Metaphors of mindfulness in pediatric occupational therapy practice

Abstract

Introduction:

Metaphors are commonly used linguistic devices that can encourage deep reflection and offer new insight. Metaphors have been used within the both the occupational therapy and mindfulness literature to describe complex phenomena. The aim of this phenomenological study was to identify, analyze, and interpret metaphors used by pediatric occupational therapists to describe mindfulness in their clinical practices with children and youth.

Method:

Eight North American Occupational Therapists participated in semi-structured interviews which were transcribed verbatim. Transcripts were read to identify idiographic or naturally occurring metaphors used by participants. Metaphors of mindfulness were also elicited from participants as an interview question.

Findings:

Three themes were identified within participants’ idiographic metaphors of mindfulness: mindfulness as a tool, mindfulness as exploration, and mindfulness as a support. Two additional themes were identified within participants’ idiographic metaphors of themselves as facilitators of mindfulness: therapist as a guide, and therapist as a gardener. Elicited metaphors generally aligned with the themes identified for idiographic metaphors while some offered additional unique insights.

Conclusion:

The findings open conversations about therapists’ framing of the use of mindfulness within the context of pediatric occupational therapy.

Introduction

In their ground-breaking work on metaphor, Lakoff and Johnson (2008) note that metaphors permeate everyday life in that they influence both thought and action. Metaphors abound in daily language use, and consideration of the deeper meanings behind metaphors can bring previously unconscious ideas to the surface (Lakoff and Johnson, 2008). Metaphors are defined as “understanding and experiencing one kind of thing in terms of another” (Lakoff and Johnson, 2008: 5). Metaphors invite consideration of the relationship between the two objects of comparison, eliciting new or different understandings (Redden, 2017). It has been argued that metaphors can make complex topics easier to understand (Schmitt, 2005), help enhance communication (Steen, 2011), offer new understandings, and facilitate action (Jacobs and Heracleous, 2006). Goatly (2011) highlights that in addition to fulfilling conceptual functions, metaphors also fulfill interpersonal, emotional, and communication functions. Nardon and Hari (2021) write that “metaphors are personal, imaginative and creative and allow for a new understanding of experience by highlighting some things and hiding others” (p. 3).

In occupational therapy, metaphors have been used to make sense of professional practice. To name just a few instances, Finlay (2000) used metaphors of “battle ground” and “safe haven” to understand occupational therapists’ experiences of working in interdisciplinary teams. Wood (2004) related the aspects of professionalism in occupational therapy to the “heart, mind and soul” of practice. Denshire (2005) used the provocative metaphor of a circus when exploring imagination and reason in occupational therapy practice.

A small body of scholarship has researched therapists’ metaphors in occupational therapy practice. Davis (2008) analyzed student occupational therapists’ metaphors for helping and found two key themes related to client-centeredness and client autonomy and responsibility. Mackey (2013) explored metaphors used by occupational therapy practitioners to describe their working lives and identified five types of metaphorical stories: the battle, the love story, the magazine, the journey, and the pantomime. More recently, Smart et al. (2022) analyzed parent- and therapist-generated metaphors to understand expectations for pediatric rehabilitation services, including occupational therapy. They identified the four metaphors of force, appreciation, illumination, and relationship (Smart et al., 2022). It appears that the use of metaphor is generative for making sense of aspects of occupational therapy practice.

Denshire (2005) argues that metaphor offers a different approach to reflection on professional practice and may be useful for clinicians to make sense of their experiences. In occupational therapy, metaphors have been used to reflect on occupational therapists’ ideal versus actual practices and to uncover “beliefs, values. . . and underlying assumptions about professional practice” (Kinsella, 2000: 25).

The value of metaphor has also been discussed in the mindfulness literature. Scherer and Waistell (2018) examined metaphors of mindfulness in Buddhist Monk Thich Nhat Hanh’s work and found they offered deep insight both psychologically and practically. Deliberate metaphors used in Buddhist teachings about mindfulness have been studied and results noted that they offered both explanatory and reconceptualization insights (Silvestre-López, 2020).

