Language is the most distinctive feature of the human mind, the skill with which we fashion our lifeworlds through acts of poiesis, giving voice to suffering, making sense of our predicaments, and finding ways to heal. Every language of suffering and affliction is deeply rooted in a cultural history, geography, and community. Every expression of distress and effort at transformation draws from these shared languages, even as individuals improvise new hybrid forms. Understanding the creative functions of language must be central to a medicine or psychiatry for the whole person.

A wealth of work in cultural psychiatry and anthropology shows how metaphor, image, and imagination can articulate, express, transform, and sometimes resolve experiences of suffering and affliction. This work springs from the recognition that metaphor is ubiquitous. Far from being a special, artful, or ornamental use of language, cognitive linguistics makes it clear that metaphor reflects the basic structure of human cognition, that is, our capacity to think of one thing in terms of another. Developmentally, this allows us to build up complex and abstract thought on a scaffolding of earlier and simpler knowledge and experience. Culturally, it allows us to extend shared metaphors to construct the elaborate models and stories that constitute our individual and collective identities and the institutions of the social world. Tracing the origins and consequences of the metaphors we use to articulate experience and explain our actions to each other can uncover the latent or implicit meaning in our models and point the way to new metaphors that lead to new ways of thinking.³

Consider the following vignettes:

These vignettes illustrate the varied kinds of suffering and healing explored in this book, including ritual healing, contemporary psychiatric and psychotherapeutic practice, and the larger social and political arenas in which psychiatric language is deployed. In each case, the metaphors used to describe affliction are meant to point to its origins based on particular ontologies—notions of what the world is made up of—that can explain the nature of the problem and the process of healing.

For the dang-ki, a kind of healer following a syncretic Taoist–Buddhist tradition, affliction can arise from many different proximate causes, but the deity has the power to discern its ultimate nature and intervene in ways that can restore health and harmonious relationships.⁹ The process of healing is embodied through the process of possession: the deity takes ownership of and inhabits the body of the dang-ki. For the dang-ki and their clients, of course, this is not a metaphor but a literal description of events. The ritual implements, setting, chants, and prescriptions all fit with a cultural and religious ontology and understanding of the world that is shared, at least in part, by healer and supplicant. At times, the dang-ki’s interventions may include practical advice on how to navigate a changing social world.

For the psychiatrist in the emergency room, depression is a neurobiological disorder. Calling it a “chemical imbalance” provides an inaccurate but useful metaphor that warrants the use of medication to correct the imbalance.¹⁰ A more accurate model would characterize mood as the outcome of a neurobiological regulatory system that has become dysregulated, with problems occurring at the level of functional brain circuitry. For the adolescent and her family, the neurobiological explanation implies her problem is not something she did but something that happened to her. Taking medication is an opportunity for her to reestablish control over her own mood and behavior.

The psychodynamic psychotherapist invokes a model of the self that has passed from psychoanalytic theory to everyday folk psychology. On this view, the unconscious is a repository of repressed conflicts that result in maladaptive behavior. Plumbing the depths of the unconscious through dreams, reverie, or free association can reveal repressed conflicts and defuse their power through exposure or point to corrective actions. While classical psychoanalysis saw the unconscious mainly as a site (or consequence) of conflict, in other therapies, the unconscious may be framed as a source of strength and resources that includes an “inner healer.”¹¹

For the cognitive therapist, the sources of affliction lie not in the depths of unconscious but in bad habits of thought. Many of these are evident in ordinary conversation or in the private soliloquy of self-appraisal. They can be explicitly identified and replaced by more salutary statements, images and metaphors. In the case of third-wave cognitive therapies, like dialectical behavior therapy (DBT) or acceptance and commitment therapy (ACT), the recognition of the metaphoric nature of cognition and the deliberate use of metaphors to promote cognitive flexibility are key strategies.¹²

For the TRC commissioners, bearing witness to the history of state-mandated violence against Indigenous Peoples through policies of forced assimilation provides an explanation for the high prevalence of mental health problems, a way of demanding accountability and restitution, and the beginning of a long process of collective healing and reconciliation, which will benefit nations, communities, families, and individuals. Here, the metaphor of healing implies a recognition of injury and of the responsibility for care in relationships that have been governed by a politics of domination and exploitation.

