The Yale Journal for Humanities in Medicine

Metaphor and Meaning: How Words Work Magic in Our Patients

“[The poem]…begins in delight…and ends in a clarification of life… in a momentary stay against confusion.”—Robert Frost

Abstract: The way physicians employ words has important implications for health care. Our use of inappropriate images or metaphors can adversely affect our patients’ sense of well-being; conversely, an empathic metaphor can be an aide to healing. Poetry Therapy is a more systematic way of using language as part of the healing process, and has been used as an adjunctive treatment modality in both medical and psychiatric settings. However, all physicians can use what Theodor Reik called “the third ear”—listening empathically to our patients’ language, and helping them to express the “poem” inside that is trying to get out.

***

I want to suggest in this essay that words work magic. Magic, as tradition tells us, may be for good or ill. As physicians and scientists, of course, we don’t need to assert that magic exists in the way that red blood cells or bacteria exist—and we don’t need to assert anything supernatural about words to say that they can work magic. We just need to realize that words seem to have special and mysterious properties—properties that may heal or harm. Indeed, the word “magic” may be defined as “…a mysterious quality that seems to enchant.” [1] “Magic” is derived from the word magus, which, in Latin, is usually translated as “sorcerer”. However, in the Persian tradition, a magus was a member of the priestly caste. And in the New Testament, a magus was a “wise man”—a meaning we still associate with the story of the three magi who came to the site of Jesus’s birth. So: “magic” is linked with priests and wise persons. Doctors—the word means “teachers”—have also been linked with wisdom and priestly functions, since ancient times. It is not surprising, then, that doctors of the body and soul have known about the magical properties of words, for centuries. Long before we had healing drugs and medications, we physicians used words to help our patients, especially those who were suffering or dying. Words, we know, can comfort. But they can also discomfit or cause pain. The notion that “sticks and stones” can break our bones but that words can never harm us is actually untrue—though it is true that the way we interpret or attach meaning to words, not words themselves, ultimately determines how we react emotionally. Still, given our cultural and linguistic heritage, there are patterns of interpretation and meaning that are almost inescapable, almost inevitable, no matter what our cognitive schema. Consider how any of us would feel if one of our most esteemed teachers referred to us as an “idiot” or a “jerk”. To be sure, we can do some rational “self talk”, and argue to ourselves that we don’t need the approval of our teachers [2]. But this sort of cognitive strategy is usually helpful in mitigating pain that we have usually already felt. It is a kind of cognitive poultice we put on our hurt feelings. How we use words with our patients, I want to suggest, has important emotional reverberations—for good or ill. One type of linguistic device—what we call metaphor—may have a particularly strong effect on our patients—again, for good or ill.

But before we drown in abstractions, let’s do a little thought experiment. Imagine that you are a patient—Mr. or Ms. Jones—sitting in the doctor’s office. You are seeking help for severe, chronic pain of uncertain origin. The pain has been impeding your everyday abilities and activities, and you have not gotten relief from over-the-counter remedies, massage, hot baths, etc. So, you are seeing Dr. Smith for some relief of your suffering. In scenario #1, Dr. Smith presents you with a pain medication and says the following: “Well, Mr./Ms. Jones, you clearly have some very severe pain, and I’m going to prescribe a pain relieving medication. I’d like you to think of this medication as a kind of crutch. It will help you walk around until we can figure out what is causing your pain.” Now, scenario #2: this time, Dr. Smith says, “Well, Ms. Jones, you have some very severe pain, and I’m going to prescribe a pain relieving medication. I’d like you to think of this medication as a kind of bridge—a bridge between feeling miserable and feeling better. Of course, you will still have to walk across that bridge, but this medication will at least put some boards beneath your feet.”

Each scenario presents a metaphor: medication as crutch, or medication as bridge. Which is usually the more helpful in working with patients?In my work as a psychiatrist,I am often confronted with a patient’s reluctance to take medication for anxiety or depression because he or she sees such medication as “a crutch”. And a crutch is for—for whom? For “cripples”? Or for weak people? People with a lack of fortitude or will power? You can pick your negative association, but the metaphor of a “crutch” is almost always strongly pejorative. This is not to malign our colleagues in physical therapy or orthopedics, who often use crutches to very good advantage in their patients. It is simply to acknowledge a linguistic reality for many people. On the other hand, I have found that the metaphor of a bridge—a structure that helps you get from here to there, but which still requires effort on your part—has been very helpful to patients for whom a psychotropic medication is necessary.

