Taking the journey from the battlefield: Do metaphors help or hinder pain management?

Mike Stewart works as a Clinical Specialist Physiotherapist for East Kent Hospitals University Foundation NHS Trust. He is a full-time clinician and visiting university lecturer with over fifteen years of experience managing complex, persistent pain conditions. He is currently studying for a PG Cert & MSc in Practice-based Education at The University of Brighton. In addition, he is a dedicated practice-based educator committed to providing evidence-based pain education to a wide variety of health professionals. Here he discusses the impact that metaphors have on the management of pain.

Pain is an extremely complex beast. As a Clinical Specialist Physiotherapist, I have spent the past fifteen years attempting to understand pain in order to tame its persistent and all too frequent consequences.  Of course, pain is not a beast in much the same way that the heart is not a pump and the pelvis does not have a floor.

As humans, we instinctively rely on metaphoric expressions to help us make sense of the world around us.  James Geary, a leading author on metaphors, suggests that, on average, we use six metaphors every minute! For those of you who are in any doubt, try counting the metaphors that are contained within this short story.

Do you remember that game, Snakes & Ladders? I know the thought of it probably hasn’t crossed your mind in years but I bring it up for a very special reason. When I was a kid I hated that game. If there were even a whisper of it happening I was filled with dread, my stomach would be in knots. The reason was, I never really understood the rules of the game. I was like a deer in the headlights.

Convinced?  As I’m sure you can see, we do not stand under the rules of the game nor do our stomachs get tied in knots.  When metaphors form such an intrinsic part of our everyday communication that eight of them can appear within six sentences, we must remain mindful of their impact when discussing the complexities of persistent pain.

Pain is an ideal habitat for worry to flourish.  As both patients and clinicians we all too often pour unhelpful fertiliser onto pain’s rocky foundations through our use of language. For example, I have known many people with back pain who believe that they are internally bleeding.  When explored further, this particular worrying seed is invariably sown through an unhelpful metaphoric explanation of lumbar discs as jam doughnuts.  It is therefore important to remember that one person’s jam doughnut is another person’s internal haemorrhage.

Metaphors provide a frame through which we paint unique cognitive landscapes, but, as clinicians, we must remain mindful of our eagerness to impose our brush strokes onto the canvases of others.  In order to help people with pain make sense of how their nervous system works, healthcare professionals often resort to describing pain in metaphoric terms that relate to electronic devices such as burglar alarms, thermostats and computers.  Whilst this might enable some people to reframe their pain as ‘sensitive wiring’ rather than damage or harm, such metaphors may also implant the unhelpful notion that a simple ‘off switch’ can be found.

Unfortunately, our nervous system is far more complex than any electrical appliance and, as such, whilst some metaphors can provide effective and meaningful ways of transferring complex, abstract information, we must all remain aware of their ability to oversimplify.

When we consider the implicit nature of language and metaphors related to pain, we cannot fail to mention the influence of the media.  Having recently spent no more than five minutes searching a variety of media sources for evidence of military battle metaphors within healthcare articles, I was confronted with a plethora of unhelpful and misguided words and phrases.  Words such as ‘tackle’, ‘beat’ and ‘jab’ leap out from many headlines and suggest a swift, ruthless end to pain.  The ‘fight’ against cancer mirrors this predicament.  Susan Sontag spoke on behalf of many people with cancer when she argued that living with cancer is a process, not a fight.  Equally, we must reframe pain away from our cultural tendency towards fighting battles.

The permeation of military metaphors into the language of healthcare sheds light into poor outcomes in persistent pain management.  Many people who live with pain fall into a cycle of short-term solutions, which often leads to an ongoing escalation in the arsenal of modern day healthcare.  For example, many patients begin their fight against pain with simple medications (the light armoured division) before eventually moving onto injections (the tank division) and surgery (the nuclear warhead).  Unfortunately, this is not a war that is often won.

Military metaphors lead us to assume that failure lies with the patient, and not the treatment.  Equally, they might lead some clinicians to perceive themselves as incompetent soldiers.  Practitioners and sufferers who go in pursuit of a specific diagnosis (the perceived enemy) often feel disappointed when faced with the complexities of persistent pain.

A reframing of our beliefs about pain away from the battlefield and towards a more pragmatic metaphor is long overdue.  Unlike military metaphors, journey metaphors shift the focus away from a win, lose or fail notion.  Journeys provide opportunities for optimistic explorations, whilst also acting as a realistic reminder of persistent pain’s long and winding road ahead.

In order to make sense of the pains that we experience, we will always continue to use metaphors.  It is clear to see that our metaphoric expressions can simultaneously help and hinder the management of pain.  Within international pain research, we have only just begun to scratch the surface of this critical and far-reaching area of practice.  There are many more roads to explore in the years that lie ahead.  I am hopeful that they will lead to a brighter future.

Mike’s recently published work entitled “The Road to Pain Reconceptualisation: Do Metaphors Help or Hinder the Journey?” can be found at www.knowpain.co.uk or in the latest editions of Pain and Rehabilitation – The Journal of the Physiotherapy Pain Association and The Journal of the Acupuncture Association of Chartered Physiotherapists.


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