I have already written about the pre-conference workshop I attended (on Fatigue) and the the first full day of the conference proper.  Today's post looks at the second day of this annual BABCP get-together.  As is true for all three days of the full conference, there are typically 15 or 16 concurrently running symposia, panel discussions & skills classes to choose from each morning and afternoon.  Even with the additional twice daily plenary sessions, one gets a choice of three or four of these major lectures.  On this second day I went for skills classes on metaphor and on imagery as well as a plenary on ACT.  I would also have gone to a presentation on depression treatment but I chickened out as it would have involved a trek through a fierce downpour to get to it!

So first the morning skills class given by psychiatrist Paul Blenkiron on "Making CBT memorable: How to use story and analogy in daily practice".  Paul has obviously been fascinated by this area for a while as he's written a book about it - "Stories and analogies in cognitive behavioural therapy".  It's a fairly "soft" subject as there has been only very limited research checking out experimentally whether using stories & metaphors improves therapeutic outcomes, and there is even less work testing the benefits of one kind of story/metaphor against another.  However there's a real gut sense in many of us that stories can be surprisingly therapeutically powerful.  Back in 2003, Thomas Newman - a professor of epidemiology & biostatistics - wrote a very interesting article on this area entitled "The power of stories over statistics".  He said "What makes these stories so powerful? Firstly, the brains of human beings seem built to process stories better than other forms of input. Secondly, the storytellers themselves are important. It's not just that these awful things happened, it's that they happened to the person telling the story. This enables a connection with the listener or reader beyond what would be possible if the story were recounted by a dispassionate observer ... Thirdly, the powerful effect of these stories relates to the way people estimate probabilities. If we are trying to estimate ... risk ... one method we use is to base the estimate on how readily we can recall or imagine a case, and in what level of detail. This technique, called the availability heuristic, leads us to overestimate probabilities of events that we can easily and vividly imagine ... Finally, these stories are compelling because they describe particularly tragic outcomes and because they seem to offer a solution - a way to extract some meaning and redemption from tragedy by preventing its reoccurrence ... The trouble with these compelling stories, however, is that their apparent simplicity and focus can lead to the neglect of complicated considerations ... Lacking specific stories, we are reduced to impersonal numbers and calculations that are often viewed with distrust."  

Last year Haigh & Hardy published an interesting review relevant to this area - "Tell me a story--a conceptual exploration of storytelling in healthcare education" - and Houston et al began to put some hard data onto the map, suggesting that story-telling may sometimes be an excitingly useful intervention - "Culturally appropriate storytelling to improve blood pressure".  There has been interesting evidence for some time that stories affect us in surprising ways - see Foroni & Mayr's "The power of a story: new, automatic associations from a single reading of a short scenario" - and there is a great surge of interest in narrative therapy more generally - see a blog post I wrote about this back in March.  The potential benefits & risks of therapists telling stories that involve personal disclosure overlaps into all this - see an earlier blog post I wrote "Self disclosure by health professionals".  The whole area of using stories & metaphors definitely interests many therapists and, I think, rightly so.  I certainly use them all the time with clients.  Sometimes they are linked to particular conditions or symptoms, sometimes they are linked to the phase of therapy, sometimes they involve myself or my work, sometimes they are general stories/fables, sometimes similes, quite often they are metaphors that the client has come up with themselves.

I actually should have heard Paul talking on this subject two years ago at the BABCP conference in Manchester. He was one of three scheduled contributors to a panel discussion on "Metaphors and stories in CBT". If you're interested in this subject do follow this link to the blog post about that panel discussion. However I gather that, back then in 2010, Paul's wife had a baby on the morning of his scheduled presentation, so we ended up with only two panel members - Ann Hackmann and Richard Stott - both of whom had contributed to the "rival publication", the "Oxford guide to metaphors in CBT: building cognitive bridges". I mentioned with approval in this earlier post, Richard Stott's comment on Lakoff & Johnson's book "Metaphors we live by" with its argument that: "People use metaphors every time they speak. Some of those metaphors are literary - devices for making thoughts more vivid or entertaining. But most are much more basic than that - they're ‘metaphors we live by', metaphors we use without even realizing we're using them. In this book, George Lakoff and Mark Johnson suggest that these basic metaphors not only affect the way we communicate ideas, but actually structure our perceptions and understandings from the beginning ...". So we use metaphors whether we choose to or not, and the metaphors profoundly affect how we experience ourselves and our lives. Sounds like an important subject to look at!

