Metaphor and the politics and poetics of youth distress in an evidence-based psychotherapy

Introduction

Metaphors have the potential to both reflect and shape conceptual landscapes and bodily states (Gibbs et al., 2004; Kirmayer, 1992). Emotion metaphors in particular may tap into recursive loops that link cognitive, bodily, and social processes and as such, have the capacity to shape and reshape experience in powerful ways. What happens, then, when specific kinds of metaphors are utilized within therapeutic interventions with emotionally distressed youth? This article explores this question through a close examination of both emotion metaphors spontaneously used by youth, and the “prescribed” metaphors deployed by clinicians, within a larger study of Mexican American adolescents receiving mental health care. I begin by illustrating the use of spontaneous metaphors by adolescents in their narratives of emotional distress, using the case of 16-year-old Ericka. Following Ericka's story, I offer a more in-depth discussion of emotion and metaphor, and the processes through which metaphors both reflect and shape embodied emotional experience. I then move on to analyze a specific clinical metaphor deployed in Cognitive Behavioral Therapy (CBT) with youth and explore the kinds of cognitive orientations and embodiments this metaphor helps instill. Finally, I examine youth interpretations of, and responses to, the clinical metaphor and the models of thought and emotion it imparts. In doing so, this article contributes to an understanding of the dynamics of metaphor use in contemporary evidence-based psychotherapies and their “potential mechanisms of efficacy” (Kirmayer, n.d.). I contribute as well to illuminating the models of emotion inherent in manualized CBT and the politics and poetics of youth engagement with these models.

Under a grey cloud: Emotion metaphors and adolescent distress

When I met her, Ericka was being treated at an outpatient psychiatry clinic for her severe depression and anxiety. Ericka, who was 16 at the time and identified herself as Mexican American, drew often on metaphors to describe her experiences of psychological distress and psychotherapeutic treatment. But Ericka didn’t just speak in metaphors, she seemed to actively live them out. Her father, who had immigrated to the US as a young adult, worked long hours at a factory and the burden of caring for Ericka, her brother, and younger sister fell entirely to their mother, who had to drive Ericka an hour to her therapy appointments each week. She had a close relationship with her mother and described herself as motivated to get better in part by wanting to alleviate some of this burden on her mom, who had recently been diagnosed with skin cancer. In contrast to her close relationship with her mother, Ericka identified her emotionally distant relationship with her father as a primary source of her distress. Moreover, these family dynamics unfolded within the highly stressful context of constant financial strain and a neighborhood plagued by gang violence. ¹ Ericka had to commute to a private parochial school, and her father, who was raised with the understanding that the most urgent imperative for a man is to support his family financially, kept a grueling schedule in order to fund the education of her and her siblings. In the period leading up to her initial help-seeking, and already distressed by what she perceived as her father's disinterest, Ericka began a relationship with a boy from her church youth group that soon became what she described as “mentally abusive.” That is when Ericka began experimenting with self-harm. She had heard from a friend at school that self-cutting “released her pain,” and Ericka found the practice compelling.

I had the whole concept that if I cut myself, like blood would come out, and like my problems would go out … It felt good doing it, cause just like an alcoholic has a problem with alcohol, I had it but with cutting, and um, like it kind of was like my drug, you know? I’d get a reason to just cut whenever I felt really down but … that's how I would do it.

She described her eventual suicide attempt in a similar way:

It was March 1st, I tried committing suicide and my mom found me and we were just arguing, we were fighting, like I was throwing my fists and she was trying to hold them down and that's very emotional. That's what kind of shaped me.

Here, her unreleased emotions emerged violently into social space via physical behaviors; first as an effort to kill herself, and then as she lashed out at her mother with her fists. She described these emotional experiences as having shaped her, offering an embodied metaphor that portrays her way of being in the world as itself a material substance, molded by her socio- emotional experiences or by the action of her emotions in social space.

At the same time that she experienced her emotions as internal substances in need of release, Ericka also understood her depression as an external force.

And depression, I’ve always thought about it like it's a person, like right here, like, and there is a cloud over them, um, and that cloud is gray, but just because that cloud is still over me doesn’t mean I’m happy, and when I have it over me it doesn’t mean I’m sad. It could mean I’m sad it could mean I’m happy, but I’m always going have that cloud. So, it goes away eventually.

In this metaphor, depression hovers over her, looming and inescapable, its chronicity a presence she feels even when she is happy. Notably, her discussion of depression begins from a more detached position, in the third person, but shifts midway to a first-person point of view: “there is a cloud over them, and that cloud is grey, but just because that cloud is still over me …” This shift underscores the degree to which Erica personally embodies this metaphor; though she tries, she is not able to offer an account of depression that is abstract or ‘merely’ conceptual, but one instead that is intimate and experientially grounded. Nevertheless, Ericka expresses hope that, like real clouds in the sky, her depression will go away eventually.

Like many metaphors we use, the metaphors that Ericka drew on in her narrative were learned, often directly from those around her, or more diffusely from conventional metaphors circulating in the popular consciousness. For example, the metaphor of emotions as substances contained within individual bodies is highly conventional within Euro-American cultures, as is the related hydraulic metaphor in which emotions, like liquids under pressure within a container, must be vented or released to prevent explosion (Kövecses, 2003; Lakoff & Kövecses, 1987). Conventional or derived though her metaphors may have been, they nevertheless seemed to directly influence her experience. She had learned from her school friend that cutting would release her pain, and she experienced her problems flowing out whenever she cut. Her grandmother, deeply religious and known for her clairvoyance, had admonished her that if she ever tried something like self-harm, it would be “kind of like [her] drug.” Ericka experienced her cutting habit in ways that mirror phenomenological accounts of substance addiction—as both a dependency and a deep attachment. She compulsively turned to cutting whenever she felt down, and experienced it as filling an emotional void.

I argue that Ericka experienced cutting in this way in part because of these metaphors. In other words, I want to explore the idea that metaphors do not simply reflect embodied experience: they shape ² it. As such, taking up learned and conventional metaphors is a means through which individuals internalize and embody ways of feeling, and more broadly, ways of being, that are socially and culturally intelligible, appropriate, and even desirable. At the same time, the act of creating, playing with, elaborating, or testing metaphors represents an active effort on the part of individuals to capture, express, communicate, and even transform their experiences in ways that, both consciously and unconsciously, are positioned in relation to operative social norms—either aligning with or transgressing them.

