Introduction
Across both traditional Beckian cognitive therapy and third wave cognitive-behavioural therapies, similar terminologies have been used to convey that an important aspect of intervention is the facilitation of more functional relating to unhelpful cognitions that maintain psychological difficulties. For example, Beck referred to distancing as an important aspect of the cognitive therapy process, indicating that “a person who can examine his automatic thoughts as psychological phenomena rather than as identical to reality is exercising the capacity for distancing” (Beck, Reference Beck1976; pp. 242–243). Within mindfulness-based cognitive therapy, the notion of decentering is emphasised and reflects the idea of “seeing thoughts in a wider perspective, sufficient to be able to see them as simply “thoughts” rather than necessarily reflecting reality” (Segal et al., Reference Segal, Williams and Teasdale2002; p. 39). In acceptance and commitment therapy (ACT), defusion or deliteralisation echo these constructs and aim to help clients “see thoughts and feelings for what they are (i.e., a verbally entangled process of minding) rather than what they advertise themselves to be (e.g., the world understood; structured reality)” (Hayes et al., Reference Hayes, Strosahl and Wilson1999, p. 150). Furthermore, detached mindfulness within metacognitive therapy refers to “an awareness of thoughts in which they are experienced as passing events of the mind that are distinct from reality and separate from the self” (Wells, Reference Wells2009; p. 74). Whilst all these terms are nuanced and can refer to slightly different processes (for an extensive review, see Bernstein et al., Reference Bernstein, Hadash, Lichtash, Tanay, Shepherd and Fresco2015), in clinical practice there is probably more similarity than difference, and all reflect a more adaptive relationship with cognition. The fact that so many similar terms have emerged across different cognitive behaviour-based therapies, likely reflects that this process should be an essential feature of any CBT practice. Importantly, research supports that facilitating such processes is psychologically beneficial (Naragon-Gainey et al., Reference Naragon-Gainey, DeMarree, Kyron, McMahon, Park and Biehler2023).
Cognitive detachment
To add to the mix of aforementioned terminologies, this paper similarly introduces the term cognitive detachment, meaning the capacity to treat thoughts as just thoughts, with no greater significance or importance. This is in contrast to the typical significance or importance many clients place on their thoughts, that of being truth and/or dictators of behaviour. The intention behind this terminology is particularly the focus on non-significance of cognition, which is very much implied across all aforementioned terms and is explicitly emphasised here. To understand this concept within a traditional cognitive-behavioural framework, only a minor adaptation is required (see Fig. 1). We can consider human experience from the perspective that it is both the content (i.e. what I think) and significance (i.e. how much importance I give to what I think) of cognition, which determines emotional, physiological, and behavioural responding, with second wave therapies originally attending more to the former (content) and third wave therapies attending more to the latter (significance). Put simply, if I have an unhelpful thought but do not give it too much importance, I probably will not experience a strong emotional shift. Likewise, if I have a fairly benign thought and place extensive importance on this thought, again I probably will not experience much emotional impact. It is the two combined that triggers an aversive emotional experience.
Conceptualising Cognitive Detachment and Metaphors Within an Adapted Cognitive-Behavioural Framework.
When viewing cognition through this lens, second and third wave therapies can then provide different options for working therapeutically with cognition (see Fig. 1 again for a mapping of these intervention options onto the adapted cognitive-behavioural framework). Deciding which option to take might be guided by many factors (e.g. client preference, therapist preference and training, what has and hasn’t been effective in previous therapeutic encounters, etc.), with either option providing different pathways to therapeutic change. Following a more traditional CBT approach we might work more on cognitive content by implementing cognitive restructuring; questioning and testing what a client thinks via thought records and behavioural experiments (Clark, Reference Clark, Hofmann, Dozois, Rief and Smits2014). Equally, following a third wave approach we might work on cognitive significance by facilitating cognitive detachment; modifying the importance a client places on what they think via various methods such as mindfulness practices or thought defusion techniques (Harris, Reference Harris2009; Hayes et al., Reference Hayes, Strosahl and Wilson1999), thought postponement (Dippel et al., Reference Dippel, Brosschot and Verkuil2024; Wells, Reference Wells2009), etc. In addition to these more well-known therapeutic methods, the remaining and primary focus of this paper is to highlight an additional lesser-known method, the use of metaphor to facilitate cognitive detachment.
