The Positive Power of Imagery

Harnessing Client Imagination in CBT and Related Therapies

Tammie Ronen

• Publisher: Wiley
• Year: 2011
• Print ISBN: 9780470683026, 9780470683033
• eBook ISBN: 9781119996194
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

The Positive Power of Imagery presents the theory and practice of imagery therapy as a creative intervention that challenges therapists to learn the skills for creatively designing personalized exercises to match clients' specific needs, problems, and personalities.

• Presents a unique integration of imagery therapy with CBT and positive psychology
• Challenges therapists to develop imagery therapy techniques tailored to fit their individual clients' personalities and problems
• Features case illustrations and guidelines for the use of imagery and metaphors for both adults and children

Part I

Theoretical Background

1

Introduction: On Becoming a Therapist

The present book is an outcome of my self-guided, personal journey toward becoming a therapist. My journey has been rich and variegated, peopled along the way with a broad range of clients of all ages from diverse ethnicities and cultures, suffering from various disorders, and bringing with them different life experiences, gaps in motivation for change, and, of course, a richness of abilities, skills, and resources. As I worked with these clients along my personal and professional path to becoming a mental health practitioner, some experiences helped me craft my choices about where I should go next as a therapist; from time to time, my path deviated from the main roads to encounter sudden detours, obstacles, and hazards; and eventually, some clients and some of my work gradually began to seem like familiar signposts on roads traveled daily.

As I look back at roads I already traveled as I grew and developed as a therapist, the memories come to me mainly as pictures. Some are snapshots – actual, colorful, visual pictures that I see in my mind's eye – like a certain client's proud facial expression, or a couple's body language as they shout fervently at one another. Some are metaphorical; that is, I can hear or see a story playing itself out in images with hidden meanings – like the vision of a wild animal family interacting against the backdrop of a natural landscape as a mental metaphor I created while treating a certain family. Some pictures more resemble abstract art, like a complex image I envisioned for the interrelationships between the components of the human psyche.

Indeed, as I survey those landscapes and experiences on my road to learning this profession, the most striking discovery is how replete with imagery my journey has been. In this book, I hope to open up a vivid album of all my travels up to this point in time, and to share with my readers the fascinating pictures and memories I have been privileged to see, feel, and sense, and how I learned to navigate and draw on countless images to help my clients and myself over the years of my career. The current volume is a crucial milestone in my journey, because here I hope to assemble some key highlights of my travels and some insights I reached that shaped my therapeutic work over the years, all related to the world of images and pictures, and to the meaning of imagery.

As a means for helping readers enter into this world of imagery, in the next sections of this chapter I will share some more details about my own journey toward becoming a therapist. Over time, my metaphorical picture of myself as a therapist has gradually blended several main orientations or entities. I see myself as a cognitive-behavioral therapist, as a skills trainer, as a structured and goal-directed practitioner, as a positive therapist, and as a creative therapist. I found that these entities merged well into one united approach for working with imagery. First, in this Introduction, I will share how I myself developed and harmonized these entities during my long journey toward becoming a therapist who uses cognitive-behavioral intervention in a creative way in light of positive psychology theories. Then, the book will focus on each of the basic entities and will guide readers in how each entity may be relevant to their therapeutic work, and in how to integrate them through metaphors and images.

Who Am I and What Am I Doing? (The Emperor is Naked; The Wingless Bird)

I never made a conscious decision to become a cognitive-behavioural therapist. As I graduated from my School of Social Work, I began working in a psychiatric hospital and, later on, in a mental health community center. At that time, despite my license to practice, I felt completely inadequate. I was terrified that everyone would find out that I, like the emperor in The Emperor's New Clothes (Andersen, 2004), was actually naked – no skills, no ability, and just parading around as if I were a genuine professional. I felt I had no inkling of what therapy really was or how to conduct it.

I had many proofs for that self-perception. I attended many staff meetings where I never understood the language. The discussions used complicated, abstract concepts to analyze the therapeutic process, which everyone except me seemed to understand. In those meetings, I found that I was concerned about different notions from the rest of the staff. Rather than focusing on my own emotions and internal processes, I was preoccupied with what was happening with my clients. I thought my clients were the center of therapy. I was talking more about facts and goals and less about processes. I wanted to focus on what I needed to teach and what the client needed to learn. I was talking here and now, and also looking at the future, not so much at the past. I so much wanted to help my clients, and I had so many ideas, but I felt different. I thought that there must be some locked away secret of therapy, and that everyone knew the secret except me. How could I unlock the deep box and find the hidden secret of what it meant to conduct therapy? I felt like a bird without wings. Aching to fly, I hoped that one day I would find a mother bird or father bird who would finally understand my different way of thinking about therapy, and that maybe it could be a beginning of a new family…

Meanwhile, I focused on imparting the skills they needed to my clients, helping them change, drawing with them, helping them map out where they wanted to go in life, aiding them in looking for their own goals, and trying to improve their subjective wellbeing. I knew that what I was doing was not “therapy” – but this was all I knew how to do. So, as a wingless, naked bird, I did the best I could.