In each of these situations, specific metaphors frame the nature of affliction in terms of causes rooted in a cultural ontology—that is, a locally shared view of what kinds of agents and entities constitute the world—and guide the process of healing by suggesting actions that address the underlying problem. Key metaphors in one context may be viewed as inapt, irrelevant, counterproductive, or even unintelligible in another context. Exploring the personal and social effects of these metaphors can clarify some of the mechanisms of suffering and healing. Critical analysis of these metaphors can reveal their underlying assumptions, limitations, and unintended consequences.¹³ Critique can also serve the creative function of generating alternative metaphors that may better capture facets of experience and provide new possibilities for transformation.

The Ubiquity of Metaphor

Metaphors are present in every form of thought and communication. Many of these are “dead” metaphors that go unrecognized as such because they have become literal expressions. As the philosopher Owen Barfield put it:

In everyday speech, the bare bones of dead metaphors are animated by a living tissue of novel tropes and images that enrich and enliven thought and charge it with emotion. Studies of natural language find about one explicit metaphor for every ten to twenty-five words in everyday talk and about one metaphor for every twenty-five words on TV.¹⁵ Situations that are emotionally charged or in which people struggle to describe unfamiliar experiences tend to have still higher rates of metaphor use. In psychotherapy, patients may produce about six metaphors a minute.¹⁶

Profound experiences of affliction evoke rich metaphoric language. Here is how the novelist William Styron described his own experience with severe depression in his memoir Darkness Visible:

In this passage, metaphor is used to convey some of the bodily feeling and existential predicament of depression (“being imprisoned in a fiercely overheated room”), to sketch a theory of the underlying problem (an “evil trick upon the sick brain by the inhabiting psyche”), and to point to ongoing dynamics in which the person’s response contributes to the symptoms and course of the illness (“because there is no escape … it is entirely natural … to think ceaselessly of oblivion”). In invoking a “sick brain,” Styron acknowledges the dominant theories of current biological psychiatry, which explain depression as a brain disorder (a broken brain; a chemical imbalance).¹⁸ But by describing depression as an evil trick by the psyche that inhabits the brain, he leaves room for psychology, including processes of self-understanding, interpretation, and personal agency (Who is playing the trick?). The choice of metaphors reveals important dimensions of his ongoing struggle with the illness, as well as the ways that the conceptual resources of medicine and popular culture can be used to make sense of experience.¹⁹

A metaphor can point to an explicit analogy or explanation for an experience or an event. It can change our perspective on a situation or event by drawing attention to aspects we have ignored or charging it with new meaning and connotations. Viewing a person in terms of a sensory metaphor (e.g., “she is a warm person”; “she has a sunny smile”)²⁰ modifies our way of relating to them. Evocative metaphors provided by psychiatry and psychology like broken brains, chemical imbalances, trauma, and resilience can reshape our sense of agency and subjectivity. In recent years, thinking about the brain as a computer has inspired a rich body of scientific work in computational neuroscience and psychiatry²¹; in popular culture, thinking about one’s own brain as a computer leads to modes of self-reflection that can change our way of being in the world, allowing distance from affliction, deliberate attempts at self-modification, or leading to self-estrangement.²²

While some of the chapters in this book explore patients’ metaphors for illness, equal attention is given to the discourse of healers and clinicians, especially to the metaphors of biomedicine, psychiatry, and psychotherapy, whether implicit in theory or explicit in clinical conversation. My interest is in two related aspects of metaphor: its place at the center of conceptual models and its use as a powerful tool in rhetoric, that is, in speech aimed to influence others and to position oneself in the social world. The language of healing is always embedded in larger discursive frames that are conveyed through specific metaphors and narratives. Any given metaphor captures only part of the ways that cultural models are deployed. Every metaphor also has unintended connotations and surplus meanings that influence the ways we think and act. An especially apt or compelling metaphor can take us off in unexpected directions that change the way we see the world and ourselves, for better or for worse. My aim, then, is to uncover how the metaphors produced by patients and clinicians shape the process of clinical interaction, the negotiation of meaning, and the bodily, psychological, and social processes of coping, helping, and healing. This provides a way to look at the embodiment of illness experience and its therapeutic transformations that can illuminate the processes and practice of contemporary psychiatry, psychology, and psychotherapy, as well as the great diversity of symbolic healing systems around the world.

