Metaphors in Psychiatry

Metaphors have been used for improving communication since the beginning of recorded history. By using them to understand and communicate about psychiatry we may get some interesting insights.

Court metaphor for drug research.

Currently almost all research on drugs for psychological problems is done by the pharmaceutical companies. They study their own drugs to find out if they are effective. They actually “study their own drugs” that they can make billions from if proven marginally effecive on vaguely defined symptoms. There is very little research done by independent researchers. The little that is done is meta-analysis, a systematic compilation, of the same studies done by the manufacturers. Companies publish only what they want. They can choose to not publish trials showing that the drugs are harmful or have no effect, and if they find a positive effect in a few studies, they can publish them as many times as they want. FDA requires only two positive trials to approve a drug. In a worst case scenario a company can do 100 trials of an antidepressant, and even if 98 of them show harm and no positive effect, the drug will be approved if the company can come up with 2 trials that show benefit and “acceptable” harms, even if this is after considerable massaging of the data.

Since something is being judged as good or bad, it is natural to use a court case as a metaphor to see clearly how wrong this is. The person on trial gets to produce just the evidence he wants to. He does his own DNA testing and presents only witnesses favorable to him. As if this is not bad enough: he is also his own judge and his own jury, or he fills up the jury only with people who work for him (Journal editors who need pharma advertising to survive).

Can we expect a guilty verdict? Obviously not.

Another metaphor is Coca Cola Company deciding if Coke is better than Pepsi. The mind blowing result of using these metaphors is that we realize that what we call evidence based treatment is worse than having no evidence at all, it is really evidence BIASED treatment.
Drug metaphors. Giving drugs for a psychological problem can often mask the reason for the suffering, e.g. depression because of relationship problems, ADHD concentration problems because of bullying. Giving drugs for these problems without doing everything to remedy the cause would be like giving you a pain killer if you had a broken ankle, and just continue walking.  With enough numbing, you would be able to walk, but would it help in the long run? You would need more and more pain killer and the ankle would never heal.
Could there still be a use for numbing drugs? Yes, of course. I ask for pain killers if I have a very bad headache or a broken ankle. But that would be temporary, and I would try to find out what was wrong and do something about it right away. I would never want to take the drugs permanently.

Drugging may also be like just giving painkillers to someone with an infected wound without disinfecting the wound. This can numb the pain but be very dangerous and make the problem go on and on.

You have stepped on a nail. It is sticking out of your foot. You put a bandage on and take a strong painkiller, but leave the nail there. This is similar to not removing what made you depressed in the first place, but just numbing the feelings with an antidepressant.

Drugs may also be thought of as a crutch. A crutch could enable you to function even if your ankle was broken. But I would not want to become a permanent crutch user. The usual treatment for a broken ankle or bone would be to have a competent person align the relevant bones, immobilize the area and then rely on the body’s spontaneous healing process.

If I had been left in the wilderness with my broken ankle, pain would have made me keep it as immobile as possible until it healed. I would probably be able to walk again, but likely with a limp. If a physician had used evidence based methods (x-Ray and anatomical charts of how a healthy ankle looks ) the results would be close to perfect. But I would have to not walk on it for some weeks.

If we translate this to treatment for depression, we may get many insights. First of all: there is a reason why the ankle broke. We would not start looking for a vulnerability for breaking ankles. Anybody who has broken an ankle by jumping from 10 feet down on concrete will avoid doing that in the future, without thinking they had an underlying ankle breaking syndrome. There is a reason why you become depressed. Some get more easily depressed than others, just like some break their ankles more easily. But the reason for the depression is what you can do something about. You can get out of that horrible job or relationship, just like you can avoid jumping from 10 feet.

If you just numb the psychological pain, then you would be able to stay in the bad situation. With enough painkillers you can continue jumping from 10 feet.

Computer metaphors can also be quite useful. Doctors have used chemical imbalance as an explanation for both depression and psychosis. The solution is to “restore” balance with more chemicals. This would be like fixing a fault in the software by changing the voltage on certain parts in the computer. If there were offensive videos playing, we would disable the video card so they would not show up on the screen. Electroshock would be like giving the computer a voltage surge until the video stopped playing. Of course the normal solution would be to find out what had started the video playing in the first place and then give instructions in a language that the computer could understand, mouse clicks or keyboard presses (corresponding to talking to the suffering person) instead of brutal physical interventions affecting the whole system.