While metaphors are often learned and conventional, they are nevertheless effective at expressing deeply embodied experiences of suffering. As Kirmayer (1992) puts it, metaphors need not be original, merely apt. Moreover, individuals may insert idiosyncratic meanings into conventional metaphors, re-interpreting and reworking what is shared and familiar into hybrid forms that reflect their own experiences, thereby serving both intrapersonal functions of expressing and affecting feelings, as well as interpersonal functions of communication, social positioning, and identity making. Some metaphors may be more underdetermined or possess an abundance of surplus meanings, making them porous and especially inviting of, or accommodating to, idiosyncratic meanings. Moreover, different metaphors are resonant for different individuals, depending on how easily they link to existing or desired models of self and identity. ³ This means that metaphors may be understood and interpreted differently by different people (Gibbs, 2008).

Ericka's metaphor of depression as an external force, and depressed mood as a dark cloud, draws from conventional metaphors (Kövecses, 2003), yet the emphasis in her telling on the chronic presence of the cloud no matter what her momentary mood expresses her embodied experience of depression in a deeply personal way. Because metaphors are both reflections and shapers of experience, the emphasis on chronicity in Ericka's cloud metaphor reflects, but also may contribute to perpetuating, her experience of depression as inescapably overshadowing her ordinary, day-to-day affect. At the same time, like many conventional illness metaphors, depression-as-cloud also serves to distance Ericka's self and personhood from depression, which is represented as a force outside of her and not under her control.

Ericka's self-harm-as-alcoholism-metaphor similarly depicts her cutting as a compulsion over which she had little control, rather than as a personal choice. In the context of her larger narrative, in which her distress resulted in transgressive behaviors directed at self and others, the externalizing of depression might be understood as an effort on Ericka's part to avoid moral judgement on her past behaviors. This interpretation resonates particularly in light of the guilt Ericka expressed in relation to the burden she felt she had put on her mother. She ends her elaboration of the cloud metaphor and its evocation of chronicity with the seeming afterthought that the cloud goes away eventually—signaling hope that the burden on herself and her family will not be permanent.

At other points in our interview, Ericka also spoke of “being lost” when she was at her most depressed, of being “dragged down” by her depression, and of having bad things come “crashing down” and injuring her emotionally. Ericka's efforts to describe her distress illustrate the way that people may, at different times and in different contexts, try out multiple metaphors in an effort to both express and communicate their experience (Gibbs and Frank, 2002). Some metaphors may stick, while others may not, depending on what they do for the individual—both intra- and interpersonally. Evidence from our study of adolescents receiving psychotherapy suggests that, among youth suffering from emotional distress, certain metaphors may feed forward to shape experience in ways that serve to dampen feelings or enhance perceived self-regulation. Other metaphors may simply serve to express and communicate different aspects of their embodied experience. Which aspects they choose to highlight with a given metaphor is likely related to the dynamics of context. For example, late in our interview, as we discussed how things have changed since she was first hospitalized, Ericka struck a defiant tone in describing her depression and anxiety:

They’re just my enemies that I am trying to fight back. That's the way to put it—they like, try to be part of me but I don’t want to let them, so I just kind of push them away.

These metaphors suggest that explicitly distinguishing between herself and her problems helps Ericka to embody and project a sense of strength and control that she sees as important aspects of her treatment and recovery. Whereas before she characterized herself as “dragged down” by the force of her distress, here Ericka uses multiple interrelated metaphors (enemies, fighting, pushing away) to underscore the agency she has developed against that distress, and to vividly communicate to me that there has been change.

Ericka's story provides a vivid example of how youth may employ their own metaphors when communicating about their emotional experiences and distress. When they seek help for their depressed and anxious feelings, youth like Ericka bring these metaphors to the clinical context with them, along with the embodied experiences in which they are grounded. In mainstream psychotherapeutic settings like the one in which this study took place, they are likely to encounter a different set of metaphors deployed by clinicians as part of their practice. Metaphor use is common in psychotherapeutic settings, where it can be used to scaffold new cognitive models or serve as a source of insight, normalization, and positive meaning (Goncalves & Craine, 1990; Kopp, 2013; Martin et al., 1992). Metaphors are also used in psychotherapeutic settings as a means to help reshape or retrain the cognitive orientations and emotional responses of patients. That is, clinical metaphors are often designed to do something very specific. But, as I discuss below, metaphors also have the potential to shape experience in ways that are not necessarily intended, or entirely understood, by clinicians. In addition, because metaphors tap into embodied meanings, they may be particularly potent in shaping and reshaping emotional experience.

Metaphors and mind–body loops

Scholars of metaphor have convincingly demonstrated that they are grounded in our embodied experience (Gibbs et al., 2004; Lakoff & Johnson, 1999). Our bodies are the medium through which we experience the world, and corporeal experience therefore represents a dominant and often default domain through which we understand and represent our ideas and meanings, and onto which we map concepts. For example, we draw on our bodily experience of upright posture as a basis for conceptual understandings and linguistic expressions in numerous domains, from moral virtue (i.e., an upstanding citizen) to skill and talent (i.e., she stands out, or he stands above the others), to rankings and hierarchy (i.e., the athlete's standings in the competition).

Emotion and affect⁴ are central aspects of bodily experience and therefore deeply implicated in metaphorical thought and expression. In fact, according to phenomenological philosopher Merleau-Ponty (1945), the corporeal experience in which our experience of the world is grounded is “immersed” in affect and emotion (Roald et al., 2018, p. 205).

