”It’s bone on bone at L4, mate”If you have your brain thinking in a neuromatrix and neuroplasticity mode you could probably see that a limp output that is making someone hobble around is not much different to a language output such as “it’s bone on bone in my back”. Both are made by the brain, both are repeated innumerably, and both exist in widely distributed brain neurosignatures with probable overlap. There is no doubt that a limp would be a therapeutic target for any reasonable therapist. Get your patient to see what is happening in a mirror, stretch this bit and strengthen that bit etc. etc. And you could expect that better gait could decrease pain through a combination of altered limp circuitry in the brain, and healthier and more appropriate use of the body structures. But an alteration of the language output may be as clinically potent in desensitising pain neurosignatures and it certainly has not been considered as deeply in rehabilitation.Nearly all readers would aim for full and best expression of motor outputs, but many patients are left with a limited linguistic expression of their injury and therapeutic journey. For example, left with language neurosignatures such as “I have a popped disc” or “it’s bone on bone in my neck/lower back”. I am sure you can think of many more. It’s like leaving someone with an uncorrected limp – any educationalist will tell you that what is uncorrected one semester will show itself magnified the next semester or year.
Metaphors in a diagnostic sense
Modern, high quality, clinical skills require assessment and delivery of neuroscience knowledge in both narrative and metaphorical forms, but it is metaphor in particular which dominates patients’ descriptive language and our education.
Metaphor has had limited study in the pain area, but a way to start viewing metaphors in a diagnostic sense is to listen to the patient’s stories and to try to categorise them.
On the NOIjam blog there are posts seeking information and feedback on various metaphor categories to help our research. We welcome your help. Here are some suggested categories adapted from Lackoff and Johnson’ classic work on metaphors (1980).
‘Pain in the arse’ to ‘it’s totally stuffed’
We all use simple equalising metaphors all the time (‘he is a pain in the arse’, ‘she has a heart of gold’, ‘it hurts like hell’) – these are common, useful, colourful, open ended ways to express yourself.
Many patients use invasive metaphors (‘like a knife in there’, ‘my head is in a vice’) and sometimes therapists give them to patients ‘it feels like something is out of place’, ‘your pelvis has slipped’. X-ray findings – ‘degeneration, compression’ etc. – also create a perception of invasion, which these days we are aware could have potentially unhealthy immunological ramifications with glial cells on alert for challenges to the representation of the part in the brain. These metaphors need softening, reframing, removing.
Ontological metaphors are when people try, often desperately, to verbalise and objectify abstract notions such as pain and emotions (‘I feel as though I am going to pieces’, ‘It’s so fragile’). Just like new movement is precious post injury, so is emerging language as patients try and objectify and grasp what is often not objectifiable – i.e. pain, especially chronic pain often has nothing to link it to as smell has coffee, touch has texture and hearing has The Bee Gees. Patients want to grab this thing ‘pain’ inside then take it by the scruff of the neck, give it a damn good shake and have a look at it. No wonder they cling to a mere mention of ‘disc bulge’ if it gives it some object. This emergence of language needs to be helped and guided.
Some metaphors are orientational as in ‘my back is out’, ‘it goes up to my head’, some are static (‘something is wedged in there’) or mobile as in ‘it moves from back and goes into my groin’. I have no ideas what it might mean – maybe it will show up as a diagnostic in some smart study, but the change in language to a more normal output would be ideal.
Yet other metaphors suggest a separation of body and mind or ownership, as the problem gets labelled ‘it’, or even ‘my back is killing me’ suggests a separation of ‘back and ‘me’. ‘I want to cut it off’ or ‘give me a new one’ are also suggestive of disembodiment and the need, where possible, to get that person to take back and love the body part again.
Yet others are prognostic. ‘It’s stuffed’. ‘It’s completely ruined’ are common, but it’s not all bad as another metaphor could be ‘there is light at the end of the tunnel’.
I think that analysis of metaphors, based on the clinical question of ‘why are they saying this at this particular time’ and then considering whether the language could be diagnostic or need change/reframing, or is it just the local vernacular? This discussion continues on NOIjam and we would love to get your input.
