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If you listen closely to everyday conversations, you will notice how often people use metaphors: for example, ‘I’ve been offered a new job on a plate’ or ‘I’m sick to death of my job.’ You will know instinctively that these statements are not describing plates, sickness or death in a literal sense. They are invoking an imaginary likeness – which is exactly what metaphors are about. Some people may get an image of plates or sickness when hearing these phrases, but this is not essential, because metaphors work through unconscious as well as conscious associations. Interestingly, the two statements I have quoted also contain other metaphors, although you may not have noticed these. For example, the word ‘offer’ derives from the act of presenting a gift or sacrifice and still carries resonances of this, although we now apply it more commonly in an abstract sense. Similarly, the word ‘job’ originally meant a single task, as in ‘a repair job.’ Although we still recognise that meaning too, we mainly use the word now to refer to paid employment.
To put matters at their simplest, all language is metaphorical. The literary critic and poet William Empson wrote ‘Metaphor, more or less far-fetched, more or less complicated, more or less taken for granted (so as to be unconscious) is the normal mode of development of a language.’1 Two linguistic philosophers, George Lakoff and Mark Johnson, took things further. They argued that human thought processes are themselves largely metaphorical and based on ‘understanding and experiencing one kind of thing in terms of another.’2 Cognitive psychologists have mostly agreed with them. When we think we are describing something, we are really creating it by building up a matrix of imagined likenesses. Think of the brain as a kind of neural dictionary, where no concept can ever be defined except by the use of other concepts.
Medicine has always been shot through with metaphors. (It is hard to think about metaphors without using them, as I have just done.) Medical metaphors often attest to their era and culture. Nowadays a lot of medical language describes bodies in terms of machines, which may ‘break down’ or be ‘mended.’ This is now being supplemented by expressions related to computing, such as ‘operating systems’ or ‘functionality.’ As many writers have pointed out, such sets of metaphors not only mirror the socio-technical world around us. They also determine the ways that we and our patients experience our bodies and our ailments. Telling someone they have a ‘slipped disc’ – a metaphor that corresponds poorly with the condition but evokes strong mechanical associations – will have an effect on that person, and possibly on their pain too. There is sometimes only a fine line between the semantic and the somatic.
Among the different sets of metaphors that cluster around medicine, none have attracted more attention, or more criticism, than those referring to warfare and the military. As the writer Susan Sontag pointed out in her famous essay ‘Illness as metaphor,’3 cancer cells do not simply multiply, they are ‘invasive. They ‘colonise’ parts of the body, overwhelming its ‘defences.’ Treatment is ‘targeted’ to ‘kill’ the cells, while the patient feels obliged to ‘fight’ disease’ and ‘overcome’ it. Since Sontag wrote her piece in the 1970s, a debate has raged about her crusade to liberate us from such language – although commentators have noted how hard it is to enter the discussion without using military metaphors oneself. One well-known medical teacher in the UK has argued that such metaphors, and other ‘big picture’ ones such as seeing the body as a machine, are not intrinsically bad. The problem only arises when they shut down thinking and disable the kind of critical analysis needed to engage fully with patients.4 In contrast to this, a distinguished Canadian educator has suggested that we should ‘reimagine illnesses through new language’ altogether. Among other suggestions, he proposes replacing tropes of war and battles with metaphors of human ecology.5
I sympathise with both approaches as general principles but this raises the question of how to apply them in the hurly-burly of interactions with real patients – who might, for example, wish to ‘fight a battle’ with their diseases, contrary to the best instincts of their doctors. In this connection, I admire an essay on ‘reclaiming metaphor’ by Martha Stoddard Holmes from California State University. Her view chimes with the approach already used by many doctors of picking up on patients’ utterances and inquiring into these, inviting further evolution of their narratives. In her essay, Holmes writes:
Doctors must listen not simply to correct and realign the metaphors…but rather to engage in shared learning, as co-owners of the capacity for metaphor, co-directors of the operative metaphors for a particular illness experience, and equally, if differently, informed participants in the culture of medicine.6
The happiness bank
How then might we harness the power of metaphor more in clinical consultations? Here, I want to cite a case example presented a few months ago at a workshop on metaphor in Norway, led by the Scottish general practitioner and writer Peter Dorward. He read out an anonymised story about two of his patients who are drug users. He told us how the first of these patients, whom he called Margot, described her dependence on cocaine by using a remarkably powerful metaphor: ‘It’s a debt that just gets bigger,’ Margot said, ‘like a bad loan from the happiness bank…’
Later the same day, he happened to see another patient, ‘Big Tam,’ who in his words ‘has issues with alcohol, gambling, cocaine, violence, his past, his future and his personality’ – not to mention large debts. In the consultation, Big Tam was trembling with rage and asking for some Valium for ‘anger management.’ His doctor first tried reasoning with him: ‘If I prescribe this for you,’ he pointed out, ‘it will work, a bit, for about a week. Then you’ll not be able to manage without it. You’ll need more… It’s like…’
At this point he paused to think, and then recalled Margot’s expression from earlier and said it out loud: ‘It’s like a debt. A high interest loan. From the happiness bank…’ To his surprise, Big Tam, who appeared until that moment to be on the edge of coercion, nodded with understanding: ‘So what can you do for me doc?’ The episode shows exactly the quality of metaphorical co-production that Martha Stoddard Holmes has described. If anything, it is made more powerful by the fact that co-production involved not just one patient but two.
Peter Dorward ended his story with the following commentary. It may say almost everything about metaphors that we as doctors need to know:
A good metaphor is flexible, arresting, immediately and effortlessly understood. It is creative, a little unpredictable…Metaphor entails risk: we can’t always know what powerful change it might produce. Metaphor requires that we understand our patient: her language, her history, her culture, her humour, her education, how her imagination might work, what we must, at all costs, avoid saying. Like all good medical practice, metaphor demands that we listen.7
Patient consent for publication
I am grateful to Dr Peter Dorward for his permission to include his story of Margot and Big Tam and his comments on it.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.