While mindfulness has been described in a variety of ways, one commonly utilized definition of mindfulness describes it as “the awareness that emerges through paying attention, on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment” (Kabat-Zinn, 2003: 145). Research into the applications of mindfulness within the profession of occupational therapy is emerging. A recent study linked a mindfulness-based occupational therapy intervention to improvements in occupational performance and satisfaction in adults as measured with the Canadian Occupational Performance Measure (Alfuth et al., 2022). In a scoping review exploring the value of mindfulness for children receiving occupational therapy services, Hardison and Roll (2016) reported that mindfulness-based approaches appeared to be helpful for children with musculoskeletal disorders and chronic pain.

Study purpose

Given the reported power of metaphorical language, and the emergent nature of mindfulness within the profession, an analysis of the metaphors used by occupational therapists to describe mindfulness in their professional practices was undertaken. The purpose was to inquire into the metaphors used by therapists to describe their experiences of using mindfulness in their practices, and to explore the meanings invoked. The primary question of this study was: What metaphors are employed in pediatric occupational therapists’ accounts concerning the use of mindfulness in their practices, and what do these suggest us about their views on the use of mindfulness with children and youth?

Methods

This study adopted hermeneutic phenomenology as its methodology. In hermeneutic phenomenology, understanding of a phenomenon is revealed through the first-hand accounts of those who have lived the experience. Hermeneutics focuses on the art of interpretation (Kinsella, 2006). The hermeneutic circle is commonly used in hermeneutic phenomenology and encourages deep reflection on meanings inherent in a text (Grondin, 2016).

A Heideggerian phenomenology of practice was utilized as the theoretical framework for this study. Such a framework draws attention to the experience of being-in-the world and to action in the world. While Heidegger (2010) voiced objections to the use of metaphor, leading some to contend that metaphor analysis falls outside the scope of a Heideggerian phenomenological study, other scholars have noted that Heidegger makes regular use of metaphors in his writing (Stellardi, 2002; Ricoeur, 1978). Ricoeur (1978: 280) writes,

In Heidegger himself the context considerably limits the import of this attack on metaphor, so that one may come to the conclusion that the constant use Heidegger makes of metaphor is finally more important than what he says in passing against metaphor.

Lakoff and Johnson (2008: 4) argue that humans “live by metaphor,” in that metaphors structure the actions undertaken in daily life. As phenomenology is concerned with the study of “quotidian practices of daily life” (van Manen, 2014: 15), it can be argued that metaphors permeate phenomenological inquiries. Lakoff and Johnson (2008) also note that their work on metaphor stems from the phenomenological tradition, which further underlines a fit between metaphor analysis and phenomenology.

Participants

Eight occupational therapists who identified as using mindfulness-based approaches in their professional practices with children and youth participated in this study. Written informed consent was received from all participants. Seven participants self-identified as female and one as male. Six participants were from Canada and two were from the United States. Participants practiced as occupational therapists between 4 and 31 years, with time in pediatric practice ranging from 3 to 31 years. All participants identified that at least 50% of their caseload was focused on children and youth under the age of 18. Experience with mindfulness in clinical practice varied but ranged between 2 and 10 years. Participants were assigned a pseudonym to protect confidentiality.

Data collection

Data collection involved 90-minute in depth semi-structured interviews. The aim of the interviews was to elicit participants experiences of applying mindfulness in their professional practices with children. An idiographic approach (Grant and Oswick, 1996) was utilized to extract metaphors that appeared without prompting during the semi-structured interviews. This approach is considered to be rich and generative while reducing demand on participants (Redden, 2017).

Furthermore, as part of the interview, a metaphor elicitation or forced metaphor approach (Tracy, 2010) was utilized. Participants were asked to develop a metaphor that described their experience of applying mindfulness in professional practice. Benefits of this approach include fostering critical thinking and evaluation while offering comparisons that are rich sources for analysis. Drawbacks include the inherent difficulty of generating metaphors on the spot, which can reduce creativity (Redden, 2017). To reduce the demand on participants, they were offered a 10-minute reflective break in which to generate their metaphors. The interviews were audio recorded, and transcribed verbatim.

Data analysis

Interview transcripts were read multiple times by the first author with a particular focus on identifying idiographic metaphors, or those words and phrases that were used metaphorically as these appeared organically within the transcript. Both idiographic and elicited metaphors were extracted, grouped together and mind mapped (Davies, 2011) to aid in the analysis of patterns and relationships across the data and eventually develop a set of key themes.