Lakoff, G, Johnson M. (1980) Metaphors We Live By, Chicago, University of Chicago Press.
We are collecting examples of patient metaphors. Please add any below.
Another place to start are the metaphors and stories that the medical profession blythely use.
As part of my case management work for post accident complex trauma clients I make follow up calls to check on progress and I hear some wonderful “physio stories”.
Yesterday, following an interesting report in from a Physiotherapist I made a call to my client. During my call I asked if the Physiotherapist explained anything to her about the cause of her troubles, in other words what sort of diagnosis had the Physio provided.
My client described how the physio has told her ” my pain and reduction of movement is to do with the muscles becoming all inflamed and that the muscles have created all this inflammation inside them and that it’s all around and spreading out from inside the muscles” Further on she said “the Physio told me that her treatment would be to get all the inflammation to come out of the muscles and that she would make the inflammation go away”
That sounds particularly nasty and scary. I think all the professions have their special language that hasn’t really been thought through in terms of threat value. “Instability” is another one blithely offerred up by physiotherapists.
Yet inflammation can be made OK. its good stuff and it allows the therapist to drop the poerful term “self healer”, early on in an injury. After all, inflammation is all about self healing.
Great post David!
It’s fascinating when you step back and begin to listen out for these threatening and far from helpful metaphors and language which is so commonly used by patients (and therapists!).
Personal pet hate is the use of “bad leg” and “good leg” following a nice fresh total knee or hip replacement…
Hi Jack, I was thinking what might be a better term than “bad leg” and “good leg”. Maybe someone can help us out.
“Unaffected and affected” are no better and I don’t like the term “new bionic leg” – too machine like for me.
Maybe just good old left and right?
I would love to attend a conference that would be solely devoted to ” the language of pain and healing”. Let’s forget mirrors, manipulations, touching, exercises, and medications. let’s get to heart of the most used interventional modality that all professionals and non professionals use to heal and disable- our verbal and non-verbal communication skills. What a great multidisciplinary conference that could be. I think that we should also have a workshop offered by successful used car salesman- How do you get someone to say yes, buy in to something they do not want, and feel good about it? I am not saying this jokingly or in any disrespectful way. I think that we could learn a lot from those professionals who make their living by being “persuasive”. We don’t really learn that in school. Great blog. Language, presentation, metaphors/stories, and charms are used by charlatans all of the time. All of these techniques are just ways of getting neural tags to connect in ways that are advantageous to the manipulator. Why don’t we, as (hopefully) non-charlatan professionals, learn how to use them to our patient’s benefit. JOhnb
Sounds like a great conference idea John! I can’t see much support from Pharma though. But of course it would get enormous strength from all the disciplines with an interest incuding used car salemen. I dont mind admitting I have read a few of them, and you will can alwas pick up a gem or two.
I am glad you call language an “interventional modality”. Notably, very little research has been done where the language intervention (ie what they were told) has been separated from the intervention that they thought they were testing.
If you organise it John, we’ll be there!
David and the NOI team
Hello David et al.,
The power of language – so true. Thank you for raising it in to the health and pain arena. Peter O’Sullivan has also raised this very issue.
I thought I would draw to your attention a recent “All in the mind” episode (pod cast) ” How language shapes thought” (Radio National – ? date). There is some fascinating language research that demonstrates that different languages result in different thought processes (or could it be the reverse?).
I think and believe we (clinicians and researchers) have an obligation to be very clear and clean (as in not muddy) with our language and, with care, be candid in our interactions with others.
Regarding a conference – sounds like a plan.
Metaphor is a powerful organiser of though, emotion, perception and action. As a Feldenkrais Practitioner and NLP trainer, I often notice how the potential for improvement has been limited by the apparently absolute statements that the client or their health professional have used. Once you have “bone on bone” or “one rouge muscle” causing the pain what options are there? I have found several approaches that can often be helpful in beginning to loosen up the options for change. One is to introduce the element of time. Things that have been gradually get”ing” worse can start getting better NOW, because of a change in movement pattern, drug regime, workplace, etc. The addition of the little word YET to an ability, implies progress over time. Another is to engage in the metaphor of the human system as a self healing machine, grazed knees usually heal quickly without long term damage, broken bones take a little longer and some external support, so most things have the possibility to heal. Sometimes taking things to an absurd extreme can bust the image. If it is like there’s a knife in there could you have it go round and prune out all the dodgey bits so that it will be easy for the regrowth to come back to a nice strong healthy system? Finally the most important strategy is to provide some HOPE of improvement. Whatever metaphoric or linguistic strategies can be found to add this profound ingredient into the mix, could make the difference in progress or decline.