Metaphor in cognitive behaviour therapies
The use of metaphor in CBT or psychotherapy more broadly is not new or novel (Blenkiron, Reference Blenkiron2005; Butler et al., Reference Butler, Fennell and Hackmann2008; Otto, Reference Otto2000; Ronen, Reference Ronen2011; Stott et al., Reference Stott, Mansell, Salkovskis, Lavender and Cartwright-Hatton2010). Metaphor, within the psychological therapy context, refers to the comparison of one thing that is not fully understood, with another thing that is seemingly unrelated in a literal sense, yet is well understood (Stott et al., Reference Stott, Mansell, Salkovskis, Lavender and Cartwright-Hatton2010). Linking the two can then generate new insight into that which is perplexing to the client and sometimes the therapist. The many ways of utilising metaphors within psychological therapy and its many benefits have been outlined elsewhere, especially in the Oxford Guide to Metaphors in CBT (Stott et al., Reference Stott, Mansell, Salkovskis, Lavender and Cartwright-Hatton2010). Across the literature, it would seem the most common purpose metaphors have served in therapy, is as a way of helping clients understand their experience and/or key concepts relevant to intervention, hence metaphor has had a strong psychoeducational role (Malkomsen et al., Reference Malkomsen, Røssberg, Dammen, Wilberg, Løvgren, Ulberg and Evensen2022). The proposed benefits of metaphor use within the therapy room typically include increasing client understanding by relating the complex or unfamiliar to something simple or familiar (Killick et al., Reference Killick, Curry and Myles2016), greater emotional and motivational impact compared with more literal discussions (Malkomsen et al., Reference Malkomsen, Røssberg, Dammen, Wilberg, Løvgren, Ulberg and Evensen2022), significant memory benefits for recalling important therapy concepts (Blenkiron, Reference Blenkiron2005; Otto, Reference Otto2000) and enhanced therapeutic alliance (Mathieson et al., Reference Mathieson, Jordan, Merrick and Stubbe2017).
Some research has focused on the natural frequency of metaphor use in therapy for both therapists and clients (Mathieson et al., Reference Mathieson, Jordan, Carter and Stubbe2016), whilst others have considered more deliberate metaphor use in the therapy setting (Martin et al., Reference Martin, Cummings and Hallberg1992; Mathieson et al., Reference Mathieson, Jordan, Bennett-Levy and Stubbe2018). The importance of metaphor use being highly collaborative and the process of metaphor elaboration being important has been highlighted (Mathieson et al., Reference Mathieson, Jordan, Carter and Stubbe2015; McMullen and Tay, Reference McMullen and Tay2023). Therapist-generated metaphor to impart understanding seems to be the most common metaphor application; however, the notion that personalised client-generated metaphors are more effective than therapist-generated metaphors has been advocated (Killick et al., Reference Killick, Curry and Myles2016; Kuyken et al., Reference Kuyken, Padesky and Dudley2009; Padesky and Mooney, Reference Padesky and Mooney2012). Clients will often speak in metaphors without realising, something referred to as ‘metaphoric kernel statements’, meaning something ‘essential’ has been communicated via metaphor (Witztum et al., Reference Witztum, Van der Hart and Friedman1988; p. 3). The idea is that these types of metaphors are more meaningful and memorable for clients, and when therapists attend to and use these metaphoric kernels in therapy, change can be powerful. This is most likely because metaphor work typically taps into the imaginal experiential mode of processing, and we know from extensive research that imagery is more powerfully connected to emotional and bodily experience than verbal modes of processing, given its simulation of perceptual experience and hence sensory impact (Holmes and Mathews, Reference Holmes and Mathews2010; Saulsman et al., Reference Saulsman, Ji and McEvoy2019). When considered in this context, this potentially makes metaphor an emotionally and physiologically evocative therapeutic tool.
When this body of work regarding the therapeutic use of metaphors is taken collectively and then applied to the proposed aim of facilitating cognitive detachment, it seems that the principles of collaborating with a client to intentionally generate their own personalised cognitive detachment metaphor, that is then elaborated during the therapy process, may be what is most important. As mentioned, many metaphors used in therapy perform a psychoeducational function, helping build client understanding. However, the use of metaphor being proposed here is more than this, instead becoming a core therapeutic strategy utilised by clients when faced with repeated unhelpful thinking that is driving psychological distress, using metaphor as a means of adopting the attitude of non-significance cognitive detachment requires.