Results

Within the interview participants used many idiographic metaphors of both mindfulness and themselves as facilitators of mindfulness practices with children and youth. Three dominant idiographic metaphors were identified within the interview transcripts, whereby mindfulness was described as (1) a tool, (2) exploration, and (3) support. In addition, two predominant idiographic metaphors for occupational therapists as facilitators of mindfulness practices were identified. Facilitators of mindfulness were described as (1) a coach and (2) a gardener. While many of the elicited metaphors align within the above-noted themes, some stood apart as unique. As a result, the elicited metaphors have been presented separately.

Idiographic metaphors of mindfulness

Mindfulness as a tool

The most common metaphor for mindfulness, appearing 38 times in the data, was that of a “tool.” Participants identified that mindfulness could be applied by themselves and their clients to achieve certain goals. For Emma, the tool metaphor was a salient one. She observed, “I will introduce it as this is just another tool to help us to tune into our bodies and understand how our brains and bodies are working together.” She reflected, “I think that being able to tune in and use mindfulness tools to understand ourselves better so that we can engage in our environment and with the people in our lives and in our occupations in a more effective and joyful way.” Isla also made frequent use of the metaphor of a tool, stating, “Mindfulness is such a useful tool because it only needs you and your body. You already have everything you need with you.” Isla noted that mindfulness did not need to replace other approaches but could complement other tools used by a child: “We don’t need to strip them of tools that help them. We can just add to their toolbox.” Brigid also used the metaphor of mindfulness as a tool frequently in the interview. She commented on mindfulness as a clinical tool she could make use of “I have a lot of tools in my toolbox. Mindfulness is one of them.” She also connected this metaphor to the teaching of mindfulness to clients: “I want to equip these kids to have as many skills as they can to help them be functional adults. We have to equip them with the tools they need, like mindfulness.” Like Isla, Melanie observed that mindfulness was only one of the strategies she might draw upon, stating, “Mindfulness is one of the many tools that I’m using to help get the children to be in a much calmer state.” Likewise, Ashley observed, “I often tell kids that mindfulness is just a tool in their toolbox.” Furthermore, she reflected, “We give kids a lot of tools and strategies. Mindfulness is one.” Claire also noted that mindfulness was just one approach she might take, stating, “It’s one of the tools in my toolkit.” She also observed that choosing the “right” tool was important, “We have to be careful to use the right tool with each client. You know mindfulness is one tool, but one size doesn’t fit all.” George observed that he made use of mindfulness practices to support a specific goal with clients. He offered, “I have used mindfulness practice like a body scan as a tool to help support relaxation.”

Three participants, Brigid, Isla, and Melanie described how the metaphor of mindfulness as a tool was useful but perhaps oversimplified what mindfulness was about and needed to be used with caution. Brigid stated, “I get lost sometimes in the ‘tool’ of it. Mindfulness is who we’re supposed to be. We’re supposed to be present in our own lives.” Similarly, Isla said, “I often call it our most underutilized tool. But I don’t want to jump to that language. It’s not just a tool. It’s so much more.” For Melanie, the metaphor of mindfulness as a tool was tempered with caution about expectations: “What I say to parents often too is there are all these tools and strategies we can use to help like mindfulness. But it’s not a magic wand.”

Mindfulness as exploration

Another common metaphor, appearing 21 times within the data, was that of mindfulness as exploration. Ashley noted that her own experiences with mindfulness felt like exploration: “Once I explored with mindfulness, I started to apply it to practice,” and “I’m still exploring a lot of different practices.” Ashley also talked about exploration with clients: “I encouraged the client to explore mindfulness to see what worked for him. He tried different things and said deep breathing was helpful.” Claire observed the following about exploration within her practice: “We explore with mindfulness. I jump into playful games and activities and encourage the kids to be curious about what our bodies are telling us.” Emma used the exploration metaphor to highlight the fit of mindfulness for children and youth: “We use mindfulness to do a lot of exploration and it helps kids to start to tune into the signals that their bodies are sending them.” Brigid, when speaking about mindfulness, observed, “It’s really an exploration. The yoga mat is a place to explore and mindfulness is about exploring.” She also noted, “We have a lot of freedom to just explore the practices and see what fits for the child.” George used the metaphor of exploration saying “I’m a big fan of exploring. I’ll ask them if they are willing to try a mindfulness practice and see what happens.” Melanie also used this metaphor noting: “I love to explore yoga, meditation and mindfulness practices to see what might work for my clients.” Isla echoed what other participants had said, “With one client we explored a bunch of different practices until we found what was calming for her. It helped her articulate what worked or didn’t work for her.” Finally, Sophie noted that she felt she helped to facilitate exploration on the part of her client: “So I explored the experience of mindfulness with the client. What did it look like? What did it feel like?”