To that end, I offer a poetics—not in the narrow sense of a treatise on literary style or form, but in its broadest sense, as a consideration of the aesthetics of language and action through poiesis, the act of making or fashioning with words. This broad use of “poetics” has a venerable tradition that goes back to Aristotle.²³ Here, the term poetics is meant to help us keep constantly in mind the fact that ordinary thought and action are shaped by the creative faculties of imagination and largely governed by aesthetic values that make particular constructions or construals of experience especially apt, evocative, rhetorically powerful, and transformative. It also reminds us that the languages of suffering and healing, though they borrow from conventional idioms, are endlessly inventive.

4-E Cognitive Science and the Pragmatics of Communication

While this book is concerned with the poetics of experience and its expression in clinical discourse, I approach discourse from a situated, social-pragmatic perspective. This approach emphasizes that discourse is not a self-contained or autonomous domain of linguistic or social process with its own logic, force, or agency, but rather part of social, cultural, and institutional practices that provide individuals with background knowledge, resources, norms, and possibilities for self-fashioning. These resources are deployed through culturally mediated interpersonal interactions in the diverse social contexts or settings in which people collaborate to create and negotiate meaning. Any newly minted meaning must be tried and tested and, when taken up by others, lived out in a social world. Understanding the effectiveness of metaphor in healing therefore must appeal to knowledge about the intentions of actors and the larger social ideologies, norms, and values that inform, energize, and constrain individuals’ actions and agendas.

The chapters in this volume weave together phenomenological, cognitive, and social accounts of meaning and sense-making. The framework that brings this together is based on contemporary “4-E” cognitive science, which offers us a picture of perception, thought, and action as bound together in ongoing cycles or loops of sense- and meaning-making.²⁴ In this view, cognition is embodied, embedded, enacted, and extended in ways that make it deeply social and cultural. Embodiment reflects the ways that cognition and imagination emerge developmentally from basic bodily experiences and continue to be elaborated through both internal physiological processes and engagements with the external environment in both its material and symbolic or linguistic dimensions. A rich experimental literature shows the ways in which bodily processes both structure and interrupt or intrude on everyday thinking.²⁵ These bodily processes involve actions in and on the environment and hence are always embedded in a particular context or niche that provides affordances (opportunities for action and perception) and that structures the process of cognition. The world then appears to us full of signs: our local niche is a matrix of affordances for perception and action. These affordances are both natural—that is, based on our inborn, physical capacities, and cultural—arising from socially patterned possibilities in the humanly designed and constructed environment and its associated scripts and modes of attention.²⁶

The realization that action and perception are closely coupled and that the (original, evolutionary) purpose of cognition is to guide adaptive action in specific niches or contexts has led to work on enactivism that aims to show how cognition has its origins in modes of action and interaction between the body and the world. Enactivism argues that even complex cognitions that appear to involve internal models or representations involve not only the computational machinery of brain but also action-oriented engagement with the world.²⁷ Moreover, these actions allow us to extend our thinking through interactions with others in the world, as well as with cultural artifacts and institutions, in ways that dramatically amplify our cognitive capacities.

Our own self-understanding through metaphors and narrative constructions plays a key role both in internal regulation and engagement with our environments, which are largely constituted through the ongoing cooperative social actions of ourselves and others. The language we have available to articulate and express our experience changes the very nature of that experience. This is the case even for seemingly preformed, obdurate experiences of pain and suffering, no less than for the stories we borrow or invent to project ourselves into new and better circumstances. The implication is that an adequate picture of the emergence of illness experience and its transformation through healing practices must lay bare the embodied process of imagination, as well as the social processes of self-construal, social positioning, and active engagement with the cultural affordances that constitute our local worlds and niches.²⁸ This very general scheme can shed new light on the mechanisms of healing and points toward a way to integrate phenomenology and mechanistic explanation in an ontology and epistemology adequate to address the key questions and concerns of psychiatry.²⁹ This approach also allows us to situate mental health practices in relationship to broader ecosocial processes of human adaptation, revealing both their potential mechanisms of efficacy and their sometimes unexpected social and political consequences.

Languages of Suffering and Healing

A central concern of this book is how to understand the process of healing across diverse systems of medicine through the psychophysiological, cognitive, and social-rhetorical effects of metaphor. Although I draw examples from a variety of healing rituals and practices to illustrate this efficacy of metaphor, the emphasis will be on contemporary psychiatry. Perhaps, this emphasis requires some justification beyond the fact that I have been a participant observer in this enterprise and so have a ready source of observations and examples at hand.