It must be acknowledged that metaphor has long been recognised as important in CBT (Beck et al., Reference Beck, Rush, Shaw and Emery1979) and is central within the ACT model (Hayes et al., Reference Hayes, Strosahl and Wilson1999; Stoddard and Afari, Reference Stoddard and Afari2014). Whilst the ACT approach employs many metaphors, most reflect experiential psychoeducation, aiming to increase client understanding, make a point, or illustrate an important concept. Many ACT metaphors can also be used to serve a cognitive detachment function, or in ACT terms cognitive defusion or deliteralisation (e.g. the Passengers on the Bus, Soldiers in the Parade or Master Storyteller metaphors; Harris, Reference Harris2009; Hayes et al., Reference Hayes, Strosahl and Wilson1999). However, historically the ACT approach has worked with therapist-generated metaphor more so than client-generated metaphor. No doubt within ACT there would be scope and support for client-generated metaphors to be used if they arise; however, ACT protocols have not typically included explicit instruction on the elicitation of client-generated metaphor (Stoddard and Afari, Reference Stoddard and Afari2014), although this is likely to change over time (Torneke, Reference Torneke2017). Given the plethora of ACT metaphors available generally, and specifically for allowing thoughts to come and go (e.g. thoughts as cars, clouds, people, suitcases, bubbles, waves, birds, trains or leaves; Harris, Reference Harris2009, p. 115), there is a very good chance clients will be introduced to a metaphor that resonates with them. However, given the proposed superiority of client-generated metaphors, it is argued that there is value in therapists knowing how to facilitate these, in addition to being able to draw on their own metaphor repertoire.
Otto (Reference Otto2000) wrote extensively about the use of stories and metaphor in CBT and in this writing some 25 years ago made explicit suggestion of what could be considered a cognitive detachment metaphor. Otto described introducing clients to the metaphor of the “gargoyle of depression … which whispers critical, deprecating comments in your ear” (p. 169). Otto goes on to point out that “the trick is to make sure you don’t buy into the gargoyle’s message” (p. 169). Through this metaphor, externalising or personifying depressive cognitions and responding with differential attention is encouraged by the therapist. This example certainly illustrates the use of metaphor to facilitate cognitive detachment; however, as is seemingly more common, it is via therapist not client generated metaphor.
Similarly, in the Oxford Guide to Metaphors in CBT, Stott et al. (Reference Stott, Mansell, Salkovskis, Lavender and Cartwright-Hatton2010) also write of something very similar to the notion of a cognitive detachment metaphor:
Metaphor can be helpful with rumination in a number of respects … Sometimes clients will offer a metaphorical description, and if not, some other people’s descriptions can be shared; e.g. thoughts tangled up like spaghetti, like a ferris wheel going round and round, racing out of control, and so on. Having a metaphorical description and image on which to hang the abstract concept of rumination is likely to be helpful in assisting clients to notice and to accurately label their mental experience. Sometimes the metaphors may then be extended creatively to move beyond mere description. For example, client and therapist could work together to slow down, step off and step back from the ferris wheel so that two feet are firmly on the ground. (p. 120–122)
Stott et al. are undoubtedly advocating the use of metaphor for cognitive detachment purposes. However, what this description does not offer, is the option for therapists to specifically guide clients to develop their own metaphor for this purpose, instead relying on spontaneous metaphors or using other people’s creations. In addition, the notion of elaborating the metaphor is encouraged, but specific instruction in how to do this is limited. The seed of the cognitive detachment metaphor is most certainly planted by Stott and colleagues, but the next step is to more specifically articulate how to make the seed grow and bear fruit.
Both Otto (Reference Otto2000) and Stott et al. (Reference Stott, Mansell, Salkovskis, Lavender and Cartwright-Hatton2010) are illustrating that metaphor can be used to shift perspective from being immersed within and seeing the world through one’s cognition, to looking at cognition and seeing it for what it is and hence being less responsive to it. Bernstein et al. (Reference Bernstein, Hadash, Lichtash, Tanay, Shepherd and Fresco2015) have outlined in detail the potential mechanisms that may underpin decentering and other related concepts via their ‘metacognitive processes model of decentering’. This model points to meta-awareness (i.e. awareness of subjective experience) as a core mechanism that then facilitates disidentification from internal experience plus reduced reactivity to thought content. The use of metaphor for cognitive detachment proposed here is very much in tune with this model, as the intention is to use metaphor to ‘kick’ a client’s meta-awareness ‘into gear’.