Mindfulness as a support

A final commonly used framing of mindfulness was that of offering support, such as a foundation or a pillar. This metaphor appeared 19 times within the data. George used this metaphor most frequently. He framed mindfulness as a foundation, saying “It’s come to me that it [mindfulness] is kind of a core or foundational part of the work we do. We have to work on those foundation pieces first or we’re not really addressing the problem.” Emma also used this metaphor, referring to mindfulness as a support: “I try to work from a lens of how can I support this client? Mindfulness helps me do that. It helps to support kids to meet their goals.” Likewise, Claire stated, “It [mindfulness] helps me to support my clients and meet them where they are.” Brigid used the language of a foundation, saying “I started creating mindfulness programs for my clients because it is just so foundational. There is so much emphasis on development and the social-emotional piece gets thrown to the side like it doesn’t matter.” Sophie used the language of mindfulness as support for building a foundation: “Mindfulness is like building your foundation. It’s like building the base for doing other work.” Ashley noted about her clients, “Mindfulness supports the kids in doing something they need to do.” Isla echoed this idea, saying, “Mindfulness supports them [children] in getting through a school day when its stressful and scary and hard.” Finally, Melanie framed mindfulness as supporting individuals to carrying the metaphorical weights inherent in life: “Mindfulness is about moving forward each day despite all the weights that we carry on our shoulders.”

Idiographic metaphors of therapist as mindfulness facilitator

Therapist as guide

The most common metaphor participants used to describe themselves as facilitators of mindfulness was that of a guide, teacher or coach, supporting the client to develop skills and strategies for life. This metaphor was salient, appearing 32 times in the data. Brigid observed that like a coach, she supported her clients to achieve certain aims. She reported, “The thing that we want to teach kids all the time is how to get a pause, just be more conscious in general. I have to coach the kids to help them find their own pause.” She discussed benefits of coaching the adults around her pediatric clients as part of her practice: “When we teach or coach the adults in the room [about mindfulness], the benefits extend to the kids. Adults impact kids more than we realize.” Claire also noted an impact from coaching adults: “Part of supporting the kids is coaching the adults around them.” She also observed the impact of regular opportunities to practice mindfulness, saying, “Part of coaching is building confidence. I want the kids to feel confident in their mindfulness.” Emma echoed the role of adults in children’s lives: “Working with kids means we are also working with parents. This means I am sort of the coach for mindfulness.” She also observed that mindfulness helped to shift her approach to clients, stating, “Mindfulness shifted me from ‘doing therapy to someone’ to coaching them and supporting them to learn about themselves.” Sophie noted that she shifted in and out of the role of coach, saying, “When there are moments when I’m able to coach a client through a mindfulness practice, then I do. I often coach them to do mindfulness practices and they’re able to do it and they feel good after.” George described his overall approach to mindfulness in practice as coaching:

I approach it like coaching. We don't learn to play basketball by only ever playing in the championship game, right? Like we usually practice things and we practice them when there's not as much going on. If you’re practicing the shot, you’re doing it. You don’t have everyone kind of running around, right? And that’s like when we’re learning mindfulness skills. We have to practice them at the times when we already are kind of calm.

Ashley highlighted the benefit of practicing mindfulness with the support of a guide: “We practice together. I can show them what it looks like and how it works. Then later I see them applying mindfulness without really thinking about it. All that practice sort of became ingrained in the child.” Melanie used the metaphor to describe how she modifies mindfulness practices for children, noting: “I find breathing exercises with kids, they don’t really get it. So I guide them through more active mindfulness practices.” Isla used this metaphor to describe a specific client encounter:

I guided her through an exercise where we did some imagery of her favorite place. Because of her trauma history, it was easier for her to do this than to start by observing the present moment. We got there, but we had to start somewhere safe.