Recent decades have seen interesting changes in the models and metaphors at play in psychiatry and other mental health professions. Psychoanalysis and psychodynamic psychotherapy dominated North American psychiatric practice from the 1940s through to the 1970s, but, in recent years, psychotherapy has been on the wane within psychiatry as the profession reconfigures itself as a branch of biomedicine rooted in the neurosciences.³⁰ This effort reflects the conviction that mental health problems are fundamentally brain disorders and that explanations for the range of psychiatric conditions eventually will be found in neuroscience.³¹ Confidence in such neurobiological explanation has persisted despite limited evidence and translation into effective clinical interventions. Psychiatry increasingly focuses on diagnosis and medication prescription, while other mental health practitioners, including clinical and counseling psychologists and social workers, have become the main professional providers of psychotherapy and psychosocial care. They can provide the “talking cure” with less stigma than psychiatrists, who are associated with the treatment of severe mental illness. Of course, these changes in health care and professional roles have also been driven by economic considerations. The pharmaceutical industry is big business, and psychotherapeutic and psychosocial interventions are time and labor intensive. Insofar as psychiatrists command high fees for their time and expertise, limiting their role to diagnosis and drug prescriptions and leaving psychotherapy or psychosocial interventions to other professions may be more cost-effective.

Despite this enormous investment in biological approaches in psychiatry, the number of psychologically oriented practitioners and the availability of psychotherapies is growing globally, through popular media, humanitarian practices in global mental health, and even as a by-product of marketing efforts to promote pharmaceuticals. This has effects on how people understand and talk about themselves and others. Psychosocial counselors and others engaged by nongovernmental organizations in every corner of the world offer new ways of framing human predicaments. Psychotherapeutic idioms and ideas that are conveyed through popular media may work to transform ways of thinking about self and other far beyond the clinical setting. Indeed, through both biological and psychosocial models and metaphors, psychiatry shapes our concepts of self and personhood in diverse social contexts, from the classroom to the courtroom, and from the family to the political arena.³² Psychiatry, psychology, and psychotherapeutic discourse provide models and metaphors for mind, self, and experience. Laying bare these models and metaphors is essential for understanding the ways we narrate our lives, the logic of reasons and causes, and the corresponding moral modes of experience in health and illness.³³

Of course, every model or metaphor reveals some facets of reality while hiding others. Consistent with the perspectival nature of metaphoric thinking, the arguments and examples in this book suppose that each of the many different theories and schools of psychotherapy and the myriad forms of symbolic healing have something important to show us. In the 1950s and sixties, therapeutic eclecticism was in bad repute in psychiatric training, equated with a lack of clarity, rigor, or commitment. This criticism was possible because the adherents of some schools, notably psychoanalysts, believed they already had the last and best word on what works in psychotherapy. Other approaches were seen as watered down, inferior, or simply misguided. In recent decades, the critique of eclecticism has been revived but reoriented on the assumption neurobiology alone can provide a solid foundation for a scientific psychiatry.³⁴

The other common reason for rejecting eclecticism was the claim that all therapy works by similar underlying mechanisms (e.g., providing positive expectations, mobilizing hope, and improving morale). If so, then much of the variation in therapeutic practice was just window-dressing, an artifact of the struggle for market share, or irrelevant detail, and clinicians were free to adopt a single mode of psychotherapy and fit the patient to it. Unfortunately, patients who did not act in ways that fit the model were then judged “untreatable.” In settings where psychodynamic theory was dominant, many patients preoccupied with physical symptoms, from non-Western cultures, or with less formal education, found it difficult to speak the idiom of psychology and were judged “not psychologically minded.”³⁵ If they were offered treatment at all, they were usually referred for supportive counseling or behavior therapy, which were viewed as second-class forms of treatment by these same practitioners.

Times have changed. The embrace of biological treatments for psychosis, mania, depression, and anxiety promoted the view that common mental health problems and even “problems in living” can be traced to underlying neurochemical disorders. This claim has persisted despite mounting evidence that mental health problems involve complex interactions among many brain circuits, as well as interactions with the environment, none of which usually can be reduced to a few neurobiological parameters. In psychotherapy, cognitive-behavioral approaches are in ascendance, buoyed by the reams of research carried out by generations of graduate students in psychology. Within psychiatry, some of psychodynamic theory has been translated into cognitive or neurobiological terms.³⁶ Outside the mental health professions, psychoanalytic ideas have been adopted by literary theorists glad to curate and contribute to its nuanced language of desire, conflict, and ambivalence.