But let’s back up a moment and ask, “What exactly is a metaphor?”. The word is conventionally defined as an “implied comparison”, such as “the twilight of life” to describe old age. But if we go back to the root of the term--the Greek metapherein--the term “metaphor” means, literally, “to transfer” or “to carry” [3]. In psychiatry, we use the term “transference” to describe the feelings patients carry over from some figure in their past, such as a father or mother, to the therapist. A metaphor, then, may be understood as a linguistic device that carries meaning over from one context or object to another. Thus, the linguist and cognitive scientist, George Lakoff, explained metaphor in terms of “mapping” from one conceptual domain to another—what Lakoff referred to as the “source domain” and the “target domain”, respectively.[4] So, when we speak of love as a “journey”, we are mapping constructs from the realm of journeys (“fork in the road”, “dead-end”, “turning point” etc.) to the realm of relationships.In a sense, then, a metaphor is a kind of bridge between two conceptual realms. So my comparing an antidepressant medication to a bridge was a special case, in which I used the word “bridge” as a bridge—a bridge that conceptually and emotionally linked medication with a physical structure that bears weight, and which may help a person across “troubled waters”, to borrow from the old Simon and Garfunkle song.

Now, why is all this important in the care of patients? I believe—and my experience confirms-- that the kind of metaphors we use can help patients heal, or cause them more pain. I believe that metaphors may help a patient bear suffering, or make suffering harder to bear. I believe that even a patient’s adherence to medication regimens may be influenced by the kind of metaphor we employ, regarding that medication.

Let me give you an example from my clinical experience. I once had a very psychotic patient who would take only one antipsychotic medication, which happened to go by the brand name Navane. It wasn’t necessarily the most effective antipsychotic for this man, but it was the only one he would even consider. Why? Many years before I treated him, he had taken an over-the-counter “nerve” remedy called “Nervine”. This was actually a bromide-based drug produced by Miles Laboratories—Miles’ Nervine. Along with a number of bromide-containing drugs, this was taken off the market in the 1970s, because of neurological and other side effects due to bromide intoxication. But for my patient—let’s call him Mr. Gray—Navane reminded him of “Nervene”. Now, Mr. Gray was not stupid or demented. Even when you explained to him that the two drugs were completely different--and he clearly understood this--he would still refuse anything except Navane. It turned out that “Nervine” was associated in Mr. Gray’s mind with relief of anxiety—the medicine had apparently worked for him. You could say that Mr. Gray simply “associated” Nervine with Navane. But I think it was more complicated than that. The drug Navane was acceptable to him because it was a kind of metaphor; that is, it carried meaning over from one context or object to another. In this case, the name “Navane” carried emotional meaning over from the days of Miles’ Nervine to Mr. Gray’s present predicament. You could also consider “Navane” to be a kind of transitional object—a bit like the “security blanket” made famous by the character of Linus, in Charles Schulz’s “Peanuts” comic strip. The English psychoanalyst Donald Winnicott spoke of transitional objects as things, such as a teddy bear or blanket, that allowed the child to retain some of the security of the mothering figure without always having the mother or father physically present. You could say that a transitional object, such as a blanket, is a kind of physical metaphor for mother’s comfort. So, too, with Navane—it is a metaphor for a kind of comfort Mr. Gray had with Nervine. So, what was the practical upshot of this? I tried to respect Mr. Gray’s wishes because I was aware of the symbolic importance of the Navane. I prescribed it even though there might have been better drugs, pharmacologically speaking, than Navane.