Therapist as gardener

A less common, but salient metaphor used by participants to describe their use of mindfulness in practice was that of a gardener, focused on nurturing the growth and development of young clients, both as humans and practitioners of mindfulness. This metaphor was identified in the data 15 times. Brigid reflected on her role as a mindfulness facilitator as that of planting seeds and nurturing them: “We practice taking a pause. That pause is really the seed of executive functioning. My job is to plant this seed and help it flourish.” Ashley drew on the gardener metaphor stating, “My job in bringing mindfulness to them is to help deepen their roots so that they’re strong and can grow and flourish.” She also observed that her own growth was linked to her mindfulness work: “I love practicing together. I want to grow together with these kids.” Claire noted that, like plants, an individualized approach was necessary to support each client’s growth: “We know that we are wanting to cultivate awareness in the child. It doesn’t need to be a certain way. We can be creative to help each child, even when doing something like mindfulness.” Emma observed that mindfulness helped her to establish a positive therapeutic environment for her clients. She stated mindfulness, “helps me to cultivate a safe environment to work with the child. It helps me to be calm and grounded.” Sophie expressed similar ideas, saying, “I had to cultivate my own mindfulness practice. Only then could I share mindfulness with the kids I work with.” Isla described mindfulness as “planting seeds of calm.”

Elicited metaphors

In the concluding section of the interview, participants were invited to describe a metaphor of mindfulness within their professional practice. Many of these metaphors resonate with the key themes presented above; however, some were unique. Elicited metaphors are presented in Table 1.

Table 1.

Elicited metaphors.

Participant	Metaphor
Ashley	Butterfly—“It’s like turning into the butterfly. Once you hatch, like once you become that butterfly, it’s beautiful and you feel free. I can do what I need to do, just like fly freely be happy. The little caterpillar eating the leaf is like getting little bits of knowledge that help you grow. You start to learn and then you grow. And then once you actually apply it, you hatch and then you see the benefits in your life. As a butterfly, as somebody who’s kind of emerged at the other side, these kids are still caterpillars that you’re showing the way to become a butterfly.”
Brigid	Mirror—“Mindfulness for me has been a mirror, separating me from my thoughts and allowing me to be more of a witness to what is happening in my life. So using mindfulness has made me realize that make that that. My mission should really be about bringing out the light in others by bringing out the light in myself. I feel like kids are just a reflection of us. You know, they hold up a mirror to us, so anytime that we take the time to really see the light in kids and that's all the time you know really they are the light bearers you can see the light in yourself, you know? So you start to realize that we’re one.”
Claire	Exploring—“Mindfulness is curious, fun exploring. It is like being in a submarine exploring the depths of who we are.”
Emma	Anchor—“Mindfulness is an anchor. The reason I said anchor is because mindfulness allows me to be present with the child I am with, in the moment we are in, regardless of what it is. Mindfulness is something that I can come back to regulate myself and to help to co-regulate the child. For the child. . . it allows them to tune into what their body, the signals of, what’s happening on the inside and the outside of the body. It helps them to return to self and find what feels good for them so that they can engage in what they want to and what they need to. So that's why I think that it's an anchor.”
George	Binoculars—“Mindfulness is like binoculars that help us see the lion of big emotions out in the distance. Then we can choose an action about what we're going to do in that situation, rather than having to react because the lion is attacking us.”
Isla	Weather—“Mindfulness is like your body is like the weather and you’re just observing what’s happening with it. You’re not trying to control it, you're not trying to make it rain or make it the sun shine on you. You’re not trying to do anything but notice what is happening and then respond to it so. So you really are the meteorologist. I help kids notice what's happening and then recommend what they can do. For example, if there is a tornado coming, you can’t stop it from coming but you can prepare yourself for it. My job is to prepare others, like these kids.”
Melanie	Tree—“What comes to my head immediately is a tree that’s grounded and rooted, but growing and spreading out. The groundedness piece is the piece that allows them to be connected and staying present in the moment and that staying present and connected in the moment is what then allows them to grow and branch out and, and become this big full spectacular tree.”
Sophie	Coach—“If you think about soccer, I’m kind of the coach. You can have the ball, and I can tell you all kinds of different ways that you can score a goal. But when you’re in that moment you’re going to have to choose which way you want to score the goal because I am not on the field doing it. Same for mindfulness, I can teach the different ways of doing mindfulness but in a way, they’re going to have to choose in the moment which one they need or what makes sense because there are so different many ways to do mindfulness.”

