November 8, 2021: Using Metaphors in the Medical Experience

Poetry and medicine share a long history, something for which we can thank Apollo, the Greek god responsible for both healing and poetry.  If you had any idea that metaphors are only the creativity of poets and poetic imagination, think again.  Metaphors are common and pervasive in our everyday lives, influencing the way we think and act.  Metaphors, which compare two seemingly unrelated things, are not only common in poetry and everyday life, but also in medicine.  (Lakoff & Johnson, Metaphors We Live By, 1980).

Consider the sports talk that dominates the televised football or hockey seasons.  Sports metaphors are commonly used to describe experiences in our daily lives, for example, in companies, where employees are encouraged to be team players” or “run with a good idea.”  When I was young, high school football games were not only popular, but the language of the game made its way into aspects of our teen-age dating lives, as when someone might “made a pass at you,” or behaved in a way that were “way out of bounds.”

Why do we use them?  Metaphors are visual and illustrative, but they sometimes run the risk of creating stereotypes, confusion, or becoming clichés.   Some, like sports and military metaphors are so common in our daily language, they are frequently used to describe the medical experience.  Common examples include parental metaphors, “she’s too sick to know the difference,” engineering metaphors, “coming in for a tune up”, or the commonly used military metaphor of cancer as a “battle” to be fought and won.  Nevertheless, metaphors are essential in our ability to describe and convey the experience of illness—and not just for the patient, but for the physician as well.

Dhruv Khullar, MD, in a 2014 article, “The Trouble with Medicines’ Metaphors, “published in The Atlantic, stated:   

The words we choose to describe illness are powerful. They carry weight and valence, creating the milieu in which goals of care are discussed and treatment plans designed. In medicine, the use of metaphor is pervasive. Antibiotics clog up bacterial machinery by disrupting the supply chain. Diabetes coats red blood cells with sugar until they’re little glazed donuts. Life with chronic disease is a marathon, not a sprint, with bumps on the road and frequent detours...  Military metaphors are among the oldest in medicine and they remain among the most common. Long before Louis Pasteur deployed imagery of invaders to explain germ theory in the 1860s, John Donne ruminated on the “miserable condition of man,” describing illness as a “siege…a rebellious heat, [that] will blow up the heart, like a Myne” and a “Canon [that] batters all, overthrowes all, demolishes all…destroyes us in an instant.”

As Khullar points out, “…we’ve internalized these metaphors, so much so that we often may not recognize how they influence us.”  Nevertheless, they are important and necessary to help convey what is difficult, at first, to describe, offering a shorthand way of making sense and communicating the experience of serious illness.   Just as we use metaphors to communicate to our friends and others, physicians use them to help patients understand the ramifications of their illnesses.  Interestingly, Khullar cited a 2010 study finding that physicians use metaphors in nearly two-thirds of their conversations with patients diagnosed with serious illness.  In fact, the doctors who used more metaphors in explaining medical conditions were seen as better communicators. Why?  Because “patients reported less trouble understanding them, and felt as though their doctor made sure they understood their conditions.”

 Metaphors get our attention.  They offer us a vivid way to communicate in an understandable way our experience of serious and life-threatening illnesses, whether patient, physician or care-giver.  If you explore any poetry of the medical experience, you’ll discover it is rich with imagery and metaphors that resonate with your own experience. For example, I have often used Mary Oliver’s poem, “The Fourth Sign of the Zodiac,” with its extended metaphor to encourage writing group members to explore their metaphors used describe the experience of diagnoses and treatments.

Why should I have been surprised?
Hunters walk the forest
without a sound.
The hunter, strapped to his rifle,
the fox on his feet of silk,
the serpent on his empire of muscles—
all move in a stillness,
hungry, careful, intent.
Just as the cancer
entered the forest of my body,
without a sound…

(In: Blue Horses, 2014)

Donald Hall, in his poem, “The Ship Pounding,” creates a powerful, visual metaphor of a great ship to describe the hospital and his experience of the final days spent with his dying wife, the former poet, Jane Kenyon.  He first describes going to the hospital to visit his wife:

Each morning I made my way   

among gangways, elevators,   

and nurses’ pods to Jane’s room   

to interrogate the grave helpers   

who tended her through the night   

while the ship’s massive engines   

kept its propellers turning…

—–

At first the tenor of the poem feels almost hopeful:

—–

The passengers on this voyage   

wore masks or cannulae

or dangled devices that dripped   

chemicals into their wrists.   

I believed that the ship

traveled to a harbor

of breakfast, work, and love…   

When the infusions

are infused entirely, bone

marrow restored and lymphoblasts

remitted, I will take my wife,

bald as Michael Jordan,

back to our dog and day.

But Kenyon’s illness is terminal, evident in the final lines, and as her disease progresses, his trips to the hospital become anxious, as he and his dying wife return to the hospital:

I listened in case Jane called

for help, or spoke in delirium,

ready to make the agitated

drive to Emergency again

for readmission to the huge

vessel that heaves water month   

after month, without leaving   

port, without moving a knot,   

without arrival or destination,   

its great engines pounding.

(In: Without, 1998))

“The Ship Pounding” is a moving and visceral image offered by Hall, one that makes experience of the narrator and his dying wife readily understood.

I often return to the wonderful book by former literary critic, Anatole Broyard, who died in 1990 from prostate cancer.  Entitled, Intoxicated by My Illness and Other Writings on Life and Death (1993) Broyard also explored the use of metaphor to think about and describe his illness:

Always in emergencies we invent narratives. . . Metaphor was one of my symptoms.  I saw my illness as a visit to a disturbed country. . . I imagined it as a love affair with a demented woman who demanded things I had never done before. . .   When the cancer threatened my sexuality, my mind became immediately erect. 