Two of my teachers at the university finally swooped in to help me make the move toward behavioral therapy (at that time I was not yet a cognitive-behavioral therapist). I was already treating clients when I met the first of these teachers, Dr. Yair Abraham at the School of Education of Tel Aviv University. I was a graduate student and soon became his assistant. He introduced me to behavioral therapy. Israel was (and still is) very psychodynamically oriented, and I had never studied cognitive-behavioral therapy (CBT) formally. When I discovered that my employer was a behavioral therapist, I thought: “Well, that makes some sense because he seems to be a very organized, structured person and I'm not. He can follow precise instructions and I can’t. I'm a very flexible, intuitive person so behavioral therapy must not be for me.”

As I started working with him, I also began visiting his clinic and watching him treat clients using cognitive-behavioral methods. I saw how helpful and effective his work was for his clients. As a result, I told myself: “Well, I may not be a behavioral therapist, but I think it would be okay and even easy to treat children who wet their beds using behavioral methods under his supervision. It is fast, effective, and makes sense.” So, I began writing my master's thesis with Dr. Abraham on enuresis and treating children with nocturnal enuresis using cognitive-behavioral therapy. Soon enough, I realized that in a relatively short time I was able to help many children overcome their bedwetting, and even become more independent and confident. I gradually saw more and more clients and eventually became an expert in this area. Still not grasping my identity, I told everyone: “You know, behavioral therapy is a very good technique for treating nocturnal enuresis in childhood.” Although I was nowhere near ready to fly, I began to feel like some feathers were growing stronger on my naked, birdlike body.

Beginning to acknowledge that this behavioral approach to therapy had some merit, I started reading every book I could find on behavioral therapy and cognitive therapy. I wanted to fully understand the theory behind my practice and to learn the techniques’ rationales to see if I wanted to adopt them more. And all that voracious reading reached a pinnacle one day, as I looked in the mirror (before I learned from Michael Mahoney how to work properly with mirrors in therapy) and it dawned on me: all those years, all that time, I had considered myself to be a naked, wingless bird, when what I had been doing naturally had actually been to practice CBT all along. This approach just fitted who I was! It matched my way of life: the way I planned my day, the way I thought positively, the way I used reinforcement, the way I changed my thoughts, the way I used self-talk. It was strange how much of this approach I used daily. Looking in the mirror, I finally recognized the image facing me: I really was a therapist! I knew what therapy was. I was a cognitive-behavioral therapist. I felt my wings actually extending and growing larger and more powerful. Suddenly I understood that I was ready to fly. After that, as I began to feel good enough about my work to believe in myself as a therapist, I began flying high.

Thus, having arrived at cognitive-behavioral therapeutic work through a back door, serendipitously, I first recognized one entity within my self-identity, that of “A Cognitive-Behavioral Therapist.” One of the first things I did then was to seek out other people with whom I could collaborate, talk, and explore this new identity. Eventually, Dr. Abraham helped me establish the Israeli Association for Behaviour Therapy, and I finally felt my wingspan spread. Once my internal bird discovered this flock of colleagues who felt like I did, treated clients like I did, and lived like I did, I truly began to soar. My early experiences made me invest great efforts in preventing my students from suffering the horrific fear of being emperors without clothes. I insisted that my students come watch me conducting sessions – either through video, a one-way mirror, or direct observation of therapy – or be my co-therapist in sessions. I was determined that they should understand what I did not: that every individual therapist must unlock the box and find his or her own solutions. Equally, I was willing to show them some of the secrets I had found.

By that time, I realized that I had indeed found my “therapist's identity.” I finally knew what was important for me in conducting therapy. I knew that therapy for me is a combination of educational and therapeutic processes, where my role is to guide, teach, and supervise clients in the process of change. I also discovered that it is extremely important for me to ensure that what I apply with a client is an effective, provable method for change, one that really works.

Later on, I met Professor Yochanan Wozner at the School of Social Work, who became my doctoral supervisor. He was (and still is) one of Israel's traditional behaviorists. He has devoted much time and effort to investigating the efficacy of treatments, assessments, and evaluations. His academic courses strongly influenced my later insistence that I apply evidence-based therapy.

