if not most people in developed cultures have computers and probably have gotten several generations of computers—both hardware and operating system updates. It’s becoming clear that within the next decade and more there will continue to be improvements, some more modest and some more revolutionary.We are living in a time when things are speeding up—not only technology, but life itself. It has become increasingly difficult to cope with the postmodern condition unless we become more flexible with our minds. In the past, one could manage—barely—by carrying forth most of the sets of attitudes and response patterns that one learns before the age of twenty, but now people need to “update” more frequently—at least every ten years—throughout adulthood, because the culture and life challenges change so that fresh, more flexible modes of adaptation are required.
The usefulness of this metaphor is that it makes the process of updating your own mind less of an occasion for shame. In the past, finding that you were no longer adaptive was complicated by cultural (and internalized) attitudes that good people (meaning strong, competent, virtuous) were (or should be) free of “neuroses” or any other problems of adaptation. It was not okay to even need to upgrade your life program—it “should” have sufficed. In a sense, this attitude was relatively adaptive for a century or two ago—for most people living in small towns. Of course, even then, though, thoughtful people were struggling over major cultural and political issues regarding slavery, women’s rights, child labor, cruelty to children and animals, gross prejudice, racism and xenophobia, passive acceptance of the tyranny of kings and church, and so forth. Still, the cultural norm for most people was more stable.
This no longer applies, as the rate not only of technological change, but social change— introduced by increased mobility, inter-cultural mixing, the growth of media, the continuation of the ideal of democracy and egalitarianism as extended into civil rights for all sorts of sub-groups that had been previously subjugated or marginalized, as well as many other factors, all contribute to the acceleration of change in culture. (What is known as the postmodern condition might be in part defined as a discernable increase in the rate of acceleration.)
The point of this metaphor is to normalize the process of active participation in the maturational process. Instead of letting it just happen, hit or miss, one engages in the tasks of taking stock, identifying strengths and weaknesses, re-evaluating values, attitudes and assumptions, broadening and bring finer discrimination to categories, developing greater sensitivity to subtle perceptions that were previously overlooked, over-ridden, or misinterpreted, and so forth. In a sense, this process is analogous to what in major businesses and industry is called “quality assurance.” In large systems, it is recognized that machinery wears out, there are turn-overs in personnel, sub-systems become entrenched in their own procedures, and so forth, and that preventive maintenance programs, ongoing training, and procedures to check out the actual effectiveness of procedures are needed. All this goes on in city governments, school systems, and even in religious denominations. So it should be no shame to begin to recognize that mature adults need to advance their maturation process correspondingly.
There is no such thing as “being” grown up, as if it were an attainable, stable state. Mature people are prone to lapsing into less mature modes of thought, belief, and action, and there are further many levels of maturity beyond basic “adulthood.” Indeed, many who have seemed to fulfill the requirements of adulthood rather than childhood in fact are carrying forward many childish and adolescent patterns of thinking and behavior.
These, then, are some various metaphors. Others I've used include the therapist as gardener, as director of the symphony, and as coach–in the sense of helping clients increasingly become their own life managers, directors of symphonies, etc. Often I find myself shifting among several metaphors, even during a single session. Admittedly, it makes the process less "scientific," because not only the variables shift, but the frame of reference itself. However, people don't mind being worked with in their complexity and multi-faceted nature. Indeed, it validates just that, that they are complex, and that their growth may need to be multi-faceted.
Returning to the educational metaphor, for example, I'm reminded of the variety of courses in a college catalogue, the diversity of academic departments. In the ‘University of Yourself' clients need to develop a diversification of role activities in order to feel more balanced, and the learning in each channel may require different modes of teaching or facilitation. (See my other paper on Four Types of Learning.)
These and other metaphors can be valuable in evoking the patient's imagery and utilizing the more experiential and non-verbal parts of the mind. It can open up channels of intuitive understanding, and bring out associations that are meaningful, yet which are not connected logically. As the person begins to create and learn new patterns, these can be "anchored" (another metaphor) in these same, more emotionally vivid parts of the psyche.
A good therapist, then, is not only eclectic in methodology and aware of a wide range of different theories, many of which speak to different facets of human functioning. It's also helpful to use different metaphors of what the process is all about to help include clients in understanding therapy and making it a more collaborative experience.
Lakoff, George, & Johnson, Mark. (1980). Metaphors we live by. Chicago: University of Chicago Press.
LeGuin, Ursula. (1985). Always coming home. New York: Harper & Row.
Moon, Bruce L. (2007). The role of metaphor in art therapy: theory, method, and experience. Springfield, IL: Charles C. Thomas.
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