Discussion

While a rich variety of metaphors were used by participants, five salient themes were identified, as well as an array of interesting elicited metaphors. Three themes discuss mindfulness as a tool, as exploration, and as a support. Two themes relate the participants to a coach or a gardener. These metaphors highlight practitioners’ knowledge about the experience of mindfulness in pediatric occupational therapy practice and provide opportunity for deeper reflection on its meaning.

The theme of mindfulness as a tool reveals how mindfulness may be viewed as helpful for therapists’ practices with children. Occupational therapists use the language of tools to describe both clinical interventions (Dibsdall, 2021), and theories and models that inform practice (McColl and Stewart, 2003). It appears that for practitioners in this study mindfulness was part of a toolbox of approaches used in therapeutic practice, with a number cautioning that it was not necessarily a panacea, and one stating it was not “a magic wand.” While calls for incorporation of mindfulness into occupational therapy curriculum exist, they predominantly consider the role of mindfulness in supporting students’ and clinicians’ well-being (Dean et al., 2017; Reid, 2013). Given the findings of this study, it appears that mindfulness facilitation education within the professional curriculum may offer an important contribution to the training of occupational therapy students. A few participants highlighted that despite their description of mindfulness as a tool, mindfulness was more than a tool and linked to the ‘being’ of a person. A number of participants expressed caution regarding the use of instrumentalist language to describe the affordances of mindfulness. It is not uncommon for metaphors to serve as a means of simplifying or making accessible a difficult concept (Lakoff and Johnson, 2008), and it appears that this application of metaphor may be present.

The theme of mindfulness as exploration highlights the way in which mindfulness may offer opportunities to test out approaches with clients. Participants often noted that mindfulness offered opportunities to “explore what worked” for an individual client. It may be that mindfulness is useful for an aim of the profession to respond to the individualized needs of each client and recognizing their unique circumstances (Meadows et al., 2020). The metaphor of exploration highlight a sense of the unknown outcomes of mindfulness as a process. In this way, mindfulness may lend itself to a process-oriented approach to therapy. Finally, the metaphor of exploration appears salient within occupational therapy literature. For instance, in one study, student occupational therapists identified “exploring the unknown” as a metaphor for healing (Davis, 2008), perhaps mindfulness offers one way of engaging healing through such exploration. The participants in the Davis (2008) study identified “exploring” as navigating the unfamiliar terrain of rehabilitation as a potentially negative or frightening experience. Interestingly, participants in the present study tended to frame exploration as a neutral or positive experience. It is possible that perspectives of participants in the present study aligned with attitudinal qualities of mindfulness (Kabat-Zinn, 2013), whereby they did not label or judge the exploration as positive or negative, but rather adopted the attitude of allowing it to be what it is.

The theme of mindfulness as a support was linked to participants’ accounts of building mindfulness as building a foundation. Participants differed in their ways of applying this metaphor, noting that mindfulness was foundational for health and well-being, and also for participation in daily activities, or what is referred to as “occupations” within the occupational science literature. Given the body of literature linking occupational participation with well-being, it is unsurprising that this dual consideration of mindfulness as a foundation for well-being and occupation was seen (Reitz and Scaffa, 2020). The framing of mindfulness as a foundation of well-being or health appears well supported by the literature; research into the role of mindfulness for enhancing the well-being of children and youth is flourishing (Semple and Burke, 2019). The consideration of mindfulness as supporting participation in daily occupations is nascent (Goodman et al., 2019) and appears a fruitful avenue for further research.

The theme of occupational therapist as guide arose frequently in the study. The metaphor of guide suggests a relational orientation between therapist and child and aligns with a “power sharing” rather than a “power over” view. It is also consistent with the professions’ philosophy of enablement of occupation (Restall and Egan, 2021). In a study of occupational therapy students’ metaphors for healing, Davis (2008) reported that students identified “being a tour guide” as a metaphor for facilitating healing. The students noted that this metaphor helped to highlight the nature of a collaborative approach to therapy, providing space for the client to make individual choices within therapy (Davis, 2008). The findings from the present study resonate with this use of guide as a metaphor. Furthermore, “coaching,” which implies a guiding relationship with clients, is a key approach detailed in occupational therapy’s enablement-oriented framework (Townsend and Polatajko’s, 2007), such that “coaching” or “guiding” align with therapeutic approaches advocated within the profession.