Most scholars acknowledge that emotions are neither purely psychological nor purely bodily phenomena, but instead are fundamentally psycho-bodily. Nevertheless, dating back to James and Lange (Cannon, 1987), most theories of emotion have divided it into its cognitive and bodily aspects, suggesting that emotional appraisals and bodily responses, or feelings, are separate, sequential processes. Until recently, most theorists have not questioned this sequential model, debating instead which, the cognitive or bodily, is primary (Barrett, 2006; Barrett et al., 2007). However, as philosophers Hacking and Hacking (1999) and others have noted, our minds and bodies fundamentally shape and influence one another in ways that are simultaneous and “mutually reinforcing” (p. 109). Hacking refers to this as “bio-looping,” and other scholars (Kirmayer & Ramstead, 2017; Ramstead et al., 2016; Seligman, 2014, 2018a, 2018b) have elaborated on this idea to explore the mechanisms through which our bodily experiences are produced via meaning, and our perceptions of and attributions about the world around us are constituted by bodily experience.

Hence, the bio-looping model itself serves as a metaphor for the continuity between the cognitive and bodily aspects of emotion. The continuous recursive feedback of the loop is intended to capture the way that bodily aspects of emotion are actually constitutive of emotional meanings and evaluations, and emotional appraisals are by definition “embodied appraisals”—which in turn constitute emotional meanings, and so forth (Barrett et al., 2007; Colombetti, 2014; Colombetti & Thompson, 2008, p. 59). Anthropologists have also emphasized that such embodied appraisals are fundamentally cultural, with cultural models of and for emotion shaping what emotions are understood to be, how they feel, when they are felt, how one displays them, where they are located, of what they are made, and so on (Beatty, 2014; Ilouz et al., 2014; Leavitt, 1996; Lutz & White, 1986; Rosaldo, 1984; Shweder et al., 1993; Stodulka, 2017). Because emotions are embodied appraisals, these cultural models of emotions, including the language we use to express and communicate about them (Reddy, 2001), are not merely reflexive ideas or abstract representation of what emotions are and how they feel, but actually constitute, phenomenologically, what emotions are and how they feel. Thus, shared cultural meanings shape our carnal responses and feelings, while what is felt constitutes the meanings we make. From this perspective, then, emotions are not things, but processes, constantly unfolding and transforming through the interactions of bodily states and meanings.

As Kirmayer (1992) has argued, metaphors stand between larger meaning structures and bodily givens. As such, metaphors represent key expressions of the culturally situated, bidirectional loops that constitute emotional experience (Seligman, 2018a, 2018b). Moreover, a bio-looping model suggests that metaphors not only reflect but also influence the recursive links between bodily states of feeling, and how we learn socially to perceive, attend to, and express such feelings.

Emotion metaphors express emotional experience, but they also help to constitute it. Findings from recent studies, such as one in which lonely people who lack social contact and are deprived of interpersonal “warmth” take more warm showers (Bargh & Shalev, 2012), lend further empirical support to this looping model, by demonstrating that metaphors may actively influence perceptions of the body via associations or attributions circulating within particular cultural and social contexts.

The metaphor of release/relief that Ericka used to describe the sensation of cutting can be understood in these terms. This metaphor may reflect the bodily experience of making an opening in the skin and allowing blood to flow out, as well as the flow of endorphins that are released in response to the cut. But knowledge of the metaphor also draws attention to those particular sensations, increasing the likelihood that cutting is perceived in this way. Hence, self-cutting may produce a sensation that is aptly captured by metaphors of release, but exposure to circulating metaphors of “cutting as release” also already shapes how the experience of cutting is perceived by youth like Ericka. There is a feedback, in other words, between embodied states and the meanings they afford in particular contexts. ⁵ Metaphors distill and encapsulate this merging of meaning and experience.

In Euro-American contexts, the metaphor of the body as a container and emotions as a content is deeply implicated in the embodied experience of interiority that many people associate with their emotions (Kövecses, 2003). Emotions are felt to materialize inside of the individual self, and to be private experiences that may then emerge into social space through various forms of expression (Ilouz et al., 2014; Reddy, 2001). Cultural models of emotion influence people's perceptions of their feelings; in this case, the notion of interiority draws attention toward internal physiological cues, which in turn reinforce the experience of emotions as stemming from inside the individual. However, anthropologists and philosophers have demonstrated the cultural and historical specificity of this experience of interiority, which is neither shared across all cultural and social groups, nor consistent across time even in “western” contexts (Campe & Weber, 2014; Rosaldo, 1984). Instead, emotions are often understood and experienced to come from outside of individuals or exist in the space between them (Lutz & White, 1986).

Similarly, in Euro-American contexts a dominant metaphor for sadness is the spatial metaphor of “down” ⁶ (Berger, 2011; Kövecses, 2003). In fact, the term “depression” is itself a part of this spatial metaphor for sadness. People experience sadness as physically pushing or pulling them down to a low point, as illustrated by the link between depressed mood and slumped, sagging postures (Gupta, 2009; Wilkes et al., 2017). Depression is also associated with symptoms of psychomotor retardation, in which people's speech, movement, and cognitive function are literally slowed down (Buyukdura et al., 2011; Lecrubier, 2006). Recursive links between body and meaning are thus encapsulated in spatial metaphors for sadness.

Youth who suffer from depression and anxiety use metaphors in an effort to express their embodied evaluations of their situations, and as a means of communicating these appraisals to others. Their emotion metaphors thus serve both expressive functions as well as social functions of self-making and positioning relative to people and institutions in their social worlds. But such metaphors may also act to create and reinforce particular embodied appraisals and stabilize particular patterns of intertwined attributions, bodily experience, and social feedback (Kirmayer & Sartorius, 2007). New metaphors introduced in therapy thus have the potential to draw attention to and influence interpretations of embodied emotion, reshaping and stabilizing experience through recurring use of, expansion upon, and social reinforcement of particular metaphors. In what follows, I explore the kinds of embodied appraisals generated by a central “prescribed metaphor” in a manualized version of child and adolescent CBT.