In summary, metaphors are used extensively in therapy whether therapists realise it or not, and there are many ways metaphor can be applied in this context with some uses already resembling a cognitive detachment function. This paper focuses on the construction of client-generated idiosyncratic metaphor, conducted in a collaborative and elaborative way, for the purpose of intervention not just psychoeducation, to facilitate cognitive detachment from thinking styles that drive psychological distress. This approach brings the use of metaphor front and centre, rather than being on the periphery of CBT practice.
Cognitive detachment metaphor
I became interested in how clinicians might guide clients to develop a metaphor that enabled them to relate to persistent unhelpful thinking with detachment, after being tuned to metaphors that clients had spontaneously generated themselves during therapy that could perform such a function when nurtured well by the therapist. My favourite example of this is the seagull metaphor. Whilst running a therapy group, a client within the group spontaneously described their worry as being like a ‘seagull squawking for a chip’. With prompting (such as, what does the seagull represent or symbolise?) the client went on to explain that the seagull was the worrisome thought nagging for the client’s attention via its loud squawk, and the chip was the client’s attention. I further probed, if you throw a seagull a chip, or in other words if you give the worry your attention, what happens? The client responded that more seagulls flock towards you, or more worries engulf you. This was such a lovely and rich metaphor and everyone in the group was in hysterics as we unpacked the metaphor further. Aside from the good humour it bought to therapy, the metaphor gave the client a clear strategy on how to then deal with their worry, which they phrased as ‘don’t feed the seagull!’. Or in other words, don’t give the worry your attention. From much picnicking experience the client knew it was also futile to try chasing the seagull (worry) away, noticing how a seagull immediately comes back when you return to the picnic blanket, just as worry rebounds back when we engage in thought suppression strategies (Wegner et al., Reference Wegner, Schneider, Carter and White1987). The client knew that adopting the strategy of not paying too much attention to the seagull, would eventually lead to the seagull losing interest, and moving on to harass some other poor picnicker. In other words, not giving the worry too much attention would allow it to ‘run out of steam’ and resolve itself like other thoughts in our stream of consciousness do when we simply leave them be. Going forward, the client then adopted the catch phrase, ‘don’t feed the seagull’, whenever they noticed they were worrying.
This very memorable experience got me thinking how I might be able to facilitate this same type of cognitive detachment via the use of idiosyncratic metaphor, for someone who did not spontaneously generate such a wonderful metaphor as this during the course of therapy. With this thinking in mind, the following exercise evolved, with much guidance from Ann Hackmann, James Bennett-Levy and Emily Holmes (Reference Hackmann, Bennett-Levy and Holmes2011) through their publication of the Oxford Guide to Imagery in Cognitive Therapy, which has a chapter devoted to working with metaphorical imagery. Specifically, their guidelines on exploration of a metaphorical image (see p. 154) were particularly influential. Imaginal re-experiencing of a real and relevant situation is suggested as a starting point, and is then used as a platform to allow a metaphorical image to arise that symbolises the experience. Guidance on how to explore the meaning, emotional, bodily and sensory qualities of the metaphorical image are also provided. Such ideas greatly influenced the development of the following script for eliciting an individualised cognitive detachment metaphor with clients.
Individualised cognitive detachment metaphor script
When your mind is being really negative or unhelpful, what types of things does it usually say to you? Can you think of a specific time when your mind was doing this, a typical example of what it is like when your mind really ‘throws’ lots of negative thoughts at you. Your mind might have been worrying about the future, ruminating over the past, or criticising you. What specific example can you think of? [Discuss the example, checking it is a typical example of repetitive unhelpful thinking for the client].