The theme of occupational therapist as gardener also resonated with the analysis of student occupational therapists’ metaphors for healing with participants describing healing as like “watching a flower grow” (Davis, 2008: 247). This metaphor describes the role of the therapist as “nurturer and cultivator of new growth” (Davis, 2008: 247). While these students were reflecting on occupational therapy practice broadly, this emphasis on growth appears particularly salient for clinicians working with children, who are often asked to apply developmental models when framing therapeutic interventions (Reitz and Scaffa, 2020). This primary focus on linear developmental models has been critiqued in recent years (Burman, 2008; Gibson et al., 2015), and a shift in perspective may be present within participant metaphors in this study, whereby some participants noted a focus on cultivating mindfulness, with less of an emphasis on comparing children against “normal development” models of growth. It should be noted that this was not the case for all participant metaphors. Finally, this metaphor offers insight into the ways in which mindfulness may support the development of safety within the therapeutic relationship. Further research in this area is warranted.

The elicited metaphors varied broadly, but generally offered insight into occupational therapists’ experiences with mindfulness in practice. Some fit with themes identified within the idiographic metaphors. For example, the butterfly and coach metaphors offered by Ashley and Sophie fit well within the guide theme. Isla’s metaphor of weather appears to fit with the guide theme, in that she noted her aim to support children in preparing for whatever comes. Claire’s metaphor of exploring aligns with the theme of exploration. Some participants, including Emma and George used specific artifacts for their metaphors, an anchor, and a pair of binoculars respectively, which potentially aligns with the tool theme. Melanie’s metaphor of a tree fits well with the gardener theme. One elicited metaphor stood as unique. Brigid’s metaphor of a mirror pointed to the interconnectedness of each person:

My mission should really be about bringing out the light in others by bringing out the light in myself. I feel like kids are just a reflection of us. You know, they hold up a mirror to us, so anytime that we take the time to really see the light in kids . . . you can see the light in yourself, you know? So you start to realize that we’re one.

The findings of this study offer unique insights into metaphoric representations of occupational therapists’ experiences of mindfulness with children and youth. Metaphors are commonly used linguistic devices that can help describe experiences that may be difficult to articulate (Kinsella, 2000). These metaphors offer interesting representations of pediatric occupational therapists’ interpretations of their use of mindfulness with children and youth. As mindfulness practices are a relatively new adoption within the profession, it is revealing to see the ways in which the metaphors of mindfulness reveal alignments with the theoretical foundations of the profession. These metaphors serve to foster conversation about the contributions of mindfulness to occupational therapy in terms of their affordances as tools, as means of exploration and as an approach to supporting clients. In addition, they reveal conceptions of the work of therapists as deeply relational and as cultivating conditions of growth (i.e., as gardener or guide). Future study into the affordances and challenges of using mindfulness practices with children, youth and families, and within rehabilitation practice with different groups are important as the use of mindfulness in health care practice continues to grow.

The strengths of this study include the focus on metaphors to illuminate key themes related to the practices of occupational therapists who use mindfulness. The research was strengthened by application of a theoretically grounded methodological design, and the focus on the lived practice experiences of the participants. This sample size of eight is robust for phenomenological data; however, a larger sample size may have offered more richness in the data. Furthermore, there was limited diversity across participants; a more diverse population could have contributed to a wider range of perspectives.

Conclusion

The aim of this phenomenological study was to identify, analyze, and interpret metaphors used by participants to describe mindfulness in their clinical practices with children and youth. Three themes were identified within participants’ metaphors of mindfulness: (1) mindfulness as a tool, (2) mindfulness as exploration, and (3) mindfulness as a support. Two additional themes were identified within participants’ metaphors of themselves as facilitators of mindfulness: (1) therapist as a guide and (2) therapist as a gardener. In addition, elicited metaphors generally aligned with the themes identified for idiographic metaphors, and some offered additional unique insights. The findings open conversations about therapists’ framing of the use of mindfulness within the context of pediatric occupational therapy.

Key findings

• Metaphors demonstrated broad alignment with theoretical foundations of occupational therapy.

• Metaphors identified mindfulness in pediatric occupational therapy as a tool, as means of exploration, and as an approach to supporting clients.

• Metaphors revealed mindfulness as relational and holding potential to support clients’ development.

What the study has added

This study offers insight into metaphoric representations of pediatric occupational therapists’ experiences of mindfulness with children and youth and opens conversation about the framing of mindfulness within the profession.