Setting and methods

The data presented here are drawn from an ongoing study exploring Mexican American adolescent experiences of mental health problems and treatments. Data were collected during more than 18 cumulative months of fieldwork at an outpatient psychiatry clinic in a large urban center. Ethnographic methods in the clinical setting included over 80 h of observation in case conferences, grand rounds, staffings and clinical trainings, as well as extensive review of clinical materials (i.e., manuals, diagnostic scales, and psychoeduation materials). In addition, we conducted qualitative interviews with 37 adolescent patients (12–18 years old), the mothers of 21 of the adolescents, and 17 staff clinicians. Patients and parents were recruited through their clinicians and were included if they had been in treatment for a minimum of three post-diagnostic sessions. Adolescents were not asked to participate if they were psychotic or acutely distressed, as determined by their clinicians. The majority of adolescents in the study were diagnosed with mood, anxiety, or attention deficit disorders—or some combination. With the exception of just a few families, participants all came from working- or lower-middle-class backgrounds.

Adolescent interviews were designed to gather data on subjective experiences of mental health problems and treatment, as well as models of self, emotion, and emotional distress. Interviews also included the use of a visual prompt related to a clinical metaphor commonly used in manualized CBT for children and adolescents, to which youth were asked to respond. Analyses presented here are drawn from ethnographic observations, clinical materials, and transcripts of patient interviews coded for metaphorical content. Coding was accomplished using a two-pronged process beginning with inductive coding following a grounded theory approach, followed by a priori coding based on theory and data from the literature. Institutional Review Board approval was granted by both the research site and the principal investigator's home institution.

The ambulatory psychiatry clinic (hereafter APC) where this research took place is part of a children's hospital that also includes an inpatient unit for more severely distressed youth. Staff at the APC include a mixture of psychiatrists, psychologists, and social workers, arranged in that order into a loose hierarchy. The patient population is ethnically and economically diverse, with a particularly large proportion (around 40%) classified as Latinx and 67% of these patients either uninsured or on public insurance (e.g., Medicaid). The large percentage of Latinx patients seen at the APC is noteworthy, given that most studies of mental health care utilization suggest that people from backgrounds grouped under this heading are typically “under-utilizers”—meaning that they seek out specialty mental health care less often than non-Latinx white youth, despite epidemiological data suggesting that they may be at higher risk for mood disorders than their peers (Brown et al., 2007; Kapke & Gerdes, 2016). Evidence suggests that risk factors for mood disorders among Latinx youth include discrimination, poverty, cultural hassles, and acculturative stress (Nair et al., 2013; Zeiders et al., 2013).

Clinical practices at the APC reflect mainstream models in contemporary child and adolescent psychiatry and psychotherapy—in particular, use of standard diagnostic categories and methods of evaluation, and the combination of psychopharmacology and Evidence-based Psychotherapies (EBPs), especially CBT, to treat most diagnoses. The specialty mood and anxiety program at the clinic is especially strict in its adherence to an evidence-based framework, with student training focused exclusively on CBT, and all clinical staff affiliated with the program required to employ a highly structured diagnostic interview schedule designed specifically to lay the groundwork for CBT. At the time when the research was conducted, standard psychotherapeutic practices at the APC did not include any formal culturally tailored treatments or other systematic programs or policies intended to address issues related to culture and ethnicity.

CBT and prescribed metaphors for emotion

CBT is by far the most commonly used among the evidence-based psychotherapy techniques. In fact, CBT is considered by many to be the gold standard of psychotherapies (David et al., 2018). A large body of evidence amassed through clinical trials, and the anecdotal experience of many clinicians, support the notion that CBT works (Jansen et al., 2012; Wood et al., 1996). This in turn shapes the rationale not only for favoring it over other therapies, but for implementing it in a highly standardized way that is understood as faithful to the techniques shown to work in controlled trials. As a result, manualized versions of CBT (literally step-by-step manuals for conducting CBT for particular disorders) are popular among some clinicians, especially within highly medicalized clinical settings like the one in which this research was conducted. Clinicians at the APC are faced on a daily basis with children, adolescents, and families who are often desperately distressed and dysfunctional. At the same time, care is shaped by the demand for efficacy and efficiency within the medical institution. In this clinical context, therapists are motivated to offer care that helps ameliorate the problems of their patients as effectively and quickly as possible. Manualized, evidence-based psychotherapies thus seem to many clinicians to represent both a pragmatic and empathic therapeutic strategy.

Disorder-specific applications of CBT for youth currently dominate the landscape of child and adolescent psychotherapy treatments in the US (Benjamin et al., 2011). CBT techniques are generally geared toward immediate problem solving and symptom relief (Umaña-Taylor & Updegraff, 2007). Aaron Beck (1979), one of the principal authors of CBT, describes the therapeutic approach this way:

[it] consists of highly specific learning experiences designed to teach the patient the following operations: (1) to monitor his negative, automatic thoughts (cognitions); (2) to recognize the connections between cognition, affect, and behavior; (3) to examine the evidence for and against his distorted automatic thought; (4) to substitute more reality-oriented interpretations for these biased cognitions; and (5) to learn to identify and alter the dysfunctional beliefs which predispose him to distort his experiences. (pp. 4–5)

While newer applications of CBT often incorporate aspects of mindfulness (Cayoun, 2011) and some also include a greater focus on emotional activation as a therapeutic tool (Samoilov & Goldfried, 2000), the basic underlying model on which CBT is grounded remains more or less consistent with Beck's formulation.

The traditional CBT model, often depicted graphically in the form of a triangle, conceptualizes cognition, emotion, and behavior as separate, though mutually influencing, processes. Desired changes to emotion and behavior are understood to follow from changes to thought and belief, and vice versa. Thus, there is a strong cause and effect logic in CBT, which lends itself to intervention. For dysregulated emotions, traditional cognitive behavioral interventions often center on creating shifts in cognitive appraisals, which are presumed to lead to shifts in the felt aspects of emotion. Mainstream CBT practices also include behavioral interventions to address dysregulated emotion, but the logic of these interventions is largely the same: through behavioral exposure to feared situations and experiences, patients are expected to become aware that their emotional responses to those situations are unwarranted and their inappropriate responses can be attenuated. Emotions are thus looked to for evidence of the effects of changes to behaviors and cognitive appraisals, thereby empirically demonstrating to patients the mechanisms of cause and consequence in their own experience. By extension, patients are expected to learn that they can control and alter their own experience, especially their thoughts and behavioral responses. Hence, through CBT youth learn to enact agency and control over, as well as responsibility for, their emotions.