Now, if you are willing, I would like you to close your eyes and experience being back in this situation with lots of unhelpful thinking going on, as if you are there right now, experiencing it firsthand. It’s OK if you can’t get a clear image, just a felt sense of this experience is fine. Now, looking through your own eyes out at the situation … Where are you? What is happening? What is your mind saying to you? How does this feel?…
Now, see if you can let that image go and allow a new image to arise that symbolises or represents your mind’s negative chatter. It doesn’t matter what it is, as long as it reminds you of what your mind is like. Particularly look for an image that conveys that your mind and all its negative thinking is not really that important or worth listening to. For example, does this sort of thinking remind you of something or someone? The image you create may be of a person or character from TV/movies/politics/anything. It could be a person or character from real-life, or it could be completely made-up. It could even be an animal that reminds you of how your mind acts. Or your image could be something else entirely. Funny or humorous images can often be particularly useful for not taking your mind too seriously, so don’t be concerned if your image is a bit unusual …
If nothing comes up, that’s OK, it might take some time to find something that represents your mind’s negative thinking as generally unimportant. Let’s just see if eventually you can settle on an image that represents your mind’s negative thinking as something you don’t need to take too seriously or give too much attention. [With eyes still closed discuss and explore any images coming up to see if they may be useful]
[If the client has a useful image] I’ll give you a moment to develop this image in your mind’s eye … [Ask questions to explore the image, asking questions that are relevant depending on the type of image created] – e.g. Tell me what you see … What does it/they look like? … Describe it/them in detail … What’s it/they doing? … What does it/they sound like? …
As you hold this image in your mind, notice what this image means to you, what does it represent or convey? … Also notice how the image makes you feel? Notice where you feel this in your body? What sensations do you experience? …
When you are ready, and without rushing, you can let go of the image and open your eyes.
Instructional script tips
There are a few things to highlight when using a script such as this within therapy. Firstly, it is important for therapists to realise the script is only intended as a guide. Whilst such a script might be used verbatim as a guided imagery exercise in a group therapy context, where it is not practical to have people speaking over each other in response to the questions posed in the script, within individual therapy it typically would not be used verbatim. In individual therapy the prompt questions would most likely deviate from the script in response to the client’s feedback about what they are envisaging during the imagery exercise. In individual therapy it can be a more interactive exercise where the client speaks back to the therapist, describing the metaphor that is evolving.
Secondly, if therapists want to create their own script or develop variations on this script, there are a few things to keep in mind. The language used in the script should consistently encourage externalisation of thinking, by referring to the mind as a separate entity. The exercise starts with re-experiencing an episode of persistent unhelpful thinking, and then encourages the client to let that go and allow a metaphor to arise, emphasising that this should represent or symbolise their mind’s activity. If clients get too distressed by re-experiencing an episode of unhelpful thinking such that they cannot step back from this experience to engage in the metaphor construction element of the exercise, the therapist may choose to drop this part of the exercise. Instead, eyes open, together you could write a list of common unhelpful thoughts the client’s mind ‘throws’ at them and from there encourage the client to close their eyes and consider what this type of thinking reminds them of. In addition, when developing the metaphor, specific instruction should be given that the metaphor not just reminds them of their mind, but the crucial element is that the metaphor captures the sentiment that what the mind has to say is non-significant in nature. Emphasising this point guides the client to develop a metaphor that might serve a cognitive detachment function and hopefully avoids people coming up with a metaphor for their mind that is all powerful and important, and hence something very hard to ignore and detach from. Finally, once a metaphor is identified, further prompt questions are used to encourage richness and vividness within the metaphor, as well as elicit emotional connection and impact.
Metaphor elaboration
If a cognitive detachment metaphor that resonates with the client emerges from this exercise, the next step would be to elaborate this metaphor in a way that leads to its active application when clients notice they are engaging in persistent repetitive negative thinking. Without active application to in-the-moment unhelpful thinking, the cognitive detachment aim is unlikely to be served and the metaphor will be ineffective. There is much to be gained from elaborating on client metaphors that emerge during therapy and Mathieson et al. (Reference Mathieson, Jordan, Carter and Stubbe2015) outline a number of ways therapists (and clients) can respond during any metaphor work that can achieve elaboration (i.e. praise, extend, clarify, rephrase, repeat). In addition to this, below are steps designed specifically to elaborate cognitive detachment metaphors.