Nowadays, eclecticism is accepted within psychiatry as the corollary of our limited knowledge about the wide range of problems encompassed by diagnostic nosology. At a deeper level, therapeutic eclecticism and bricolage seem inevitable because processes involving multiple levels of systems (biological, psychological, and social) contribute to human suffering, healing, and recovery. Even with more integrative models, eclecticism will remain necessary given the recognition that all theories are partial or incomplete and hide or distort as much as they reveal and clarify. This perspectivism is urged on us by philosophers of science on epistemological grounds, as well as by social critics concerned with the political use of rhetoric to hide manifest injustices and abuses of power. Describing problems as due to a broken brain, an inadequate childhood, weak will, faulty learning, or poor decisions all have social consequences. The choice of a mode or level of explanation, then, is never purely a technical or scientific decision but one that is inherently moral and political.

Cultural Logics of Healing and Psychotherapy

The theory and practice of any healing tradition—including the diverse forms of psychotherapy—is drawn from the norms and expectations of a society, restating these as therapeutic goals and guidelines, and aiming to return participants better adapted to some version of the quotidian. In the case of psychotherapy, these practices involve explicit talk about the “psyche.” However abstract or technical the psychotherapist’s model of psyche and suffering, the rationale for specific practices, and processes of therapeutic change are usually framed in terms of folk psychological models, normative standards of functioning, and everyday ways of narrating and explaining experience. What we take for granted in our theories of healing is just what has become culturally implicit. Psychotherapy, then, cannot help but reinforce some of our cultural blind spots, even if it successfully uncovers and liberates us from others. The cultural embedding, implicit values, and consequences of a therapeutic system can only be appreciated by standing outside its assumptions for a moment to consider alternate ways of thinking about suffering and healing. This attempt to stand outside the received wisdom is the special contribution of the cross-cultural study of healing.

Many cross-cultural studies of symbolic healing have emphasized their universal dimensions: the social power and authority of the healer and the ritual; the imposition of symbolic order on the distress, chaos, and confusion caused by disease; the lifting of morale by fostering positive expectations of cure; and the mobilization of endogenous mechanisms of healing.³⁷ But it is also possible to use cross-cultural comparison to clarify the distinctive characteristics of Western psychotherapies—by paying close attention to the specific metaphors in which our theories are framed and the practices through which these metaphors are enacted.

In his classic text Persuasion and Healing (1961), the social psychiatrist Jerome Frank argued that all successful forms of healing address a common experience of demoralization, working to instill hope, make sense of suffering, and improve morale and so promote a universal human capacity for adaptation.³⁸ But this general picture of the common factors in healing is more a statement of outcome than an account of underlying process and does not go far in explaining either the cultural fit of specific therapies or their potential efficacy. Clearly, raised morale is not the only salient or important outcome of healing. Healers aim not simply to convince the afflicted person and their entourage that they are somehow healed or cured, but equally to help them to understand, accept, or transcend aspects of their predicaments: to show that afflictions have meaning, even if they are terrible; to show how illness can be mastered, controlled, or transformed; or, when neither understanding nor control can be achieved, to show that there is a way to continue with life—in this world or the next.

Subsequent work on common factors in healing has considered a wide range of processes in physiological, psychological, and sociocultural models.³⁹ At a biological level, these include endogenous processes involved in the regulation of pain and emotional arousal. Psychological processes include changes in cognitive maps or models of the self and the social world that affect attention, symptom attribution, and problem solving. Social mediators include changes in social identity, position, and relationships with others. Although many of these processes are involved in every form of healing, they also have specific effects related to the nature of the problem and its personal and social meanings. These meanings depend on both the individual’s history and larger cultural frames that endow healing practices with social power and authority.⁴⁰

In later efforts to refine his original account of nonspecific therapeutic effects, Frank came to recognize the central importance of rhetoric in healing.⁴¹ Rhetoric is concerned with what moves people—with the use of language to transform meanings or conceptual positions along with perceptions, emotions, and moral convictions. Although some accounts of rhetoric emphasize the force of logical argument, recent attention has focused on pragmatics and poetics.⁴² The pragmatics of rhetoric include the situated nature of discourse, which mobilizes institutional authority and social power through drama and charisma.⁴³ The poetics of rhetoric addresses the evocative power of language which works on the imagination to orient, energize, and direct feeling, thought, and action.