Excellent article. I like to try to listen to patients’ metaphors. And I always make a point of suggesting to patients that their spine/knee/shoulder is healthy and strong, even if it’s completely stuffed. I used to think patients would complain and say “that’s just not true!!” but they actually like to hear things like that and it helps reduce anxiety about recovery. I’m happy to lie because it’s not really a lie at all. The mind creates whatever reality it gives focus to.
Of course if one can generate really deep rapport, then the patient will do away with all metaphors and tell you the problem directly. So instead of “my back has a knife in it” they will simply tell you that they feel betrayed by their partner/spouse. Instead of saying “my shoulder feels heavy and achy”, they say “I can’t cope with the burden of my young children”. The deep level rapport cuts through everything. When that is established there’s no need to analyze metaphors because they disappear.
As clinical psychologist AND a chronic pain patient, I’ve had personal experience with the metaphors as well as hearing a few beauties from my clients. Here are some of the little gems I’ve come across. Some may be not as apt for your research but here goes:
“It burns like fire.”
“It stabs like a knife.”
“I’m feeling much older than my age.”
“I’m not getting any younger.”
“It just needs a good oiling.”
“Creaking like a rusty gate.”
“Hinges are worn down.”
“Stiff as an old mule.”
“It’s flared up again.”
“It’s got a mind of its own.”
“It won’t settle down.”
“I’m sure it’s out of place.”
Stephen Fry has commented that language is the parent of thought and I think this is a perfect comment for this topic. The words we use have incredible power over how we think about ourselves and others and I consider this very relevant for chronic pain, both patients and health professionals.
I’m covering for my colleague at the moment and one of his patients has had back and leg pain since February. I saw him for the first time today. I asked him what the problem was and he said that his “sciatic nerve was kinked and the discs are severely degenerative”. Such changes had indeed been demonstrated on his MRI. I had to explain that a worn disc isn’t a problem (what??) and that the nerve wasn’t kinked, just a bit swollen and it would be fine by next week (what??). Actually it was a bit kinked but there’s no way I’m telling him that , after all, everyone knows that a kinked hose re-kinks when you move it the wrong way. My colleague loves using that analogy – unfortunately. By the end of my treatment, which consisted of unravelling a host of shitty beliefs he’d been lumped with, he said to me with a big smile “so it can actually get better, right?!!” He had walked in very carefully, but walked out with much less pain and much more confidence. If his pain is gone by Friday – great. If he messes it up with more negativity, I just rinse and repeat until he gets it. And I’d never, ever explain to him what I’m really doing.. It’s better (for him) if I appear to be a magician. Some people aren’t ready to own their own minds!!
Thank you for a really thought provoking article. Language can be so fascinating. I have recently been on the receiving of some NLP myself and suddenly find myself really thinking before I speak, and then listening to the phrases I use – some metaphors are really dramatic ways to express oneself!
It brought to mind that old playground saying – “sticks and stones will break my bones but words will never hurt me”. How wrong that is. Today one of my patients who is getting on very well, whose arm previously was “it” after cervical fusion surgery 5 yrs ago, is now “my arm” and has started behaving like her arm again ,had a set back. Her anxiety state was much increased, her pain worsened, and her attitude to work changed. She had become realistic about work, and pragmatic about the future but suddenly it seemed way out of proportion again. About half way through the session, the rapport mentioned above broke through, and it turned out a colleague made an off the cuff remark about how “it’s alright for her sat at home out of the stress (that is currently going on in her workplace) she doesn’t know how lucky she is!”. Since that moment she has been thinking over and over again that that is what people think and that she must go into work ( even thought it is not currently suitable – trust me) and prove to them that she is not shirking. Her pain has gone back through the roof, her recovery delayed by just a few words.