The notion of metaphor becomes very important when working with psychotic patients—often because what may seem to be a metaphor is actually not. For example, when the patient in an acute psychotic episode tells you, “Doctor, my brain is a sewer”, he or she may mean precisely that—not “My brain is like a sewer”, but rather, “My brain is a sewer, literally clogged with feces and junk and germs.” It would be a therapeutic mistake to confuse such psychotic descriptions with metaphor. [5] On the other hand, one can sometimes connect with psychotic patients through use of a metaphor. A patient with paranoid schizophrenia who tells you that her husband has been poisoning her coffee may mean this quite literally. But it may help her if you respond by saying, “It sounds like you have a very bitter marriage.” Here, the word “bitter” is the metaphoric term—it compares “marriage” to something that tastes awful. But it also links up with the patient’s delusion regarding the poisoned coffee. Dr. Robert E. Jones, a physician, has said that “the metaphor has healing power, because it can translate a pathologic unconscious idea into healthy meaning.” [6]. By using this metaphor--“It sounds like you have a very bitter marriage”-- you may be helping the patient translate her delusion into words that have a “healthy meaning”, but which resonate with the patient’s experience. Moreover, the therapeutic metaphor may allow you to empathize with the patient’s bitterness and loneliness in her marriage, without buying into the delusion of the poisoned coffee. This approach is usually more helpful than a frontal assault on the content of the delusion, such as saying to the patient, “Well, Mrs. Gibbs, there really is no evidence from any of our laboratory tests that your husband is poisoning your coffee.” Psychiatrists know that being “ambassadors of reality” sometimes means going into the embassy through the side door. (Now, there’s another metaphor!). Dr. John Sonne, a physician, has noted that an apt metaphor can link the unconscious with the conscious and can be “…as powerful in health as…a symptom can be in sickness.” [7]

Now, I don’t want to give you the idea that metaphor is something we need to attend to only in psychiatric settings. On the contrary, the importance of metaphors and imagery in general medicine is considerable, in my view. Let me give you a personal and somewhat painful example from the experience my wife and I had when my mother-in-law was declining in health, as a result of chronic congestive heart failure. Helena was a very intelligent, vibrant, and rather feisty woman her entire life, and lived well into her 90s. But a few years before she died, her congestive heart failure worsened. The doctors held out little hope for her, and one of them—a very bright but not very sensitive internist—made a telling comment to Helena. She said, “It’s all down hill from here, I’m afraid.” When you think of that metaphor, “down hill,” what comes to mind? Well, sometimes we use that image in a favorable sense, as when we are talking about finishing up a difficult project, and coasting “downhill.” But in this context, the doctor was conveying an image of deterioration and decline, and Helena immediately sensed that.

A lesser woman might have been crushed by this gloomy metaphor. In fact, when we, Helena’s family, heard this statement, we were appalled and disheartened. Fortunately, my mother-in-law was, as I said, pretty feisty. Her response to the doctor’s crude metaphor was: “I may just surprise you, Doctor!” And she did—Helena went on to live another two years, after this dire, downhill metaphor was enunciated. I think this says that some of us do have the power to overcome even a devastating metaphor, delivered by a powerful authority figure—but it is not always easy, and some people never fully recover from hearing this sort of thing from their doctor. It makes me wonder what additional comfort and solace we might bring to our patients with a counter-metaphor. Instead of “It’s all down hill from here,” how about, “You’ve got a rocky road ahead, but I’m here to help you navigate the bumps”? Or, “It’s going to be an uphill struggle, but you might just make it to the top”? It would be fascinating to do a controlled study of such metaphors, and their effect on patients with CHF and other conditions. To my knowledge, this has not yet been carried out. However, Dr. Bernard Lown—a renowned cardiologist—has eloquently described how cruel and insensitive metaphors can adversely affect the care of patients with heart disease—such as when the physician says to the patient, “You may be living with a time bomb in your chest.” [8]

In contrast, evidence from the general medical literature suggests that the right kind of metaphor may serve a therapeutic function in several disorders. For example, gastroenterologist Joseph Zimmerman describes how he uses the metaphor of a “river” in his work with Irritable Bowel Syndrome (IBS) patients:

A metaphor of a river is used to evoke both a smooth, coordinated flow through the normal digestive tract and a normal flow in the management of the patient's emotions. The possibility that some blockage has occurred in the river, resulting in perturbation of the normal flow, is then suggested to the patient. This is followed by a suggestion for the patient to clear the blockage. This approach may lead patients to work on the emotional components of their symptoms, resulting in their subsequent resolution. [9]

Other research has found that the therapeutic use of metaphor may help cancer patients find new ways of expressing and managing their emotional distress. One oncologist put it this way:

My patients use the roller coaster image as a way of conveying good moments and bad moments…whatever works is fine with me. The whole point is to find common language and to strengthen the alliance…whether it is the…[doctor] bringing the metaphor to the situation or the patient, both are looking for ways…to describe what they or somebody else feels. [10]

Can metaphor be used more systematically to help our patients? I believe the answer is yes. In fact, “poetry therapy” has been used for many years to help all kinds of patients cope with their disease and suffering. The use of creative writing as therapy actually goes back over 200 years, when the Pennsylvania Hospital used writing as therapy. When Robert Frost described poetry as “…a momentary stay against confusion…” I believe he was recognizing the healing properties of metaphor and poetry. Dr. Jack Leedy—one of the first physicians in the U.S. to use poetry therapeutically—has written extensively on how the right kind of poem can help an otherwise closed off and shut down patient find words for her grief. In his book, Poetry as Healer, Leedy describes how both the reading and the writing of poetry may be used to help such patients, and not just in psychiatric settings. [11] Patients with terminal cancer or other chronic, wasting diseases may be helped with the therapeutic use of poetry. Dr. Morris Morrison, who was not a physician but carried out poetry therapy with very sick patients, described a case of an adolescent female who developed severe glomerulonephritis [12]. This required not only 5 weeks of hospitalization, but home schooling. The patient, Tina, became lethargic and depressed. Dr. Morrison asked Tina to describe her feelings in poetry, which she did. Her first poem says it all: “My dreams/ Yellow leaves, lifeless, dead’ My life/ Skies gray, dark, filled with rain/My hope/ pale, cowardly, scared.” [12]You really couldn’t write a better description of how clinical depression feels. Gradually, with further writing exercises, Tina was able to regain her emotional footing. One of her later poems begins like this: “The sun has arrived in the sky/ Saying “goodbye” to the dark daughter of time. Life begins with the kiss of the sun. The sun is a young boy looking at me, lustful, with his large beautiful eyes…” You can see how the patient herself now expresses her mood change in metaphorical terms: saying goodbye to “the dark daughter of time” and welcoming the young and lustful boy.[12]

When I was a psychiatric resident working on the inpatient unit, I was privileged to co-lead an unusual therapy group. Patients were encouraged to bring in poetry—whether their own or that of others—and read it to the group. A psychiatric nurse and I encouraged discussion of the feelings, images, and memories the poems would almost invariably evoke. We often selected poems that resonated with themes of loss, longing, loneliness, and love—the “Four Ls”. But we were careful to avoid poems that, in Dr. Jack Leedy’s words, “…offer no hope, or that might increase the depth of the [patient’s] depression…” [11] Indeed, in unskilled hands, the reading of some types of poetry may be a distressing experience for extremely fragile patients, who may regress in the face of overwhelming or primitive emotions. [13] But such negative reactions were by far the exception in our group. Most of our patients found the group a safe, structured setting for exploring feelings they otherwise kept tightly under wraps.

I not only use poetry with my patients, I also write it. [14] Of course, I write on all kinds of topics, and not simply those related to the care of patients. But in my own work with seriously disturbed patients, I have sometimes found it “therapeutic” to put the chaos of the patient’s illness into the structure and solidity of verse. This poem (“Crisis”) describes my work with a seriously disturbed and suicidal patient.

I've set aside
   my prescription pad
and analytic calm--
   dropped all pretense
of science:
   it's you and me now,
pressed cold
   against death's ribs.
I use
   what tricks I know
to keep you living
   through another bony night,
another flurry
   of final phone calls.
And you, as always, refuting life:
   denaturing love, companions, sex.
Well, you leave my office alive.
   That's as close
to certainty
   as our work gets. [14]

Writing this was “therapeutic” for me, if not for the patient—though I believe there is a reciprocal relationship that governs these matters: when the physician is more “settled” in the work of healing, the patient benefits.
But there is a broader sense in which we, as physicians, social workers, psychologists and healers, can do poetry therapy. It involves what the psychoanalyst, Theodore Reik referred to when he used the expression, “Listening with the third ear.” What does this mean in practice? The poet and physician William Carlos Williams once said that, inside every patient, there is a poem trying to get out—trying to make itself heard. I believe that the skilled physician is a kind of midwife—someone who helps that poem emerge from the patient. If, as physicians, we listen very carefully to our patients, we can enter what Williams called, “those secret gardens of the self.” [15]

