Researchers Propose “Metaphor Analysis” for Understanding the Experiences of People who Hear Voices

A new study, published in the journal Psychosis: Psychological, Social and Integrative Approaches, explores ways that metaphor operates in the lived-experiences of individuals who have reported hearing voices that no one else can hear. There was a particular focus on how attributions of agency, power, and control can be structured through certain metaphors that such individuals use to describe their relationships to their voices. The results highlight important links between metaphors that convey a sense of disempowerment and higher levels of distress for voice-hearers.

The team of researchers who carried out the study, led by Zsófia Demjén, a senior lecturer at the Centre for Applied Linguistics at University College London, characterize metaphorical reasoning broadly, describing it as a core aspect of embodied, social interaction. As they explain:

“Metaphors reflect and facilitate different ways of making sense of and evaluating a particular topic or experience. They highlight some aspects and background others, leading to a so-called ‘framing’ effect.”

This draws on research suggesting that metaphors in general serve important linguistic and social functions, framing our thoughts and actions in a range of ways that are sometimes more obvious than others.

As an example, the authors cite the popular use of “battle metaphors” that frame cancer “as an enemy and the relationship between the person and the illness as an antagonistic one.” Going further, they note that this way of thinking about cancer is not necessarily wrong or right. For some individuals diagnosed with cancer, especially those who benefit from treatment, construing it in this way could in fact express a certain sense of agency over it.

And yet, framing cancer through battle metaphors alternately forecloses other possible interpretations (e.g. conceiving cancer as a journey), along with other possible senses of empowerment or agency. In this way, any given metaphorical frame of reference can be said to enable certain possibilities for interpreting one’s experience while constraining others.

Demjén and colleagues describe this quality of metaphor as being particularly relevant in cases of psychological distress and/or psychiatric diagnosis, where concerns about vaguely defined concepts—like one’s own mind, personal identity, or a diagnosis—are often central to the nature of the experience. This likewise builds upon earlier research indicating that “metaphors are a prominent communication strategy used by people with psychosis to describe or conceptualise perceptual experiences and internal states that are otherwise difficult to articulate in objective, clinical terms.”

With this in mind, the authors propose that “metaphor analysis can contribute to both understanding and addressing distress in voice-hearers.” This is part of a long history of research illustrating the important roles culture, context, and meaning play in how such voices have traditionally been experienced and narrativized.

For their study, Demjén et al. carried out semi-structured interviews with 10 participants who reported hearing voices during earlier studies on the topic. There were equal numbers of male and female participants, all of whom met the following four criteria: “(i) aged above 16 years, (ii) had experienced voices in the two weeks prior to participating in the study, (iii) history of voice-hearing for a minimum of 6 months, and (iv) the experience of voices was not due to organic illness (e.g. brain injury), hypnagogic/hypnopompic states, or alcohol/drugs intoxication.”

During the interview process, each participant was asked a series of questions about prior experiences of hearing voices. They were also given the Psychotic Symptoms Rating Scale, and the Cognitive Assessment of Voices interview. The researchers then coded transcripts of the interviews according to the type of metaphors used, following closely with a “Metaphor Identification Procedure” that is often used within linguistic analyses. In total, 33,257 words were analyzed and correlations were drawn between results from the assessments and types of metaphors used by each participant.

According to the authors, metaphorical characterizations involving physical aggression or violence associated with voices were most common across the interviews. Three of the participants also attributed a sense of malevolent agency to their voices. As participant #6 (P6) describes, for example:

“It’s just like sitting where you are now [name] [. . .] and someone’s sat next to ya, shoving ya, prodding ya, slapping ya, pulling your hair – can’t pull mine but they could pull yours – and slapping ya across the face and disturbing ya all the time,” adding “it is like trying to fight with one hand tied behind your back.”

Higher levels of distress were associated with participants’ beliefs that their voices possessed authority over some areas of their lives.  According participant #24 (P24):

“In the absence of religious beliefs, I put them down as who I think of or name as the supreme commander of the universe. The boss of the whole universe.” (P24)

Participant #17 (P17) compares his experience of voices to a poolside attendant:

“You know when someone is being straight, and it’s a no-go area. Like when the pool attendant blows his whistle and points . . . you know to stop running.”

Especially in these latter two cases, Demjén and colleagues explain, participants expressed diminished agency and disempowerment in relation to their voices. For P17, voices are described as affecting nearly every area of life, while P24 focuses mainly on how they affect certain psychological states.

Metaphors conveying a sense of disempowerment can be contrasted with those expressing a more complementary relation to one’s voices. As participant 13 (P13) reports: “I try and support her, ” and “they try to support me,” adding that “they treat me as a friend.” For participants describing similar sentiments, the degree of reported distress was notably lower than it was for participants like P17 or P24.

Overall, Demjén et al. describe their study as a “proof of concept paper,” adding that a considerable amount of work is still needed to flesh out any connections they make between certain types of metaphor and lived-experiences of hearing voices. Importantly, neither metaphors nor voices can emerge out of a social vacuum. Future research might, as such, focus more on cultural and other contextual factors involved in how anomalous experiences, like hearing-voices, are framed linguistically and made meaningful socially.

Moreover, the authors do not explain how metaphors and voices relate causally to one another. It is one thing to identify types of metaphor in the discourse of interviewed individuals after they experience voices. It is another thing to understand how metaphorical reasoning occurs during such experiences, as they are lived from the perspective of the persons experiencing them. And it is yet another thing entirely to attempt to, as the researchers propose, draw on such studies to intervene on the voices individuals hear.

In other words, it is not entirely clear from this particular study whether metaphors play a determinative role in how voices are encountered, as the authors suggest, or if such experiences differ for other reasons and are simply expressed through different types of metaphor because they are inherently difficult to describe.

There are notable overlaps between this research and the goals promoted by the hearing voices network, a group of individuals well-known for challenging biomedical metaphors and their pathologizing effects on those who hear voices. Following their lead, researchers employing metaphor analysis might consider looking into how deficit-based models used by mental health professionals and clinical researchers contribute to experiences of distress for individuals who hear voices.

Here, the usefulness of a metaphor extends beyond whether or not it is an accurate portrayal of a set of events, per se, or even how well it highlights essential aspects of a lived-experience. For health professionals, metaphors serve to standardize interpretations in relation to broader objectives of social institutions. In contexts like hospitals and mental health agencies, for instance, biomedical frames of reference provide cues for how words and experiences should be interpreted, while linking them to professional issues like insurance reimbursement and sharing information across settings.

And yet, it is likewise important to recognize how such professional frames of reference conceal systemic causes of distress, like poverty and stigma. This marks an irreducible difference between diagnostic categories, like those in the DSM—interpreted as they are through biomedical frames—and the lived-experiences that such ideas point to. As Demjén suggests:

“It might be useful to actively question the semi-technical metaphors that have become so conventional in clinical practice as to be barely noticeable, but which can nevertheless have important framing effects.”

“In fact, spelling out the associations of different metaphors, exploring various aspects of metaphorical scenarios together with voice-hearers and questioning some of the assumptions that seem inherent to different framings, might provide useful resources for clinicians.”

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Demjén, Z., Marszalek, A., Semino, E., & Varese, F. (2019). Metaphor framing and distress in lived-experience accounts of voice-hearing. Psychosis: Psychological, Social and Integrative Approaches, 11(1), 16-27. https://doi.org/10.1080/17522439.2018.1563626 (Link)