If you are a therapist managing patients who have already seem multiple practitioners it is a careful job of untangling the many words, metaphors and associated beliefs that have confused and confounded the patient, while aspiring not to add any unhelpful ones yourself!
I would also be really interested to hear about a conference / study day on this.
Has anyone else read “Remember the Ice” by Bob Nichol? How the words we use can influence behaviour.
Just today, one of my veterans referred to his shoulder build as “rhinoceros muscles”. Sadly, I haven’t yet had time to really explore what that means to him, but I don’t have the impression that it is favorable in his mind’s eye.
Another recent veteran, in his 70s consulted for persistent, progressing back pain and immobility. Recent X-ray showed a 29 degree scoliotic curve. He walked in and you could feel the fear. But, it took a session or two for me to uncover the nature of his fear. He literally was viewing his spine as though it were a twig that, with a 29 degree bend, would snap at any moment with the wrong move. I debunked this for him, and he is improving rapidly, to make it short.
My favorite of all time, however, was the patient whose physician had diagnosed her with “traveling tendonitis”. Imagine this image of tendonitis packing up his bags, loading the RV and heading north to the next camp site. Yikes.
metaphors…… language that exemplifies how one sees oneself….. which directly relates to the language in our heads we use to define ourselves, perhaps? if so,
then does education that changes the way we see ourselves translate into a different language we use, that is less threatening…perhaps?
BBC R Four prog on expressive writing –not sure if available outsider UK??
A really timely post on expressive writing and the research of James Pennebaker …excellent and aspect of this relevant for any type of dialogue . At about 20 mins there is a discussion on the type of words that often promote recovery in t his type of research . Those that had their script intact and sorted (even if it was problematic ) didn’t always do so well but those who arrived in chaos but were able to change their language through the writing exercises did much better . I was thinking of this in relation to clinical work …I find this to be the case . Those people who are welded to a narrative and who often seem to be pretty angry too seldom do well but those who are confused , ‘misinformed’ and chaotic with the right mix of metaphor, empathy and mutual understanding do much better
Clean Language is a WONDERFUL tool to explore metaphor with clients
Thank you for this wonderful article and all the responses.
In the “Art of Possibility” by Rosamund Stone Zander and Benjamin Zander, they describe a scene between a father and a child. Words, such as “it feels like there is a wall between us”, created an almost physical wall between the parent and child. Therapy created the means to break down this “wall”, brick by brick, in order to improve communication.
They also comment on the way in which words create powerful mental images.
I would like to get more information regarding the way in which we as professionals at times add to incorrect mental images regarding what’s going on the body. I think metaphors can perhaps also play a positive part in the healing process, for instance using visual imagery during relaxation therapy.
Planting Positive Seeds…..
Thank you, David, for two very thought provoking pieces that being “The Linguistic Journey and Pain” and “The Drug Cabinet in The Brain”. Both of which I found very inspiring. I totally agree with the content of your former article and that we have to become much more aware of how we, as practitioners, use language/metaphors and how we equally need to ‘listen’ to our patients’ language, as it gives us deep insight into their way of thinking about their pain and their condition. Language is one way, a powerful way to seek and gather information whether it is verbal, expressional or body language. But equally and maybe more importantly language is there to express, manifest and share thoughts and feelings thus creating an inner reality for one and all concerned. Clumsy analogies and metaphors therefore can plant powerful ‘thought viruses’ or ‘thought Nocebos’ in our patients. In the biomedical world a ‘nocebo’ is defined as a harmless substance that creates harmful effects in a patient who takes it and the ‘nocebo effect’ is the negative reaction experienced by a patient who receives a nocebo. We could broaden the use of the term and relate it to the realms of Biopsychosocial Medicine when we replace the word ‘substance’ with ‘thought’. We all tend to focus on the positive (‘placebo’) but forget that it works the other way too. Persistent negative or even catastrophic thinking expressed by the metaphors such as bone on bone as you mentioned will have a powerful effect in the patient, which I believe is still very much underestimated. Therefore we need to become a lot more aware and alert to not only our own verbal but also our expressional and body language and the metaphors we use with our patients. So following on from education and understanding, I think it is our emotional state and our way of thinking, our responses to the information given and our ability to process and use the newly gained knowledge positively that is paramount. All this then naturally hooks up with your article and video on The Drug Cabinet in the Brain, doesn’t it? I do agree that understanding through education is crucial for finding a different relationship to pain. How the patient processes the new knowledge is holding the key to then open or keep shut the ‘Drug Cabinet in the Brain’. Therefore, in addition to the imparting of knowledge I believe we need to gently challenge their ways of thinking and expressing their ‘reality’, which might be influenced additionally by harmful metaphors other health professionals as well as their family and friends ‘gave’ them.