There is a story I once heard about a psychiatrist whose last name was Rosenbaum. I no longer know the source of this story,* but I remember it very clearly. This doctor had a very psychotic patient, a woman with schizophrenia. The patient approached him one morning, looking very distraught, and said, “Dr. Rosenbaum, do you have any roses in your garden?” The good doctor was probably rushed and a little caught off guard. He more or less brushed the patient off, on the theory that this question reflected the very well-known neurolinguistic deficit seen in many patients with schizophrenia: the tendency to use language very concretely. So, in the psychotic brain, somebody named “Rosenbaum” must have “roses” in his garden. Or so the doctor thought. But, not long after this initial encounter, Dr. Rosenbaum found his patient weeping softly in the corner. After exploring what was happening with her, he eventually understood the meaning of her question—that is, the “poem” she was unconsciously reciting for him. The question, “Do you have any roses in your garden?” was really a kind of metaphor. It was really a question like, “Will you take care of me, Dr. Rosenbaum, the way a gardener lovingly takes care of his flowers?” When the patient was rebuffed, she felt great sadness. So while we need to be careful with psychotic patients—and not always hear metaphors in their imagery—we also need to see beneath and through some of their images, down into those “secret gardens of the self.” I believe that, with all our patients, that is where the real “magic” of medicine does its healing work.

***

*Dr. Robert Daly has suggested that the psychiatrist in question may have been Milton Rosenbaum MD

This paper was adapted from a talk given April 27, 2007, at the Center for Bioethics and Humanities, S.U.N.Y. Upstate Medical University, Syracuse N.Y. The author wishes to acknowledge the support of Dr. Mantosh Dewan, Chairman, Dept. of Psychiatry at Upstate Medical University; and of Dr. Deirdre Neilen and Dr. Kathy Faber-Langendoen at the Center for Bioethics and Humanities. The author also thanks Richard M. Berlin M.D. for his helpful paper on metaphor in psychotherapy (Am J Psychother. 1991 Jul;45(3):359-67).

References

[1] The American Heritage Dictionary, Office Edition. Boston, Houghton Mifflin Co., 1983.
[2] Ellis A, Harper RA: A Guide to Rational Living. Hollywood,Wilshire Books, 1961.
[3] American Heritage Dictionary of the English Language: Fourth Edition, Boston, Houghton Mifflin Co., 2000.
[4] Lakoff G: The contemporary theory of metaphor. In: Ortony A (editor): Mediphor and Thought, 2nd ed., Cambridge University Press, 1993, pp. 202-51.
[5] Pies R: Poetry and Schizophrenia. In: Literature and Medicine. Ed. PW Graham. Vol 4. Johns Hopkins University Press, Baltimore, 1985.
[6] Jones RE: The double door. In: Leedy J: Poetry as Healer. New York, Vanguard Press, 1985, pp. 193-200.
[7] Sonne JC: Metaphors and relationships. Family Process 1964;3:425-27.
[8] Bedell SE, Graboys TB, Bedell E et al: Words that harm, words that heal. Arch Intern Med. 2004; 164:1365-8.
[9] Zimmerman J. Cleaning up the river: A metaphor for functional digestive disorders. Am J Clin Hypnosis, . Am J Clin Hypnosis 45;353-359, 2003.
[10] Penson RT, Schapira L, Daniels KJ et al : Cancer as metaphor. Oncologist. 2004; 9:708-16.
[11] Leedy J: Poetry as Healer. New York, Vanguard Press, 1985.
[12] Morrison MR: Poetry therapy with disturbed adolescents. In: Leedy J: Poetry as Healer. New York, Vanguard Press, 1985, pp. 212-27.
[13] Pies R: Adverse reaction to poetry therapy: A case report. Journal of Poetry Therapy 1993; 6:143-7.
[14] Pies R: Creeping Thyme (Poems). Richmond, Va., Brandylane Publishers, 2004.
[15] Stone J: A lifetime of careful listening. A centennial retrospective on the work of William Carlos Williams (1883-1963). JAMA. 1983; 250:1421-5.

Published: September 25, 2007