Talk about it
Simply talking about the metaphor is a good starting point for elaboration, and the adapted cognitive-behavioural framework from Fig. 1 could be used to guide this discussion. In terms of the cognitive component, that would involve exploring the metaphor itself. What specifically are they envisaging? Where does that come from? What is its background, history or story? What would we name it? What does it mean to them? What does it mean about their mind or thoughts? From there we can then explore the impact of the metaphor, asking about emotional, physiological, and behavioural responses that flow from the metaphor. How helpful is the metaphor? How does it make them feel emotionally? How does it make them feel physically? What bodily sensations do they notice? What does the metaphor make them want to do or not do? These sorts of questions will help bring clarity and consolidation to the metaphor uncovered.
Use it
Consider collaboratively how the client might specifically use the metaphor in their daily life when they notice persistent unhelpful thinking. Would it be visualising something? Would it be using a phrase that reminds them of their metaphor? Would it be attending to some visual or auditory cue that represents the metaphor? Would it be some physical gesture, action or token that represents the metaphor? Or would it be some combination of these methods? Here we are looking for specific, tangible, concrete things the client can say or do to signify they are using their metaphor to relate to their thoughts in a more functional way.
Remember it
Closely related to the above tips regarding how the metaphor will be used, is devising ways to remember the metaphor to facilitate such use. Increasing the accessibility of the metaphor may be achieved in several ways and again these methods could be used alone or in combination. Things such as regular imaginal rehearsal of the metaphor can increase recall, ensuring the metaphor is easily brought to mind. Finding pictures or photos or completing a drawing that represents the metaphor and placing these visual reminder cues strategically within the environment can be very helpful. For example, my clients often save such pictures as wallpaper on their mobile phone. Devising a catchy phrase that nicely captures the metaphor can serve as a powerful verbal reminder. ‘Don’t feed the seagull’ is a clear example of such phrasing. If relevant, some clients have been able to identify songs that relate to their metaphor and have the song easily accessible within their favourite playlist as an auditory reminder. Others have found it useful to source pendants or keepsakes that represent the metaphor. Touching these physical objects can bring the metaphor and the cognitive detachment attitude it elicits back into focus.
Do it
My favourite activity in the pursuit of metaphor elaboration is an exercise borrowed from ACT and adapted a little for this application. It is a slight variation on the classic taking your mind for a walk exercise (Hayes et al., Reference Hayes, Strosahl and Wilson1999; p. 163). In this exercise we first write out a list of common unhelpful thoughts that often show up in the client’s mind. We then venture out of the therapy office for a walk along the street and it is particularly nice if there is a park nearby we can walk to. I then give the instruction that for the first part of the walk (lasting a couple of minutes), I am going to play the role of their mind and say the thoughts we have written down as I walk next to them. I state these thoughts in a moderate matter-of-fact tone, enough for them but not other passers-by to hear. Their task is to listen intently, take the thoughts in, really take them on board and give the thoughts lots of their time and attention. I also clearly preface that these are not things I think about them, that I really don’t like saying these things, and that I am purely playing the role of their mind for the purpose of gaining essential practice at using their metaphor to deal with this sort of thinking. We take a walk under these conditions and then pause and reflect on what that was like, exploring how they experienced the thoughts, how they felt, what they were able to take in or enjoy around them during the walk, etc.
We then continue on for the second part of the walk. This time I do exactly the same thing and continue to play the role of the person’s mind, but the client is instructed to now use their cognitive detachment metaphor in response to each negative thought that I throw their way. Their job is to use the metaphor as their new response, and to persist with this calmly when the negative thought either returns or another negative thought pops up. In other words, part of the practice is to not give up. This relies on having already negotiated (at the ‘use it’ step) how the client specifically plans to use the metaphor – is it a phrase, visualisation, gesture or something else that signifies they are applying their metaphor? In addition, once they have applied the metaphor to deal with an unhelpful thought during our walk, they would be instructed to mindfully redirect their attention to some present moment sensory experience (i.e. the sun or wind on their skin, the colour and texture of the leaves on the trees or clouds in the sky, the sound of the birds or traffic passing by, the different scents they notice in the air, etc.). As you can see, the introduction of mindfulness-based practices can be a nice complement to metaphor application. In summary, the task on this second walk is to use their metaphor and mindful attention every time the therapist sends a negative thought their way. Again, we walk in this way for a couple of minutes and then debrief in a similar manner to the first walk, exploring what it was like, how the walk was different the second time, how the thoughts seemed this time, how they felt, what they were able to take in or enjoy around them that maybe they missed during the first walk, etc.