Metaphors have been used in psychotherapy to scaffold new cognitive models and serve as sources of insight, normalization, and positive meaning (Kopp, 2013). They have gained recent attention as a therapeutic resource in CBT specifically, where they have been identified as a beneficial tool for formulation and a means to make problems more amenable to intervention (Mathieson et al., 2016; Otto, 2000; Stott et al., 2010). While many psychotherapeutic practices adapt, expand upon, or challenge patients’ own metaphors as a means to scaffold therapeutic change (Kirmayer, 1993; Kopp, 2013), in the manualized versions of CBT for children and adolescents used in many mainstream clinical settings, what I refer to as clinically “prescribed” metaphors are intended to scaffold change in a very specific manner. These built-in metaphors are specifically designed to convey the underlying logics and assumptions of the operant therapeutic model and to set the stage for specific therapeutic practices (Buchbinder, 2015). By marshalling embodied experience and imaginal capacities in imparting such logics, metaphors help make the often abstract and hyper-rational aspects of the model seem more intuitive and natural (Friedberg & Wilt, 2010).

I use the term “prescribed metaphors” in order to index the way in which these metaphors are 1) medically authorized, authoritatively presented, and therefore part of the corpus of clinical recommendations for achieving a desired therapeutic effect; 2) literally pre-scripted, in the sense of being written in advance of any specific clinical encounter, and therefore generic; and 3) also pre-scripted in the sense of evoking a particular cultural and social script for desirable forms of emotion regulation, self, and personhood. Prescribed metaphors in manualized CBT thus represent a set of built-in, authoritatively presented, generic metaphors oriented toward instilling clinical models and achieving specific, predetermined clinical goals, rather than toward the particular contours of any instance of youth distress. The prescribed metaphors in manualized CBT are specifically designed to help orient youth toward the practice of monitoring and measuring their thoughts and feelings, in order to assess both the causes of problems and the effects of interventions. It is important to note, however, that clinicians may also use non-prescribed metaphors in their work with adolescent patients and may even incorporate and build off of the metaphors youth introduce themselves, at the same time that they employ prescribed metaphors.

Here I explore in depth one of the central prescribed metaphors used in manualized CBT with children and adolescents: the thermometer metaphor, or “The Feelings Thermometer” (Fieldnotes, Mood and Anxiety Training, July 11, 2016; Chorpita, 2006). Clinicians introduce the feelings thermometer to new patients, often in the form of a visual prompt (Figure 1), by first reminding them of how a real thermometer works. They then explain that the feelings thermometer works the same way: “it's a way to measure your internal feelings and give a number to those feelings, so we can see what things are creating problems for you” (Fieldnotes Mood and Anxiety Training, July 11, 2016). Patients are then instructed in how to use a numerical scale from 1 to 10 that accompanies the thermometer, with 10 being “the strongest feeling (of sadness or fear, depending on whether they are evaluating anxiety or depressive symptoms) that you could imagine” (Fieldnotes Mood and Anxiety Training, July 11, 2016). Measuring the child's feelings is thus equated with taking their temperature, so that the unfamiliar practice of quantifying emotions can be understood in terms of the more familiar practice of quantifying temperatures. One important cognitive mapping in this metaphor is thus the equation between the practice of using a technology to measure an objective inner state like temperature, and the practice of objectifying one's inner emotional state using the technology of the numerical scale.

OPEN IN VIEWER

Figure 1.

Visual prompt for the feelings thermometer used in child and adolescent CBT.

The feelings thermometer accomplishes this mapping by operating on the existing metaphorical link between temperature and emotion, and the dominant Euro-American notion of interiority, which treats emotions as private, inner states. Lakoff and colleagues (Lakoff & Johnson, 1980; Lakoff & Kövecses, 1987) have convincingly demonstrated that combined, these two conventional understandings form the basis of a widely shared metaphor of the body as a container for emotions that may build up inside, creating heat and pressure that need to be released, leading to such metaphors as “reaching a boiling point” and “having a meltdown” (Kövecses, 2003). This hydraulic metaphor indexes important ideas about emotion as both individually produced and experienced, and as potentially socially dangerous if not expressed and regulated properly. Many teens are likely already familiar with this metaphor and may draw upon it to express their experience—as Ericka did with her soda bottle metaphor. As such, the feelings thermometer may resonate with conventional understandings, and even shared embodiments, of emotion.

The feelings thermometer therefore has the potential to be a rather powerful metaphor in the sense that it taps into existing cultural models of emotion that likely already influence patients’ embodied appraisals. Moreover, because this metaphor is prescribed, it borrows the authority of the larger corpus of clinical recommendations in which it is nested. In other words, the power of the feelings thermometer is enhanced by the surplus meanings of medical authority that accompany it. The thermometer is a particularly effective metaphor for this purpose as it is itself a familiar medical technology, bringing its own set of clinical associations and authority. The thermometer evokes the pediatrician's office, a different kind of medical encounter in which technological instruments are commonly used to measure internal physiological processes. Here, the taken for granted idea of objectively measuring an internal physiological process is transferred to the measurement of emotion, suggesting that emotion too is an internal, physiological process that can be measured. The body temperature thermometer is a particularly familiar medical tool/technology—one that has worked its way out of the clinical context and into people’s homes. As such, the thermometer works to invoke a process that is at once technical, objective, and scientific at the same time that it is relatively familiar, intelligible, and non-threatening to children. By linking the rich set of connotations attached to the thermometer to the process of measuring feelings, a process that may be less familiar and intuitive, the feelings thermometer is intended to help patients and parents to better conceptualize and buy into this therapeutic practice.

During their interviews, youth in our study were shown a paper version of the feelings thermometer and asked first to explain/interpret it, then prompted to respond to the emotion/temperature metaphor. They were also asked to respond to the numerical aspect of the thermometer and to share their thoughts and experiences concerning the practice of assigning numbers to feelings. Many were already familiar with the feelings thermometer, but some were not. All youth had, however, previously participated in the practice of quantifying their emotions using a numerical scale. Responses to the feelings thermometer suggested overall that youth understood and accepted many of the metaphorical mappings associated with it. In particular, the metaphor seemed successful at invoking the mapping of “emotion as temperature.” For example, youth in treatment embraced the idea that feelings, like temperatures, can fluctuate from cold to hot, or low to high across time and context. Their interpretations of such fluctuations were nuanced and variable, however, with some youth interpreting the thermometer as a continuum of intensities of a single emotion, and others interpreting it to represent a spectrum of different emotions, some “cool” and some “hot.”