Medicine continues to advance and offer us much more precise understanding of medical conditions and diseases, yet “metaphor,” as some authors have stated, “remains essential” as a way to convey the experience of illness.  As Broyard remarked, “Metaphors may be as necessary to illness as they are to literature, as comforting to the patient as his own bathrobe and slippers.”

Writing Suggestions:

What metaphors have you used to describe your illness?  How did they change as your condition changed?

  • Think about the ways in which you have used metaphors with family, friends or your doctors, to describe your experience of serious or debilitating illness.  How have they helped you understand and communicate?
  • Explore the different metaphors that describe your illness or condition.  Begin with a phrase, for example such as “Cancer is a…” or “Living with heart failure is like a…,”or “A heart attack is like…”  and finish the thought, noting what image or word emerges.  Remember, write quickly, without editing. Set the timer for five or ten minutes and keep your pen (or fingers) moving. Generate as many comparisons or metaphors as you can.  Once you’ve finished, read over what you’ve written.   What surprises you?  Do you discover any unexpected insights to your feelings?  How do your metaphors you navigate and explain your illness to others? 
  • Try writing a poem or narrative using the metaphors to describe your experience of illness or disease.
  • “Physicians who used more metaphors were seen as better communicators.”  True or False for you?  Has your physician used metaphors in communicating aspects of your diagnosis?  If so, do any stand out?  Were the metaphors useful in helping you understand your illness?

October 24, 2021: Writing From the Fault Lines

“You must learn to live on fault lines.”
― Suleika Jaouad,Between Two Kingdoms: A Memoir of a Life Interrupted, 2021

My childhood and teenage years were spent growing up in Northern California, a life that included annual water rationing during summertime, seasonal forest fires and the expectation that periodically, the earth could move beneath our feet, something which had little to do with a sudden jolt of teenaged romance.  The occasional movements of the earth were due to the sliding boundaries, the fault lines that define the earth’s tectonic plates. California has many of these fault lines, and sometimes, as witnessed in the Loma Prieta quake of 1989, significant upheaval and damage–even loss of life—occur.

Living on the fault lines is not something Californians have to learn; it’s what they do.  But the periodic upheaval created by the “fault lines” is an apt metaphor for what happens in our emotional lives when unexpected trauma or life-threatening illnesses occur.  In those periods of stress and anxiety, old emotional wounds can also make their way to the surface, adding to the emotional challenges facing you in the midst of a new life crisis.   

In 2007, I began teaching creative nonfiction writing for the UCLA extension Writers’ Program.   My first course was one of several other offerings, and I titled my course “Writing from the Fault Lines:  Writing to Heal,” a title that lasted for three years, until expressive writing gained a foothold in public popularity. To distinguish it from the many and varied writing workshops that seem to blossom everywhere, the course was re-named “Transformative Writing.”

Now many years later, I live far from California, having returned to Toronto in 2017. I no longer teach for the UCLA program, but I continue to lead expressive writing groups for cancer and heart patients.  This past weekend, while working with an inspiring group of young adult cancer survivors, the Young Adult Cancer Canada “YACCtivists,” I re-read portions of Suleika Jaoaud’s extraordinary and thoughtful cancer memoir, Between Two Kingdoms:  Life Interrupted. I paused when I read her sentence, “You must learn to live on fault lines.” The young adult survivors representing YACC had definitely learned that lesson—and then some. 

I thought back to the time the word “cancerous” was spoken to me in a physician’s office in California.  My husband and had returned to California after nearly 26 years in Canada, only to run headlong into a family crisis full of resentment, accusations and the losses of my parents:  my father had died of lung cancer and my mother was lost to Alzheimer’s disease.   At the same time, I was overseeing a difficult and emotional downsizing of a nonprofit organization while trying to navigate the unexpected familial acrimony.  Writing was my refuge.   I filled page after page in my notebook with disbelief, questions that couldn’t be answered and even some misplaced sense that I must have brought on the cancer myself.  Yet my initial outpouring soon gave way to the deeper wounds, to losses and hurt I’d amassed in trying—and failing—to deal with the estrangement from my two siblings.  My “real” story was not about cancer; it was what lay beneath the surface, pressures within my emotional interior begging to be released.

I have often witnessed similar struggles for some individuals in my writing groups.  The experience of a life threatening illness can unearth other, unresolved, feelings.  Painful memories or traumatic events of the past can be triggered by the most benign of writing prompts, and as they rise to the surface, they too are expressed in what gets written.  Writing our healing stories often goes well beyond the experience of serious illness as some plumb the depths of their lives, bringing into the open what they were not able to do before.  

Did you ever think there might be a fault line
passing underneath your living room:
A place in which your life is lived in meeting
and in separating, wondering
and telling, unaware that just beneath
you are the unseen seam of great plates
that strain through time? And that your life,
already spilling over the brim, could be invaded,
sent off in a new direction, turned
aside by forces you were warned about
but not prepared for?


From:  “Fault Line” by Robert Walsh (in Noisy Stones:  A Meditation Manual), 1992.  

Emotions can inspire us or hold us hostage.  Negative emotions—anger, fear or feelings of unworthiness—accumulate, just as stresses along the earth’s plates.  They weaken our ability to fend off illness, depression or disease.  Writing allows us, if we let it, to translate those negative emotions into words, make the connections between what we feel and why, and begin to understand or even forgive ourselves and others.  It is in the act of writing and sharing our stories that we release the pressure of old wounds, that we begin to heal.

Writing Suggestion:   This week, write from your own fault lines.  Go deeper in your writing. Explore those sometimes difficult and painful life experiences that still linger beneath the surface.