This book, then, takes up where Frank and others leave off in their accounts of the nonspecific dimensions of healing, with the role of rhetoric, narrative, and metaphor in symbolic healing.⁴⁴ Instead of emphasizing common or nonspecific factors, I consider the diversity of models and mechanisms involved in healing practices around the world. This diversity is also found among the different schools of psychotherapy within the pluralistic societies that we call “Western.” Similar diversity is present as well among the range of clients who attempt to follow a particular form of therapy. Each person responds in their own fashion to the expectations and interventions of the clinical encounter. Every sufferer lives their own metaphor in sickness and in health—that is, every person’s psychological conflicts and problems in living are constituted by specific metaphoric conceptions of self and other that shape the experience of illness and healing. Each of these personal modes of construal have their own specificity, but they draw on common tropes and master narratives circulating in the cultures and communities to which individuals belong or with which they are in dialogue.

Conceptual Metaphor Theory and the Scaffolding of Experience

Although metaphor was classically approached as a matter of poetic figures that add color, emotion and rhetorical power to speech, there is a long tradition of seeing metaphor as central to culture and cognition. In The New Science (1725), the Enlightenment philosopher Giambatista Vico (1668–1744) argued that the poetic logic of metaphor was essential to the development of thought and language itself.⁴⁵ Fredrich Nietzsche recognized the “mobile army” of metaphors as the medium through which we interpret the world and seem to apprehend truth but warned of the danger in mistaking metaphor for reality.⁴⁶ Over the last four decades, work in cognitive linguistics has provided empirical evidence for the centrality of metaphor in thought.⁴⁷ This work recognizes metaphor as the master trope in meaning-making.⁴⁸ In this view, in addition to their obvious aesthetic and rhetorical functions, metaphors provide conceptual structures that organize perception, cognition, emotion, and action.⁴⁹

The general process of conceptual metaphor is thinking of one thing in terms of another. The metaphor “A is B” is an invitation to think of A (the target or topic) as if it were a sort of B (the source or vehicle). More formally, metaphors are mappings of one concept or experience (the source or vehicle) onto another (the target or topic). This mapping confers new meaning on the target and, as the term “vehicle” suggests, the cognitive process of metaphor allows us to extend the mapping to derive additional associations or implications. Metaphoric mappings are asymmetrical in that high salience features of the vehicle are applied to the topic.⁵⁰ Thus, the metaphor surgeons are butchers (which might evoke an image of the surgeon cutting crudely with a scalpel like a cleaver, leaving hunks of meat and a bloody apron) is quite distinct from butchers are surgeons (wielding a knife like a scalpel with care and precision)—each metaphor draws on salient features of the vehicle to make latent features of the topic more salient. Although the concept mapping that underlies metaphor is asymmetrical, metaphor comprehension and production involve an interaction between source and target that can alter them both, creating new meaning and salience.⁵¹

What is salient is, of course, relative to both topic and vehicle, so metaphor comprehension involves a process of exploration to find analogies that fit. The mapping of topic onto vehicle may occur in many small leaps in which features of the topic are translated into the vehicle, moved through the representational space of the vehicle and then translated back to check for coherence within the structure of the topic. This cycle of forward and back-translation is necessary because otherwise a metaphoric extension might quickly become misleading or even uninterpretable by using extraneous or irrelevant aspects of the vehicle to represent the topic (surgeons are butchers might be taken to mean that surgeons sell their services by the kilo). To be meaningful, the analogic transformations within metaphor must be widely context dependent at both ends of the metaphoric bridge from topic to vehicle and back. In the way that they function in metaphor, topic and vehicle are best understood not as isolated lexical terms but as conceptual models or structures. Metaphors relate whole structures not just their elements.⁵² The translation process inherent to metaphor is a microcosm of the larger process of linguistic translation and many of the successes and failures of translation stem from the challenge of finding comparable metaphors that carry over crucial aspects of conceptual structure and that are not sabotaged by divergent connotations or associations unique to one or the other linguistic tradition or cultural context.⁵³

The metaphors we use to make sense of experience can be described as schemas or models based on analogies. Some have argued, therefore, that metaphors are simply loose, deviant, or odd analogies that draw attention to themselves.⁵⁴ However, while analogies may provide the initial structure or mapping that prompts a metaphor, metaphors can generate meaning that is not captured by a formal analogy. This occurs because novel metaphors prompt a search for meaning—and the more novel or unexpected the juxtaposition of source and target, the wider and deeper the search for links. This search may involve considering many facets of the source to attach a potentially relevant quality to the target or it may involve constructing images, scenarios, or situations in which the metaphor makes sense (see Figure 1.1).⁵⁵