For example, Angel stated:

I guess I would say like, the thermometer, the higher it goes up, the more um extreme like feelings or negative feelings you have, but once you go down the scale, you’re more calm and cool and just fine, like doing everyday life tasks, but then here [gestures at the top of the thermometer], like your feelings are taking you over.

For Angel, the top of the thermometer represents any intense negative emotion and she notes that, in that upper range, such emotions have the potential to “take you over.” Hence Angel introduces an additional metaphorical mapping of emotions as forces that can immerse and overwhelm at high intensities.

Lucas talked about the thermometer in similar terms, emphasizing the “cool” emotional zone at the bottom of the thermometer as a place of contentment:

I would say that 10 is probably really depressed, extreme depression or something, and then 1 would be like not depressed, complete opposite, like not depressed, pretty content, happy. I guess you could say happy, but yeah, because like it would be like just laid back and really chill like you’re not like super upset you’re not like boiling like with anger or anything like that, so I would say that you’re pretty calm and cool or whatever.

Like many of the youth in the study, Lucas associates the top of the thermometer with anger, but he also imagines it to represent extreme depression, suggesting that the “hot zone” could be any intense emotion. Still other youth saw sadness and depression as the cold zone at the bottom of thermometer. In most of these interpretations, the thermometer was not read as a gradient with different quantities of a given emotion, but rather as a way of conceptualizing the different qualities of emotions. Eighteen-year-old Ester described how the thermometer had helped her realize that emotions are not monolithic, but fluid and complex. For example, she identified that a single emotion may not only have different intensities (i.e., “sadness can be a 1 or a 10—not just ‘sad’”) but also different qualities (i.e., “cold anger vs. hot anger when you need to blow off steam”).

Many youth talked about emotion and temperature in explicitly embodied terms, describing the experience of changes to their felt temperature in relation to particular emotional states. As Mina put it:

I am like a thermometer, because when I’m mad I actually get hot so it's like I mean it relates to me. I don’t know if anybody else gets really hot when they’re mad but it relates to me and then when I’m happy like how I said that I get nervous, sometimes I get chills too. So that makes sense. So it's like okay, so I’m obviously like a thermometer.

Similarly, Freddy said of his experience of anxiety, “My face would just get really really heated up, and my body would just feel like it was about to explode from so much heat.”

While clinical use of the feelings thermometer relies upon, elicits, and reinforces the kinds of embodied appraisals and familiar cultural models of emotion that youth in our study described, the explicit clinical intention of the thermometer is actually something different. In essence, the feelings thermometer is a metaphorically adorned example of a visual analogue scale (VAS), a type of linear scale commonly used in clinical contexts as a means to measure and quantify subjective states like pain and mood. The clinical intent of the feelings thermometer seems to be most focused on this scalar aspect, encouraging quantitative assessment of mood or emotional state. Use of such scales facilitates commensuration, or the transformation of different qualities according to a common metric (Espeland and Stevens, 2008; Lempert and Summerson Carr, 2016). The process of commensuration is a common means through which elusive qualities can be standardized, assigned value, and equated or compared. When emotions are transformed into numbers, it becomes possible to compare them across stimuli, time, and context using the same metric. Therapists in the clinic use quantification and commensuration of emotions to track patient emotional functioning over time, to identify their emotional “triggers,” and to assess whether their interventions are working. They use the thermometer specifically as a way to train youth to habitually monitor and measure their own emotions, toward the ultimate goal of increasing their emotion regulation.

Emotion regulation is commonly defined as the process through which individuals exercise control over their emotional experience by influencing which emotions they have, when they have them, and the form in which they are expressed (Gross, 1998). Expectations for emotion regulation are thus closely linked to cultural and social models of and for emotion, which include norms for desirable and undesirable ranges of emotion and modes of expression. Psychological research and practice in the U.S. both reflect and reinforce such norms, and emotion regulation has been identified as a key factor in both normative child development and developmental psychopathology (Campos et al., 1989; Cicchetti et al., 1995; Cole et al., 2004).

Emotion quantification in the clinical context is intended to facilitate emotion regulation by helping youth to self-identify desirable and undesirable ranges of emotional experience. Therapists use the thermometer metaphor as a way to encourage youth to make links between desirable and undesirable emotion and particular kinds of thoughts and behaviors amenable to change. The thermometer is also used to track and document desired changes in emotional experience. For example, youth were encouraged to note what kinds of situations resulted in feelings at the high end of the range, they were prompted to examine the attributions and interpretations that lead to their presumably unwanted extremes of feeling, and then to measure any changes in feeling that followed shifts in thought and behavior.

Many youth accepted and even embraced the need for emotion regulation, and saw the thermometer as a tool that could potentially aid in this process. For example, Ester told me:

Well it wasn’t just the level of the sadness but it, like sections parts of the sadness. Like in this section [gesturing at the image of the feelings thermometer] you’re just sad like you can deal with it, you can like okay you just need a little pep talk. This sadness you’re like giving people the cold shoulder, you’re just sad and you just want some time alone. And this sadness when you just want to cry and get rid of the whole world, sadness […] So it's tied in with my activities and so if I saw that I was really, really stressed or really, really sad I knew that I had to do that one thing to get me up there.

Fifteen-year-old Adam built on the “emotion as temperature” mapping of the thermometer to introduce his own metaphor about emotion regulation. For Adam, emotional stability and regulation were likened to a kind of emotional scale in which the balance between hot and cold feelings is weighed:

it's like putting a … putting a burning coal on the top of a balance thing [scale], and then putting an ice cube in the other thing and balancing it. It's like, so that they can be perfect temperature … like, normal. If something happens, someone annoys you, you put more cold on top of the other thing with the coal, the burning coal.