For me, this understanding - that the metaphors or stories we live by profoundly affect how we experience ourselves and our lives - links with Paul Salkovskis's plenary the day before and his emphasis on the central importance of challenging clients' narratives/explanations/meaning systems that aren't working adequately and helping to develop new meaning systems & viewpoints that are more functional.  It links too with what I wrote about Ann Hackmann's presentation on metaphor & story at the 2010 Manchester conference - "Ann Hackmann gave the second talk and she further developed this theme of client-generated metaphors. In fact she picked up the ball and ran right off the pitch with it! Happily where she ran to was fascinating and, for me, helpful. So she described a technique with clients that went something like: "Bring to mind a problem situation or symptom. Notice the associated emotions and bodily sensations that come up. Let a metaphorical image emerge. Stay with it, even if it seems strange. Explore the feelings and image. Maybe look at it up close and from further away; look at it from different angles. Maybe touch it. What does it seem to mean about oneself, others, the world? Notice any spontaneous changes that occur in the feelings and image." Ann commented that sometimes working in this way allowed clients to approach their problems when previously maybe their emotions had felt overwhelming - that it could allow meaning to emerge where before there had been avoidance.

She talked too about the spontaneous changes that sometimes occur when such images/metaphors/felt-sense are simply held in awareness. She quoted Carl Jung (brave at a CBT conference!) "When you concentrate on a mental picture, it begins to stir, the image becomes enriched by details, it moves and develops". The quote actually goes on "Each time, naturally, you mistrust it and have the idea that you have just made it up, that it is merely you own invention. But you have to overcome that doubt, because it is not true". Ann also mentioned with approval the wonderful story telling of Clarissa Pinkola Estes who wrote both the classic "Women who run with the wolves" and also many other works that can be a rich source of healing metaphors. One of the many great quotes from "Women who run with the wolves" goes ''If you have never been called a defiant, incorrigible, impossible woman... have faith... there is yet time." Good! Thank you, Ann. In the question time I linked this work with Gendlin's Focusing and Ann agreed. I have tended to follow the Emotion-Focused therapists in keeping focusing more for situations where there is a lack of clarity. I can see though that using this kind of metaphor/image/felt-sense exploration with more clients could provide a potentially very helpful theme that we could build on during therapy." Here's something I want to take away from the conference and try out more.    

There were three more ideas that bubbled up during Paul Blenkiron's skills class that I want to chew over.  One is the danger of over-analysing metaphor/story and losing helpful emotional charge.  A second is the potential value of developing an image/video "bank" that could provide a source of memorable information for clients.  The third is about providing some clients with concrete reminders of their new life-enhancing metaphor/story.  So first the danger of over-analysing metaphor/story.  I wrote about this a couple of years ago when reporting on Emily Holmes's plenary presentation about imagery.  I wrote "She talked too about the important distinction between thinking about things more verbally or thinking about things more using images. So considering a positive past or future experience from a verbally described observer perspective can actually drain out the "goodness" of the positive experience whereas considering the same event from a sensory-visual first person field perspective is likely to boost good feelings. Of course with painful "toxic" memories, mixing verbal processing with the sensory-visual helps to drain away the "badness" which is contrastingly a welcome outcome."  

As for developing an image/video "bank" as a source of memorable information for clients, again this is territory I've considered before - see "Therapeutic use of film, music & poetry".  It is fascinating and spills over into the third idea triggered by Paul's talk - the potential value of providing clients with concrete reminders of their new life-enhancing metaphor/story.  See the two posts on "Power objects, power postures, power clothes, power prayers: all ways to facilitate change" for a fuller exploration of this territory.