So, my new identity was that of a teacher who teaches clients how to help themselves change by applying effective skills and techniques. I started introducing myself as a teacher in helping people change. I thought that “teacher” was the right concept for me, because I strongly emphasized the importance of skills acquisition. I wanted to educate clients in what to do and how best to do it. I was not yet sure what exactly I needed to teach or how best to teach, but I knew that I was a teacher.

How Can I Do What I Plan to Do? (The Ladder; Having a Dream)

As a very goal-directed person, even back then, each time I met a new client I found it difficult to start therapy unless I first discovered what that client wanted to achieve at the end of therapy. This meant that I, together with my client, needed to have a vision of him or her in the future. This is how I work to this day. The client and I must collaborate together to address questions like: How will this client act or be when we reach the end of the process? How will we know that the time has arrived to end therapy? What reasons will there be? What will signal the differences in the client?

I learned that an effective way to trigger discussion of this vision of the future was to ask my clients to make a drawing of how they wished to look at the termination of therapy. Only after this initial drawing was completed would we start talking, drawing, or thinking about how the clients looked in the present, about the gaps between “now” and “later,” and about what they felt was missing in order to reach that future vision.

In response to my requests to look ahead and envision their future, my clients used to ask: “How can I possibly know what the future will hold?” And I used to answer: “If this is your life, you have to think about what you want it to be. You must run your life, not let your life run you. You should maneuver it, not just go with the wind. You need to have a dream in order to realize that dream!” Thus, two main metaphors emerged from these clarifications to my clients, reflecting who I came to be as a therapist. The first metaphor was the lyrics from “Happy Talk,” a song from the old musical South Pacific: “You got to have a dream. If you don't have a dream, how you gonna have a dream come true?” (Rodgers & Hammerstein, 1949). Following this metaphor, with all my clients we began by relating to their dreams. Clients need to relate to their dreams as something that can wait for them in the future, something that is worth working toward.

For example, when I treated a teenage girl who had dropped out of high school, spent most of her time on the streets, and showed delinquent behavior, we discovered that her dream was to become a scientist at the university. Of course at the time, in her current life situation, this dream seemed stupid and unrealistic to her. But we used it as a stepping-stone for creating hope and learning about working toward goals, or as the top rung on a ladder she would like to climb from her present place on the bottom rung. We started by outlining how she could try to make her dream come true, step by step. As her first goal, we decided she needed to complete her high school studies. With my support, she was able to sign up for evening classes and complete her matriculation examinations. As she experienced this success, she felt emboldened to attempt to undertake higher education. It was not easy. She did not become a university professor, but she does work today in a government laboratory and feels very proud that she achieved a profession.

As mentioned regarding the previous client, the second metaphor I began to use with my clients was the ladder, a symbol of climbing up step by step to reach one's dream. The ladder became an important part of my treatment room. With children, I brought in a real ladder for them actually to climb up, see how the top rung felt, and fall back before ascending once again. With adolescents, drawing ladders on paper could help them measure and monitor their progress. With adults, a metaphorical ladder became an integral part of therapy. Clients planned where they wanted to be at the end of therapy and then started climbing up, while I was busy teaching them the skills needed for that climb. As they worked to change their identified thoughts and behaviors, the clients could evaluate their progress using this metaphorical ladder, assessing when they fell a rung or two, or when they skipped upward quickly and easily, thus helping them gain self-awareness and confidence.

For example, in our large-scale national project to reduce aggression and increase self-control skills among at-risk Israeli adolescents (see Chapter 2), small groups meet for a series of 12 sessions with two co-therapists (Ronen & Rosenbaum, 2010). During the first session, all students receive pictures of a ladder and are asked to note where on the ladder they would like to be at the end of therapy and how they envision that place. Many adolescents draw themselves on the top rung, explaining that up there they would have many friends and would have no problems with their teachers. Then the students are asked to draw themselves where they are presently, at the beginning of the treatment. They usually put themselves either on the ground or on the first rung, explaining that right now they continually fight and argue with parents and teachers, and have few friends. We use the ladders in each session, to check where they would like to climb to and what they need to be able to climb there. The group sessions focus on giving these adolescents the skills needed for achieving these goals.

Thus, using such metaphors as dreams and ladders, at this stage I not only knew who I was, a cognitive-behavioral therapist, but I also recognized two other entities within my self-identity. I had become a “Structured Therapist,” a practitioner who works systematically toward achieving goals while planning and mapping out the process of therapy, and assessing and evaluating the o...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• List of Tables
• Acknowledgments
• About the Author
• Part I: Theoretical Background
• Part II: The Positive Power of Imagery
• Part III: Preparing to Apply Therapy Through Imagery
• Part IV: Using Imagery while Assessing and Treating Clients
• Part V: Notes and Conclusions for Imagery Therapists
• References
• Index