First published: Journal of the Association of Surgeons of Great Britain and Ireland, 37, pp. 26-29.

Download original article

Some fascinating developments in the fields of neuroscience and cognitive linguistics over the last 30 years have furthered our understanding of how we structure our thinking through metaphor. This article is an exploration of the fundamental role that metaphor plays in understanding ourselves, others and the world around us, and considers how this might be relevant to a surgeon.

For a long time metaphors were seen as merely a figurative device used in literature. In Shakespeare’s Macbeth for example, Scotland is described as a body that ‘weeps, it bleeds, each day a new gash’. But we now know metaphor is much more than this. It is fundamental to everyday language, thought and deed. ‘The essence of metaphor is understanding and experiencing one thing in terms of another’.[1] Metaphor enables us to process abstract or complex concepts by thinking in analogies derived from more familiar experiences. In science for example, metaphor is a means of creating and communicating new theories and discoveries; ‘Max Planck, a gifted pianist and cellist, conceived quantum theory in part by imagining electron orbits as the vibrating strings of a musical instrument’.[2]

The surprising ways in which metaphors shape our world

When we describe a person as cold, we are not usually suggesting that they are hypothermic. When we describe an issue as weighty, nothing has been measured on a set of scales. In both instances, concrete qualities are being used to describe abstractions. Conceptual thought is given meaning through our bodily experience, in these cases: ‘affection is warmth’, ‘important is big’. The links between metaphors and their physical roots are evidenced in a series of rather remarkable studies that manipulated the conceptual-physical equations of affection-temperature and importance-size, and noted how changing one element affected the other. For example, Williams and Bargh got participants to briefly hold a cup of coffee (the researcher was seemingly struggling with an armful of folders) before being asked to read a description of an individual and rate their personality. The key experimental manipulation being the coffee was either iced or hot. Those who held the warmer cup tended to rate the personality as warmer: physical warmth influenced the rating of metaphorical warmth.[3] Interestingly the effect has been shown to run in the opposite direction too. Zhong and Leonardelli found that people asked to recall a time when they were ostracised gave lower estimates of room temperature than those who recalled an experience of social inclusion: metaphorical warmth influenced the rating of physical warmth.[4]

It appears there is neural ambiguity between the literal and the metaphoric. Both versions of a concept are in fact processed in the same part of the brain: the insula and anterior cingulate.[5] The brain is less bothered about the distinction between the real and the symbolic than we might suppose.

Implicit and explicit metaphors

Metaphors carry a great deal of abstract and intangible information in a concise and memorable package. Thus when someone describes their conversations with a colleague as like ‘banging my head against a brick wall’, it is easy to see the frustrating, futile, and even emotionally painful nature of those interactions. But these ‘explicit’ metaphors form only a small fraction of metaphors used in everyday speech. Usually neither speaker nor listener is aware of when a metaphor is being used. The more hidden ‘implicit’ metaphors that litter our conversations, are rendered invisible by their ordinariness and familiarity. Consider:

She’s got a grip on the situation.
He wants to build his confidence.
The patient is at a turning point after surgery.

These sentences are not obviously metaphoric until you look more closely at ‘got a grip’, ‘build’, and ‘turning point’. With this in mind, it is perhaps not surprising that studies suggest we use roughly six metaphors a minute in everyday conversations, and often more in those that are emotionally laden.[6]

One of the most commonly encountered metaphors in medicine is that of treating illness like fighting a war. President Obama announced, ‘Now is the time to commit ourselves to waging a war against cancer as aggressive as the war cancer wages against us’. Less explicit versions of this metaphor abound:

• Disease is the enemy – ‘His body was under siege by AIDS’.
• Patients are combatants – ‘She was brave in her fight against cancer’.
• Health-care teams are allies – ‘The physiotherapist will help get you back on your feet’.
• Weapons can be surgical, chemical, biological and nuclear – ‘The so-called cure is no magic bullet’.
• Immune systems are a defence – ‘The body normally has its own defences’.
• Being defeated is dying – ‘The patient finally gave up the battle’.[1, 8]