Sometimes doctors say the chemical imbalance explanation is just a metaphor. However the metaphor breaks down quite quickly. SSRIs prevents the nerve cell from recycling serotonin. Half-used serotonin is kept in the synapse. It is like we have fired the garbage collectors and shut down the recycling plant. No wonder many feel numbed by SSRIs.

Antipsychotics were developed in an attempt to find better anesthesia. If so-called anti-psychotics are given in high enough doses the patient loses consciousness. Could there be a use for anesthesia like states in psychological suffering? Yes, but only very temporary in order to get through a very rough experience. Most of us would not like to go through surgery without anesthesia. But we would certainly react strongly if we were told we were going to be anesthetized for the rest of our lives.

Through these metaphors we may come to the conclusion that some drugs may be very useful for very short periods, e.g. a painkiller or anesthesia so that the wound may be cleaned/sutured or bullet removed. The point is that the drug is used in order to be able to do something with the problem: stopping the bullying, discussing the marriage problems, making the classroom more interesting.

Positive metaphors
Psychotherapy can be likened to a reprogramming of our brain through experience ( e.g. The experience of a good therapeutic relationship or success in exposure therapy). We have many rules in our minds that guide our feelings and behaviors. For instance
“IF mother has a smile on her face while looking into my eyes THEN good feelings are released AND the behavior that preceded the smile is coded as likely to bring smiles in the future”.

“IF hands do not feel completely clean, THEN wash again. (OCD).

If I feel fat THEN I will not eat today. (Anorexia).

Reprogramming for the OCD would be:
IF I feel dirty, THEN resist the urge to wash. This will make me stronger and cure my OCD. (Exposure therapy). Or :
“A little dirt is good for me. It builds my immune system.”

The settings metaphor.
Often therapy may be likened to adjusting the settings of your carefulness programs. This is a good mental program that everyone needs, but the settings are too high.  Hand washing is good in general, but OCD sufferers have a setting for “clean enough” which is too high and may therefore clean their hands for hours. However, if you are a surgeon preparing for surgery, this OCD setting may be quite useful. In other words, therapy is getting the right settings for the situation.

Often the only way to change these settings is to experience that it is safe to have other settings. This may be done through exposure therapy. Often you cannot change the settings just by being told to change. You need to experience the safety of changing settings gradually.

One result of thinking like this, with the programming metaphor, is that you realize that there are no mental illnesses, just settings that are not adapted to the situations. If you are anxious, you have too high settings for danger. If you are depressed, you have too high settings for how useful it is to think of negative things. If you have hallucinations, the “realness” setting for thoughts is too high. For delusions, the conviction setting is too high. The beauty is that all of these settings may be changed.

The brain training metaphor.
We all have many experience of getting better or stronger with training or practice. The same obviously apply for the brain processes that govern feelings. After all, our strong experiences of learning new skills are related to the brain. We have learned to walk, read, ride a bike and maybe even mastering a foreign language. These skills seemed almost impossible before we learned them.

In the same way we can train our brains to react in different ways. A good example is that the ability to think positively in almost any situation can be learned.  Martin Seligman has termed this “learned optimism”. However optimism is not always positive. The settings for optimism should be adapted to the situation. Lawyers benefit from a low level of optimism when they prepare to meet the opponent’s arguments. Manic episodes may be seen as too high optimism settings.

The ability to see the positive in the negative may be learned and practiced. One simple method for doing this is to write down every day a few sentences about 3 good things that have happened lately. If this is hard for you, you probably need this training very much, and doing it will make a big difference. If it is very easy, you are in good psychological shape and don’t have to train that much.

Metaphors may be very powerful, both to help our understanding of what is wrong with psychiatry and how we may understand our minds in positive ways. If symptoms are just signs that settings are off, and settings can be changed, we can have hope. If we can learn better mental strategies just like we learned to walk and talk, there is hope for everyone.


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


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