Some youth embraced the thermometer as a means of knowing about their emotions in a cognitive sense. These youth expressed the idea that bringing a particular kind of awareness to their emotions was important and useful, as it represented a form of mastery and the potential for greater control. For example, 16-year-old Laura said:

Yeah because like let's just say you’re like lost, you don’t even know how you feel and then you’re like you have these options and they, you choose one of those options and then you get closer to maybe the origin of how or what caused your feeling.

Laura embraces the idea that knowing how she feels in an evaluative, analytical way is the key to understanding the causes of her emotions, and that such understanding is inherently valuable. Moreover, Laura suggests that the technology of the thermometer and its numerical scale can provide a way of knowing, which she as an individual might not otherwise possess.

Just as most individuals need technology to know their internal body temperature, similarly Laura suggests that the feelings thermometer provides a window into one's own internal emotional states. The quantitative scale thus scaffolds a particular form of meta-cognitive skill building that youth like Laura seem to find useful and desirable.

Moreover, by shifting away from merely feeling their feelings, to thinking about, naming, and evaluating them, youth seemed to experience feelings as less immediate, self-implicating, and immersive.

Seventeen-year-old Olivia's comments exemplify this phenomenon:

Um, because then you can like diagnose yourself like “oh, I’m sad.” Like it's not an underlying condition or something. I don’t know … you could just think about it … think it through […] Umm for me like, I don’t know, I really like knowing everything—that sounds weird—but like, I just like being aware of what's happening.

For Olivia, the thermometer and the accompanying practice of monitoring emotions helps bring her awareness to her emotions in a different way. She suggests that this different kind of awareness allows her to recognize her sadness as a passing state, rather than a permanent condition. In other words, the cognitive grappling, or metacognition, involved in the practice of translating felt emotions to numbers resulted in a kind of evaluative stance and objectification of her emotions that helped Olivia to distance from them.

Thus, a benefit of tracking and quantifying seemed to be that it made emotion less existential for some. Evidence suggests that this kind of distancing from feeling may even have a kind of “disembodying” effect, which, in its extreme form, can itself be a source of distress and pathologization (Phillips et al., 2001; Seligman 2010). ⁷ However, for these youth, whose feelings had been a source of distress and dysfunction, the distancing aspects of emotional metacognition often seemed welcome. Youth responses to the feelings thermometer underscore how the process of distancing and objectification is scaffolded through metaphor, suggesting that emotion metaphors may represent an important part of the dynamic process through which embodied appraisals unfold across time.

At the same time that the thermometer seemed to offer a welcome means to shift their embodied appraisals in ways that made some youth feel more in control, others were more critical of the quantifying aspects of the thermometer—particularly the inducement to commensurate. In fact, some youth actively resisted the practice of taking their own “emotional temperatures.”

For example, 16-year-old Mina, who embraced the metaphor of temperature and identified with the feelings thermometer as a way to think about her emotions (see above), nevertheless rejected the practice of self-monitoring precisely because of the potential to become distanced from feelings through their objectification:

I honestly don’t feel like it really changes anything because I’m like well I know how mad I am and I’m just basically repeating the fact that I’m really mad so it doesn’t really make anything better … I just I feel like it takes off the focus of how you’re feeling so that if you’re really mad it's going to take off the focus and you’re not going to be mad anymore and to me it doesn’t work because I’m like well I’m not going to do this because I’m mad, you know?

Mina is determined to feel what she is feeling and not to be distracted from those feelings by the demand to evaluate them objectively. She rejects the analytical orientation toward her emotions that might push her into a more detached position as a witness or observer. By extension, she rejects the increased responsibility for controlling her emotions, which is the flipside of the kind of secondary agency that such a detached position often provides.

Many youth worried about issues of commensurability raised by the thermometer metaphor. They actively wondered, for example, about the transferability of the scale across time and situation. For instance, choosing a single number to represent her emotional state did not make sense to Ana:

Because um, like, sometimes like, personally like I wouldn’t know if it can get worse, so maybe like I can say a 10 but it gets worse after, so like maybe that wasn’t like a, that wasn’t like a 10, maybe that was like an 8 and it's um, like, heading my way is a 10, which I thought was a 10 but it wasn’t 10.

And Jessica put it this way:

Yeah, cuz my depression is like a shape-shifter, sometimes it's really big, sometimes it's really small, so to me, one day might be a 10, how sad I am, the next day I’m like, this, no, this is a 10. So it's like, I can’t commit, saying, this is a 10, this is the worst day, the other day, I think this is the worst.

Youth concerns about commensuration are grounded in both logic and embodiment. In a logical sense, anchoring a feeling on a fixed numerical scale is problematic given that one cannot anticipate the relative strength of feelings as yet un-felt. This problem of logic seems to connect to an embodied and expressive concern for youth as well, who grappled with the limitations that committing to a number might create on their ability to both experience and communicate the relative force of their feelings. Finally, youth doubts about the numerical scale pointed to the way in which, experientially, emotional appraisals are inseparable from context. How can I fix my feelings to a single number, they wondered, when they are so slippery, changeable, and linked to particular moments? In other words, using the same scale to try to capture feelings across time and place seems to contradict the embodied phenomenology of youth emotions as they unfold in emergent meaning–feeling loops, under different sets of social conditions.

Ultimately, youth responses to the feelings thermometer, and the practice of monitoring and quantifying emotion that it imparts, varied. Some youth experienced as highly beneficial the emotion metacognition and regulation that the thermometer seemed to help scaffold. Others felt constrained and concerned by the impetus to fix and evaluate instances of emotion in the face of the dynamic and unfolding nature of embodied appraisals. Overall, youth offered many creative interpretations of this prescribed metaphor along with many of their own metaphors, suggesting that metaphor use and the practice of reflecting on emotion metaphors could be a productive means of engaging with adolescents about their emotional lives.