And it seems that these metaphors matter, as is illustrated by a study in the US in which participants were shown a report on crime and asked to give their crime-preventing suggestions. Everyone was given the same report, the only variable being the metaphor of crime used; crime as a virus or crime as a beast. This single metaphorical noun systematically influenced the way people reasoned about crime. When crime was framed as a virus, participants proposed investigating the root causes and treating the problem by enacting social reform to inoculate the community, with emphasis on eradicating poverty and improving education. When crime was framed as a beast, participants proposed catching and caging criminals and enacting harsher enforcement laws. The differences in opinion generated by reading the two reports were not small, they were ‘larger than pre-existing differences in opinion between Democrats and Republicans’. [9] Interestingly, participants cited crime statistics as being the most influential in their decision-making, when in fact the statistics were identical in both reports. These and a growing number of experiments confirm Lakoff and Johnson’s conclusion that ‘In all aspects of life, … we define our reality in terms of metaphors and then proceed to act on the basis of the metaphors. We draw inferences, set goals, make commitments, and execute plans, all on the basis of how we in part structure our experience, consciously and unconsciously, by means of metaphor’.[1]

Metaphors in consultations with patients

Metaphors can serve as an efficient means of helping doctors communicate and patients understand the complexity of their condition. One doctor, for example, uses the following metaphor for unexplained pain with patients who are familiar with computers; ‘I’ve examined the hard drive and it’s functioning well but the software is corrupt and needs to be deleted and replaced with a new, more positive programme’.[10]

However, metaphors have their limitations. Whilst they illuminate certain aspects of an experience they leave other aspects in the dark. Our way of thinking is channelled to make sense within the logic of the metaphor. Seeing the brain as a computer, as in the example above helps our understanding of the brain as an information processor, but undervalues its role as a living organism that is adaptive to its environment. In the case of martial metaphors losing the battle against disease implicitly represents failure; both patient and clinician may feel compelled to keep fighting when little or no medical benefit is evident. For some the ‘life is a journey’ metaphor provides a gentler and richer view of life in the context of profound illness; ‘the road may not be as long as one hoped, and important destinations may be bypassed’, but there’s no ‘winning, losing or failing’. There are ‘different roads to travel, various avenues to explore, and, always, there are exits to take’ [8].

It seems that clinicians would do well to be mindful of the metaphors that both they and their patients use. Consider the case of cyclist Lance Armstrong, who is reported to have switched oncologists after being told that the chemotherapy would hit him so hard it would virtually kill him. Although no doubt well-intentioned, this explanation of the treatment that lay ahead ended up alienating the patient from his oncologist. Armstrong discovered his own much more resourceful metaphor: that of taking part in the most important bicycle race in the world! He went on to survive widely metastatic testicular cancer and win six Tours de France. When he began to show a response to chemotherapy he wrote:

I had opened up a gap on the field. I knew that if I was going to be cured, that was the way it would go, with a big surging attack, just like in a race… [the tumor markers HCG and AFP]… were my motivator, my yellow jersey… I began to think of my recovery like a time trial in the Tour (de France). …I wanted to tear the legs off cancer, the way I tore the legs off other riders on a hill.[1]

The literature is full of accounts of patients revealing personal metaphors that support them through the ordeals of their disease and treatment. It is worth noting that a patient’s metaphors often have deep, personal significance and having someone else impose their assumptions on these metaphors can feel very uncomfortable, even dismissive. Metaphors are not intrinsically good or bad, appropriate or inappropriate. Their usefulness will depend on the patient’s personal and cultural values, their life circumstances, the nature of their disease [8].

An illuminating study by Skelton et al, in which transcripts from 373 consultations were analysed for metaphoric content, showed that in many ways doctors and patients were not speaking the same language since the metaphors they used differed.[13] Doctor’s tended to use mechanical metaphors (the urinary tract was the ‘waterworks’, joints suffered ‘wear and tear’); they spoke of themselves as controllers of disease (they ‘administer’ medication, ‘manage’ symptoms, and ‘control’ disease) and problem-solvers (symptoms are ‘clues’ to be ‘solved’). Patients, on the other hand, employed a wider range of vivid metaphors to describe their symptoms (‘I’m like the cotton-wool man’ for a sense of feeling out-of-touch), and metaphors of pain were used differently. ‘The picture here is of patients coming to the surgery with a wide range of vivid, particular, and personal descriptions and of doctors reinterpreting these as emotionally neutral problems of a general, depersonalised type.’ Skelton and his co-authors think this may be ‘an appropriate way of imposing ordered calm on a disparate mass of expressive data’. But, as Armstrong’s case, it may also create a barrier to communication and much may be lost in translation.

