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Background  In the present study, we wanted to explore which metaphors patients suffering from major depressive disorder (MDD) use to explain their experience of being in therapy and their improvement from depression.    Methods  Patients with MDD ( N  = 22) received either psychodynamic therapy (PDT) or cognitive behavioral therapy (CBT). They were interviewed with semi-structured qualitative interviews after ending therapy. The transcripts were analyzed using a method based on metaphor-led discourse analysis.    Results  Metaphors were organized into three different categories concerning the process of therapy, the therapeutic relationship and of improvement from depression. Most frequent were the metaphorical concepts of surface and depth, being open and closed, chemistry, tools, improvement as a journey from darkness to light and depression as a disease or opponent.    Conclusions  Patient metaphors concerning the therapeutic experience may provide clinicians and researchers valuable information about the process of therapy. Metaphors offer an opportunity for patients to communicate nuances about their therapeutic experience that are difficult to express in literal language. However, if not sufficiently explored and understood, metaphors may be misinterpreted and become a barrier for therapeutic change.    Trial registration  Clinical Trial gov. Identifier:  NCT03022071 . Date of registration: 16/01/2017.

Digging down or scratching the surface: how patients use metaphors to describe their experiences of psychotherapy