Conclusion: The politics and poetics of emotion metaphors in the clinic

The thermometer metaphor is just one example of the prescribed metaphors used in mainstream, manualized CBT for children and adolescents. Other metaphors commonly used in CBT, such as the metaphor of being a “thought detective” to oneself, similarly locate problematic thoughts and feelings inside individuals, and emphasize methods of revealing and transforming them by adopting an objective, empirical stance (Friedberg & Wilt, 2010). The feelings thermometer and related metaphors thus help translate emotions from unruly, immersive, bodily responses associated with socially problematic forms of expression, to more distant, linguistically mediated, and socially productive forms of expression. Such metaphors appear to be effective in helping to reduce youth distress, at least in the short term.⁸

We can understand this efficacy in terms of the looping processes underlying emotion. If emotional appraisals and bodily states are co-constituted through a dynamic looping process, and metaphors are grounded in these dynamic links between mind and body, then metaphors are particularly well-positioned not only to reflect but to affect the shape of our emotional loops. Metaphors that link the phenomenology of emotions to techniques of observation and assessment introduce a form of meta-cognitive mediation into these loops, which feeds forward to affect the very phenomenology of the emotions in question. In other words, these metaphors contribute to establishing different patterns of “embodied appraisal”—ones in which the appraisals become more conscious and explicit rather than implicit, automatic, and intuitive. This meta-cognitive appraisal lends a sense of distancing from emotion, and a kind of secondary, removed agency that witnesses, rather than feels. These metaphors and the practices they scaffold thus have the potential to create the experience of both greater control over, and dampening of, affect. However, this effect seemed to vary across youth, with some teens finding more resonance in the metaphor than others. This underscores the idea that the “fit” of a particular metaphor depends in part on aspects of individual self and identity.

Given that these metaphors are prescribed—which I have argued means they are authoritative, generic, and pre-scripted around a particular model of selfhood—what are the implications of such potentially powerful transformations of youth affect?

The feelings thermometer is designed to help condition youth to a form of self-control and emotion regulation that maintains feelings within a relatively limited, non-threatening range. By definition, this kind of affect takes expressive forms considered acceptable within mainstream social and institutional settings (Bialostok & Aronson, 2016). This is in line with contemporary emotion pedagogies more broadly, and the now ubiquitous emotional intelligence construct, which favor certain kinds of emotional expression: in particular, emotional meta-narrativity and the ability to recognize, label, and articulate emotions in ways that are deemed not only socially appropriate, but strategic (Ilouz, 2008; Ramos-Zayas, 2011; Wilce & Fenigsen, 2016). In these increasingly popular models, the affective or bodily dimensions of emotion tend to be suppressed or sequestered. That is, the tears, angry gestures, and voice-raising that are not simply reactions to the feeling, but actually constitute the affect (Merleau-Ponty, 1945), are viewed as publicly unacceptable, while the meta-cognitive aspects of emotions, especially the ability to correctly evaluate and name one's own and others’ feelings, are highly valued (Ilouz, 2008). Moreover, understanding the cause and effect logic of one's own and others’ emotions is also seen as an important skill for achieving social and, increasingly, economic ends (Bialostok & Aronson, 2016). Thus, prescribed metaphors of CBT are geared toward helping youth develop forms of embodied appraisal that have crucial social and economic currency (Ramos-Zayas, 2011).

That this is not lost on the youth themselves comes across in the value they place on knowing their emotions, the links they make between knowing and mastery and control, and their clear sense of the desirability of both. For many youth in my study, who entered therapy precisely because their previous forms of emotional behavior and expression—things like cutting, emotional outbursts, aggression, and suicide attempts—were perceived as dangerous and pathological, the promise of mastery and control was particularly salient. For these youth, the prescribed metaphors and the enactments they scaffolded not only represented a pathway toward recovery, or “getting better,” but also a way of “doing better.” That is, by offering access to a kind of “emotional habitus” (Ilouz et al., 2014) linked to dominant notions of successful personhood, these techniques seemed to promise not just relief from distress, but the opportunity for youth to do better than their parents, peers, or the dominant social expectations and political representations they understood to circulate around them. The thermometer and the practices it imparts could thus easily be interpreted as “technologies of the self” (Foucault, 1984, 1988) that help to privatize and individualize, as opposed to collectivizing, responsibility for the health and well-being—not to mention the success and failure—of these vulnerable adolescents (Rose, 1990, 1998).

However, as several scholars have recently cautioned, we must recognize the potential for such therapeutic practices to “oscillate” between alignment and disalignment with neoliberal governmentality (Matza, 2018, p. 9; Pritzker & Duncan, 2019). That is, even as these psychotherapeutic techniques foster orientations and skills consistent with becoming a responsibilized, self-managing subject, these skills may also lend a sense of mastery that can be used in support of other personal, social, and political ends. The meta-cognitive skills and cause and effect rationality that the feelings thermometer helps to instill may, for example, lend themselves to a kind of distancing that allows youth to see their social and political contexts more clearly, and to gain insight into the layered causes of their distress. Certainly some youth—like 16-year-old Gina, who drew a direct link between the bullying she experienced at school and the anti-immigrant rhetoric of the Trump administration—appeared to demonstrate this capacity. We must bear in mind, therefore, that CBT and all such therapies have the potential for active, agentive, and inter-subjective engagements that inevitably result in complex and variable forms of up-take (Pritzker & Duncan, 2019).

Youth responses to the prescribed metaphors of manualized CBT underscore their active, agentive, and inter-subjective participation in the therapeutic process in general, and in the interpretation of clinical metaphors in particular. The producer (or prescriber) of a metaphor cannot entirely control how it will mean to others, since meanings are taken up through each individual's embodied experience. As I have shown, youth interpretations were not always consistent with clinical intent and their responses even suggest a level of resistance to some of the meanings, particularly the quantifying ones, which threatened to flatten their experience or constrain their options for expression. The intuitive but also expansive nature of youth responses also highlight how the very qualities of metaphor that make it an effective tool for scaffolding embodied transformations also make it an incitement to poesis. That is to say, using metaphors can help stimulate new associations and meanings, shape fresh insights, and reshape perceptions in ways that may in turn stimulate new forms of creativity. My interlocutor Jessica described a simple creative act in which she often engaged, which strikes me as an excellent example with which to conclude:

I used to draw a whole bunch like on my arm, um like flowers … like I would get in trouble for it at school, because like, you’re not supposed to be drawing on yourself. It was … kind of my like … showing love to the place where I would abuse the most.