So let’s turn all this around and use the positive power of language and expression and plant some ‘positive seeds’ into our patients’ minds via constructive, helpful metaphors, turning the often vague and abstract experience of pain into something more concrete to work with. For example we could suggest to patients: Pain can become your friend who is trying to alert you to something. Whenever you feel pain, you can greet it like a friend and ask: “You came for a reason, I might not want to see you but I trust that you are trying to help me – what is it I am not aware of, what are you trying to tell me?”
Further to my comment about Clean Language. I think metaphors are very unique to the individual. My rusty hinge may look nothing like your rusty hinge and I might have a way of oiling it regularly and then it never totally rusts up…and so on…we can never really know what the others landscape is totally like and perhaps we don’t need to? I think there is a potential danger in working towards changing the clients metaphor as it may not be appropriate. As a client I may not respond to a suggestion of oiling the hinge – I might like to give it a good clean with emery paper etc. Perhaps clients can work with their own metaphors and change them for themselves – with support (or not!) “And what would hinge like to have happen?” – As clinicians we may not need to understand the clients metaphor (even though it sounds like it might have a common ground). However, if they transform their own metaphor that would have more meaning for them and be far more powerful.
The books Metaphors in mind by Lawley and Tompkins
And Clean Language by Sulllivan and Rees – Clean Language Revealing Metaphors
give a great way of revealing metaphors and exploring them. Also the technique is not copyright and relatively easy to learn.
Ref the suggestion of the conference on metaphor/communication – great! Perhaps a clean language practitioner could be part of that?
This is a fascinating conversation to me as both a psychotherapist and chronic pain sufferer (that’s a heavy word?) In any case, in my psychotherapy practice I’m often working with people who have had many variations of trauma (and often suffer with a variety of physical symptoms, usually with no conscious connection between the two. One theory in the world of psychology is that when traumatic events overwhelm the individual’s emotional capacity (limbic system), the trauma is somehow stored in a dissociated fashion and no coherent narrative (integration with higher centers such as prefrontal cortex) is formed and thus no meaning is made of the event. Various theorists regarding PTSD then suppose that these “unprocessed, non-narrative affects” then wreak havoc through various psycho/somatic symptoms, be it the classic flashbacks, dreams, panic attacks, etc., or in what I believe are numerous somatic symptoms (back pain, fibromyalgia, pelvic pain, allergies, etc.).
Ok, now to link this to our topic. A way out of the woods for some of these folks (and myself included) has been to find ways to re-enter that traumatic affect and give it some sort of narrative and meaning so it can be processed and stored as any normal memory. That’s where metaphors come in. Many patients have very little access to knowing or naming their emotional states and use of metaphors can be tremendously helpful in linking up those parts of the brain (traditionally referred to as ‘right brain’) that can allow the patient to get to the emotions. I always consider it a gold nugget when a patient will come up with a metaphor when describing how they feel…that is a ‘royal road’ to the right brain and to potentially a coherent narrative.
What I wonder given our topic is that if perhaps physical symptoms (at least in some folks) are the actual embedded trauma somehow dissociated from the rest of the conscious mind and how use of metaphor, language and narrative might be able to allow things to shift and change in chronic pain states.
I’ll stop for now, but I’m very interested to hear others thoughts on this.
This is a topic that really interests me, I think the language we use is incredibly important in ensuring great outcomes for our patients.
There are some wonderful responses to this post.
All the best
This is a great medium for ideas.