Staff Perspective: What Makes a Good Metaphor in Prolonged Exposure Therapy?

Staff Perspective: What Makes a Good Metaphor in Prolonged Exposure Therapy?

Back when I was a graduate student learning the art and science of psychotherapy, my supervisor and mentor Kirk Dougher taught me about the power and elegance of a good metaphor.  Metaphors, he taught, can be uniquely valuable in treatment to help a patient understand difficult concepts, find meaning, and connect current experience with experiences they’ve already had.  One of the best metaphorical stories he told me at the time went something like the following (with apologies to Kirk for the artistic license I’m about to take with his story).

“Several years ago I was camping with my good friend, Doug, and his yappy, skittish, mixed breed dog, Max.  We were sitting around the camp fire in the evening, chatting and laughing about nothing in particular.  Max sat at Doug’s feet, tethered to his aluminum camp chair with a length of rock climbing safety line.  It was a cool night, so we had a large pine-log fire going to buffer us from the chill.  As the fire started to die down a bit, Doug got up to poke at the fire to coax it back to life.  Just as he poked a large pine log, a pocket of pine sap ignited and popped loudly, sending sparks into the air.

“Max freaked out.  He immediately bolted, barking and whining in apparent terror from the “explosion.”  He ran around the campsite, dragging Doug’s camp chair with him.  It clanked and clattered on rocks, tree trunks, and the ground, seemingly magnifying Max’s terror that some menacing monster was chasing him, always right behind him, and just about to catch him.

“Doug and I rolled with laughter, watching this poor dog run full speed through the brush and out into a nearby meadow, wondering how long he could keep this up.  Eventually, exhausted and unable to keep running, Max stopped and spun around to face his attacker and perhaps, go down fighting.  Just as he did so, the camp chair folded up, fell down in the tall grass of the meadow, and disappeared from view.  Max tentatively searched for the monster that had so relentlessly pursued him, breathing heavily and still a bit scared and confused.” 

I’ve often told that story to patients in Prolonged Exposure (PE) therapy to help illustrate the underlying rationale behind exposure.  In many ways, patients with post-traumatic stress disorder (PTSD), as well as most, if not all, anxiety disorders, may have an experience similar to Max.  Many people with PTSD exert an extraordinary amount of energy avoiding or escaping from things in their life that they perceive as highly dangerous.  Yet despite their intention to decrease their anxiety and discomfort, the behaviors in which they engage may actually be increasing their anxiety and confirming dysfunctional beliefs about the nature of the perceived threat.  It is not until one stops engaging in the escape, avoidance, or safety behaviors and confronts the perceived threat, that one can see more clearly the nature of the threat, or see that what one thought was so dangerous is not nearly as dangerous.

Across multiple PE training workshops at which I’ve presented, we’ve discussed the importance of helping our patients understand various aspects of treatment such as rationale, procedures, the nature of the therapeutic relationship, using metaphors.  (To be technically precise, I am actually talking about a number of literary devices, including metaphors, examples, analogies, and similes.  But for the purposes of this article I will refer to them all as metaphors, though I acknowledge that this is technically incorrect.)  The PE therapist’s manual (Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide, by Foa, Hembree, and Rothbaum) includes a number of useful metaphors suggested by the authors.  Many of the metaphors they describe are fantastic.  However, I find some suggested metaphors less useful for me—some because they just don’t resonate with my experience, some because I think they may not be a good match with a particular patient, and some because, well, frankly, I feel they’re just boring. 

So what makes for a good metaphor? Fortunately, a lot of what makes a metaphor “good” is rather subjective.  There are numerous resources online that give helpful metaphor-writing guidance to aspiring authors.  To me, a good metaphor illustrates a concept using common (e.g. almost universal) situations that the learner easily understands, are appropriate to the subject matter, and are consistent with the underlying message and tone the therapist wishes to convey.  Perhaps even more importantly in the context of therapy versus writing fiction, a metaphor has to “work” even on close inspection.  Yes, taking a comparison too far is often the death of even the best metaphors, but a good one should hold up against disastrous misinterpretation by the learner as they think about it—especially once they’ve left your office. 

Take, for instance, the story above.  My mentor said that at the time of Max’s camping chair incident, he did not think of it as a metaphor for any larger truth.  But perhaps that is part of its power—the little yappy dog being frightened by something that is objectively non-threatening is such a common experience that most people can identify with it.  It is clearly appropriate to the subject matter of PTSD, particularly fear, anxiety, and escape behaviors associated with it.  The story is also consistent with the tone that I wish to convey to my PTSD patients—that avoidance, while perhaps working in the short run to manage anxiety, prolongs and magnifies distress in the long run.

A colleague and I recently discussed the use of metaphor in PE, and shared many of the metaphors we use in treatment.  As you might imagine, as we’ve conducted dozens of PE training workshops, we’ve heard quite a range of creative metaphors used by participants in role-play exercises, some fantastic and some not-so-fantastic.  We realized that many new PE therapists might benefit from considering a wide range of metaphors that could be used in PE treatment, so we present to you several PE metaphors for your consideration.  Perhaps there are a few you will find useful and incorporate into your practice.  Check out demonstrations of our favorites in the PE Metaphors Bank. You will find a brief description of each metaphor, a video demonstration of the metaphor being used in therapy, and recommendations for situations and sessions in which they may be appropriate.

We recognize that there are likely a lot of great metaphors that many of you use that we haven’t heard before.  We’d love to hear from you.  We invite you to share in the comments section below some of the metaphors you use or have found helpful.  We may include demonstrations of the best metaphors shared here in the PE Metaphors Bank in the future.

Dr. Kevin Holloway is the Director of Online Services at the Center for Deployment Psychology.