The authors describe the role of metaphor in the theory and practice of psychotherapy. Metaphors are considered fundamental elements of our worlds of language and concepts and not just figures of speech, poetic devices, parables, or creative ways to make interpretations. Metaphors shape the process of therapy by structuring the therapist's perceptions, stance, and attitude. They also organize the way problems are discussed as well as the solution that are seen as effective. The authors review the literature on metaphor in psychotherapy and explore common psychotherapeutic metaphors such as "psychotherapy is war," "the mind is a brittle object," "the conduit metaphor," and a variety of somatic metaphors. They conclude with a discussion of how metaphors function in the process of psychotherapy.

Objective The Title V Maternal and Child Health (MCH) Block Grant is the linchpin for US MCH services. The first national performance measures (NPMs) for MCH were instituted in 1997. Changing trends in MCH risk factors, outcomes, health services, data sources, and advances in scientific knowledge, in conjunction with budgetary constraints led the Maternal and Child Health Bureau (MCHB) to design a new performance measurement system.MethodsA workgroup was formed to develop a new system. The following guiding principles were used: (1) Afford States more flexibility and reduce the overall reporting burden; (2) Improve accountability to better document Title V’s impact; (3) Develop NPMs that encompass measures in: maternal and women’s health, perinatal health, child health, children with special health care needs, adolescent health, and cross-cutting areas.ResultsA three-tiered performance measurement system was proposed with national outcome measures (NOMs), NPMs and evidence-based/informed strategy measures (ESMs). NOMs are the ultimate goals that MCHB and States are attempting to achieve. NPMs are measures, generally associated with processes or programs, shown to affect NOMs. ESMs are evidence-based or informed measures that each State Title V program develops to affect the NPMs. There are 15 NPMs from which States select eight, with at least one from each population area. MCHB will provide the data for the NOMs and NPMs, when possible.ConclusionsThe new performance measurement system increases the flexibility and reduces the reporting burden for States by allowing them to choose 8 NPMs to target, and increases accountability by having States develop actionable ESMs.SignificanceThe new national performance measure framework for maternal and child health will allow States more flexibility to address their areas of greatest need, reduce their data reporting burden by having the Maternal and Child Health Bureau provide data for the National Outcome and Performance Measures, yet afford States the opportunity to develop measurable strategies to address their selected performance measures.

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Objectives Statute for the Maternal, Infant and Early Childhood Home Visiting (MIECHV) Program requires that states and territories receiving Program funding assess improvements for participating families across six areas that address maternal and child well-being. In 2015, the MIECHV Program performance measurement system was redesigned to allow for national-level analyses and cross-grantee comparisons. The new measures were aligned with other federal performance measures to help ensure context for program analyses. The number of measures was also reduced to lessen reporting burden. This paper describes the redesign process and resulting national performance measures. Methods The redesign process included holding listening sessions with stakeholders and experts; reviewing the findings from other home visiting performance initiatives; consulting with experts; soliciting and responding to public comment on draft measures; seeking clearance from the Office of Management and Budget; and specifying each measure with detailed eligibility criteria, the timing and frequency of assessments, and the window for data collection. Results The redesign resulted in a set of 19 measures that all MIECHV-funded home visiting programs began collecting in 2016. This is nearly half the number of measures that MIECHV awardees had been reporting prior to the redesign. The measures are aligned with other federal measures, including those used in Healthy People 2020 and those used for other maternal and child health programs. Conclusions for Practice Data reported by MIECHV Program awardees will be used to assess their performance, identify areas for targeted technical assistance to support continuous improvement, and ensure meaningful impacts for at-risk families.