There is also a final third part to the walk where we walk back to the office together in silence. This time I don’t say anything, and the client is instructed to use their metaphor if they notice any unhelpful thoughts spontaneously arise during the walk, and if that doesn’t happen, they can enjoy the walk mindfully.
This do it step is essential. The idea of simulating or rehearsing what you are ideally wanting a client to do in real life when enacting any therapy skill is a crucial step in therapy, not just for this strategy or method. What we are asking clients to do when it comes to cognitive detachment is complex. They must first notice unhelpful thinking is occurring, apply their metaphor to facilitate relating to the thoughts in a detached manner, then redirect attention to present moment sensory experience, and repeat these steps in a calm and persistent way when unhelpful thinking inevitably returns. Making this task simple, clear and concrete, and actually doing this with the client, rather than talking about doing it, increases the likelihood of application and success outside the therapy space. Christine Padesky is a big advocate of ‘More Walk, Less Talk’ (Padesky, Reference Padesky2019; p. 2) in therapy, and I couldn’t agree more with this sentiment.
Clinical applications
I have used the method described in this paper with many clients within my own therapy practice (typically working with adults presenting with depression, anxiety and self-esteem issues) and I have supervised many students to utilise this process with their own clients. Anecdotally I would say this has mostly led to very positive, creative, engaging and rewarding therapeutic experiences (both for clients and therapists), although of course this method does not fit for all people. Some clients do not like or are unable to think in images and/or metaphors, and in these cases I would not push the agenda. Instead in these circumstances we can turn to the other strategies mentioned previously that can also serve a cognitive detachment function (see Fig. 1). If certain clients are not able to view how their mind operates with any distance, in that they are completely fused with their thinking and see their mind’s activity as 100% factual and accurate, then tread cautiously with this strategy, as you do not want this work to come across as invalidating. Similarly, clients who hold strong positive metacognitions that reflect repetitive negative thinking as helpful and beneficial, will find it difficult to treat their thinking as unimportant. For those who are fused and/or overvalue their repetitive thinking, other work would need to be done before embarking on this approach. For example, thought records or behavioural experiments can provide cumulative evidence of the inaccuracy of thinking (Beck, Reference Beck2020) or thought modulation experiments can provide evidence of the futility of repetitive thinking and foster motivation to abandon this practice (Wells, Reference Wells2009). However, there are many clients who already recognise their thinking is unhelpful, that their mind overthinks and is highly negative much of the time, but can’t seem to access this perspective in the moment when it is occurring, and developing an individualised cognitive detachment metaphor in this instance has the potential to be a very useful intervention strategy. Therefore, depending on how readily the client acknowledges the unhelpfulness of their thinking and desires not buying into their thoughts, this approach could feature early in the therapeutic process or much later after other foundational work has occurred.
Clinical examples
In the interest of bringing this intervention to life, here are some additional client metaphors uncovered via the Individualised Cognitive Detachment Metaphor Script, adding to our initial seagull example. Some details have been changed to preserve anonymity.
The politician
A few clients have imagined that their unhelpful thinking was a very well-known politician of the time, who was considered by many within society as almost always talking a lot of rubbish and untruths. Clients have found it very useful to respond to their repetitive unhelpful thinking by saying something like, ‘there goes [name of politician] again!’. Such a phrase seems to disempower unhelpful thoughts and see them for what they really were, mostly a load of nonsense that does not require further consideration.
The critical TV character
Similarly, another client saw their mind as being like a TV show character who was consistently scathing and critical towards others. Within the TV show, this character was very outrageous in the critical things they said to others and this extreme negativity came across as very humorous to the audience. We wondered if it might be possible to bring this same perspective to the client’s super self-critical mind. We printed out a picture of this character and put it in a frame next to the client’s bed. Their mind was most loud and critical first thing in the morning when they opened their eyes, telling them they were a ‘lazy, no good, loser who shouldn’t even bother getting out of bed’. When the client would wake up their task was to look at the picture and say ‘Morning [character’s name]!’ and get up before their mind talked them out of starting the day. This worked well in breaking the self-critical cycle each morning.