Introducing Clean Language

Communication gaps could be considerably reduced if healthcare professionals were trained to recognise patient’s metaphors, and to accept them as an accurate description of their illness, and were aware of their own use of metaphor. Counselling Psychologist David Grove was only too aware of the power of metaphor when in the 1980s he developed a questioning model for working with the metaphoric and symbolic domain of experience, which he called Clean Language. This specific set of structured questions are ‘clean’ because they use the person’s exact words and only introduce the universal metaphors of time, space and form, thus minimising the risk of unwittingly contaminating the other person’s experience with the metaphors and assumptions of the person asking the questions.[14]

It is beyond the scope of this article to give an in-depth account of Clean Language, the components of which are well documented and freely available online. But at a simple level Clean Language is a means of obtaining information that improves understanding whilst maintaining open-mindedness and respect. When one group of specialist Multiple Sclerosis nurses was trained to use Clean Language questions to encourage their patients to describe their strange symptoms in more detail (‘It’s like ants running all over my body’ and ‘It’s like cheese wire wrapped round my legs’), some patients said it was the first time they felt someone had really understood their illness.

At a more complex level exploring the symbols within an individual’s metaphoric landscape using Clean Language can become a route to profound personal insight and psychological healing.

What can metaphors teach us?

Gaining insight into our own metaphoric thinking can bring a richness of insight about the structure of our thinking. James Lawley gives a fascinating account of working in a coaching capacity with a man who wanted to ‘be able to hold the line against aggressive senior managers. A stream of subsequent metaphors were noted as this man described his situation at work; ‘I have to defend my people’, ‘I blew up’, ‘His method is to drill you and then attack’, ‘The troops are falling by the wayside’, and ‘I can lose it in the heat of battle’. No prizes for guessing his underlying metaphor: work is a battle. And the man’s response to having his exact words fed back to him; ‘I’m shell-shocked!’ He came to understand how his metaphor had significantly influenced the way he responded to his colleagues, particularly those ‘higher up the command chain’, and was able to settle upon a metaphor that suited him better; that of playing in an orchestra. Over the ensuing months he changed his behaviour to fit in with this new metaphor, using it to gauge his, and other people’s behaviour: ‘Am I participating like a member of the orchestra? When I chair the meeting, are we all playing the same tune and am I conducting appropriately?’ And as a result, his senior managers starting acting differently towards him.[15]

Gaining access to a person’s metaphoric thinking can also provide a means of sharing skills with others. One group of clinicians, considered to have excellent doctor-patient relationships were asked Clean Language questions to establish a consensus metaphor for communicating well. For them it was like being a chameleon detective – having the ability to adapt to each patient while remaining true to themselves, and getting to the heart of the problem. This metaphor was subsequently used in teaching these skills to trainees.[16] It takes only a little imagination to wonder what insights could be gleaned from asking ‘clean’ questions of expert clinicians so that they can convey through metaphor, for example, how they know when to operate and when not to, how to perform an operation with easeful competence, or how to convey difficult news to patients and their relatives.

To conclude

Metaphor is a natural way to describe symptoms and health. The metaphors that people use in their everyday language are idiosyncratic, but not random; they are consciously or unconsciously chosen because they contain an organisation that is consistent with the way that person is experiencing the world. This article is an invitation to become curious and respectful of the metaphors that arise in conversation with both patients and colleagues, and to apply that knowledge to improving medical interactions.

Suggested Introductory Reading

Geary, J. I is an Other: The Secret Life of Metaphor and How It Shapes the Way We See the World. Harper Collins 2011

Sullivan, W., and Rees, J. Clean Language: Revealing Metaphors and Opening Minds. Crown House 2008

Suggested further reading

Tompkins, P. and Lawley, J. Metaphors in Mind, The Developing Company Press 2000

Useful websites

cleanlanguage.com
cleanchange.co.uk
trainingattention.co.uk
cleanlearning.co.uk