Development and evaluation of a pictorial metaphor technique in cognitive analytic therapy

This research has explored and evaluated the use of metaphor and pictorial metaphor (PM) in Cognitive Analytic Therapy (CAT). A four part action research, mixed methods enquiry was designed and administered to explore, qualify and measure the use of a pictorial metaphor technique as part of the therapeutic encounter in CAT. The technique arose intuitively from the author’s clinical practice and had received positive feedback from individual patients and CAT therapists. In CAT metaphor is a recognised clinical focus yet there has been no systematic study of the development and effects of working with metaphor and especially PM. Study1 involved utilising a workshop and focus groups method across the CAT community at a number of regional, national and international conferences. A concurrent review of the available literature following a ‘Topical or narrative’ review methodology, to capture a wide base of literature, was undertaken. Study2, a Delphi study of expert practice, was managed across the CAT international community. Initial interest was gained from n=101 CAT therapists with a return rate of n=48. Study3 articulated the results of the Delphi and the literature review into a training programme ‘resource material’ delivered to a number of study groups. Evaluation questionnaires were completed and a follow up reflective questionnaire sent to participants who opted in. The follow up questionnaire was designed to capture responder’s reflections on utilising the technique in their clinical work. Study4 involved a pilot of a pre and post training self-assessment the ‘MaP-SELF’ measuring participant’s perceived competence in working with metaphor and PM. Study1 realised general support for the direction of the research with some preliminary cautions and process considerations to take forward. One of these was recognising working with ‘art’ is a deliberate step; the therapist being the ‘drawer’ may be a challenge as art is usually generated by patients. Study2 developed unique insights into metaphor and pictorial metaphor extracting 76 unique statements for rating that considered ways of working with the topic. A number of insights as to the process and function of metaphor were achieved alongside important practice considerations and some answers to dilemmas arising from Study1. Study3 developed, evaluated and refined a workshop and associated training materials that were designed to support therapist’s recognition and skill in the application of metaphor and PM in their clinical work. Analysis of evaluations and reflections found that it was possible to extend practitioners skill in this area. Attendees in workshops were better able to recognise and work with PM and were able to generate ‘PMs’ at the end of the workshop. Importantly Study3 extended the metaphor practice to include a heterogeneous group of counsellors which provided a reference point for the use of the technique in the wider therapeutic community. Study4 provided useful insights into the effectiveness of a self-assessment alongside further workshop evaluation. Analysis supports the self-assessment as a useful tool finding a perceived increase in self-efficacy in the PM technique. Results support the PM technique as accessible to participants, focussing their thinking as part of the therapeutic encounter. Responders valued metaphor and PM as a way to develop the relationship, generate insights and stimulate recall of problem procedures. Participants rated the workshop favourably and found them encouraging in increasing their skill level. Importantly workshops validated their current practice and increased confidence. The self-assessment had utility as an assessment as well as a guide for best practice.