The drunk guy on the bus
When asking one client what their unhelpful thoughts reminded them of, they said ‘a drunk guy on the bus!’. When we explored why, they were able to articulate that such a person just rants and doesn’t make much sense. They also described them as generally harmless, and that you just need to ignore them, not react, or humour them a bit. I asked if the drunk guy had a name? The client decided their name was ‘George’, and so ‘hey George, how you doing?’, became the client’s catch phrase for detaching from unhelpful thinking.
The chatty fish
So far it has all been about people and characters, but as the instructional script suggests, animals can make great metaphors too. One client described their persistent unhelpful thoughts as a lake of chatty critical fish that pop their heads up for air and say (in a squeaky voice) things like, ‘you’re useless’ or ‘you’re not good enough’. The client reflected that they had been spending all their life trying to get in the lake and catch each fish. Instead, they would now just sit back on the shore and observe the fish from a far and find them kind of amusing. To consolidate this metaphor, the client bought themselves a little fish pendant to hang around their neck, which they would touch as an acknowledgement when they noticed the fish getting very chatty.
The spam texts
For a different metaphor entirely, another client decided their thoughts were like spam texts you receive on your mobile phone. You instantly know they are not real or true, just fake or scams, and therefore you just don’t respond. When you come across a spam text you either just turn your phone over or swipe and delete. The client then used the physical gesture of turning their phone over when they noticed unhelpful thinking grabbing their attention, using this gesture to signify the unimportance of their thoughts and no need for further engagement.
Conclusion
Within the Oxford Guide to Metaphors in CBT, Stott et al. (Reference Stott, Mansell, Salkovskis, Lavender and Cartwright-Hatton2010) write that “metaphor provides for us a cognitive bridge between our more concrete, familiar, experiential world, and the more abstract, opaque concepts and constructs with which we grapple” (p. 25). The task of not engaging with a highly negative critical worrisome ruminative persistent repetitive mind, in other words the skill of cognitive detachment, is quite the struggle for most of our clients. This paper describes how to evoke an idiosyncratic client-generated metaphor, that captures the notion that the mind’s activity is unimportant or non-significant, and then serves as a key to unlock the capacity for cognitive detachment. When the metaphor is then elaborated in a highly experiential manner to make it memorable and bring it into the client’s daily life, the metaphor may then become a strong bridge for many clients in overcoming this struggle. Research regarding the effectiveness of using metaphor in this specific way is very much encouraged as an important next step for this area, although it should be recognised that the approach presented here does have firm roots within extensive research that supports the power of imagery-based interventions (Hackmann et al., Reference Hackmann, Bennett-Levy and Holmes2011). Anecdotally the use of metaphor in this manner can be an extremely powerful, creative, and engaging practice for both clients and therapists alike and has the potential to become a valuable and routine strategy within the CBT practitioner’s therapeutic toolkit.
Key practice points
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(1) Cognitive detachment is the capacity to treat thoughts as just thoughts, with no greater significance or importance, and is an important therapy target for many clients.
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(2) An adapted cognitive behavioural framework which breaks cognition into content and significance, can be used to understand where cognitive detachment fits within therapy and places metaphor as one method that can be used to facilitate cognitive detachment.
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(3) As client-generated metaphors are considered to be more potent but do not always spontaneously arise in therapy, therapists can use the script provided to assist clients in developing a personalised cognitive detachment metaphor.
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(4) Guidance regarding elaboration of cognitive detachment metaphors (i.e. talk about it, use it, remember it, do it), can be used to increase metaphor application and impact.
Data availability statement
Not applicable.
Acknowledgements
I would like to acknowledge the work of Ann Hackmann, James Bennett-Levy and Emily Holmes, as their Oxford Guide to Imagery in Cognitive Therapy greatly shaped the ideas in this paper. I would also like to acknowledge the many clients I have worked with over the years, whose creative and rich metaphors have inspired this work. Finally, I would like to acknowledge my previous colleagues at the Centre for Clinical Interventions where I was working when I first started formulating the ideas outlined in this paper, as many collegial conversations likely influenced my thinking in this area.
Author contributions
Lisa Saulsman: Conceptualization (lead), Writing - original draft (lead), Writing - review & editing (lead).
Financial support
This paper received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The author declares none.
Ethical standards
Ethics approval was not required. The author abided by the Code of Ethics as set out by the Australian Psychological Society.
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