Figure 1.1

The structure of metaphor

Metaphor involves thinking about one thing (a topic or target) in terms of another (vehicle or source). Finding the relevant analogies or facets of source and target involves interaction between the two in a context-driven process of search or imaginative construction. Metaphors can build a scaffolding that links developmentally earlier and conceptually simpler bodily experiences to more complex situations, scenes, or scenarios. The terms metaphier/paraphier and metaphrand/paraphrand are borrowed from Jaynes (Reference Jaynes1976). In addition to the cognitive effects of analogical mapping, the key to the transformative effects of metaphor lies in the processes that link metaphoric entailment with embodiment and enactment.

(adapted from Kirmayer, 2011a, Creative Commons)

Metaphors can provide a basis for conceptual elaboration, scaffolding more complex or abstract cognition. Lakoff argues that abstract reasoning “is a matter of two things: (a) reason based on bodily experience, and (b) metaphorical projections from concrete to abstract domains.”⁵⁶ Analogic representations (“mental models”) based on spatial relationships can encode logical properties of the world without invoking propositional logic.⁵⁷ Similarly, the logical functions of natural language can emerge from mental representations of abstract “spaces” that are intermediate between language and the world.⁵⁸ Metaphoric phrases are interpreted as instructions for constructing and operating on a mental space to simulate an action perception or relationship between objects or events. This simulation can then be worked with to explore the implications of statements.

At the base of this scaffolding, metaphors provide semantic pointers to meanings grounded in sensory experience and actions.⁵⁹ This implies a direct mapping from source onto target. But metaphors typically present multiple facets or dimensions of meaning that point in different (sometimes discordant) directions. Some of these facets are obvious but others may lie dormant, waiting to be activated in surprising ways. The metaphor the brain is a computer, for example, not only provides a rationale for building computational models of the brain; it also implies the brain can be programmed, that it is precise, and that, if burdened with too many tasks, it can get overheated. For someone with little experience with computers, the metaphor may be less evocative, shallow, or simply puzzling.

Many everyday metaphors are part of conventional idioms or expressions that have become the literal name or description of an object or event. Conventional metaphors express tacit knowledge. They may also provide reassurances that we are participating with others in the same language game, the same community or form of life, with its familiar etiquette, idioms, rules, norms, and implicit ontology. The use of a novel metaphor—or of a conventional metaphor in a novel way that reactivates some of the meanings inherent in its etymology or experiential grounding—is an invitation or provocation to rethink some aspect or domain of experience. This is a basic way we generate new ideas, actions, and perceptions that extend the boundaries of culture and convention.

Metaphors emerge from our experiential engagements with the world and, as they are enacted and deployed in that world, they reshape experience. Metaphors can influence physiology and embodied experience, constitute new cognitive structures or mental mechanisms, configure new social arrangements and relationships, and confer new forms of power. Understanding the ways that metaphors work requires the resources of biological, cognitive, and social science. The theory of metaphor can provide a crucial framework for an integrative view of illness and healing for three main reasons.

(1) Metaphors are ubiquitous in cognition and experience, although often disguised by convention as literal statements. A large body of work in cognitive science demonstrates that metaphors are not merely literary figures or ornaments applied after the fact—in moments of poetic exuberance or rhetorical excess—to our conceptual models and experiences. Instead, metaphors serve to organize categories, concepts, models, and even the structure of modes of reasoning that give rise to both concrete and abstract thought and experience.⁶⁰ Metaphoric expressions and concepts are used to frame the technical models of medicine, psychiatry, and psychology, the everyday concepts and categories that constitute our folk psychology and local worlds of meaning, and the most personal and inward or private experiences of illness, symptoms, and suffering.

(2) Metaphors have sensory, affective, and conceptual connotations and hence fuse multiple dimensions of meaning in the same verbal act or cognition. The sensory and affective levels of meaning, as well as many of the conceptual implications, of metaphor are often hidden, particularly when metaphors are taken as literal because they have become conventional or “dead.”⁶¹ These hidden or implicit levels of meaning nevertheless can be shown to influence the direction of thought and action and our conviction of what makes sense, is plausible, or self-evidently true. In this way, metaphor contributes to the production of the “natural” world.

(3) Metaphors, whether conventional or novel, are creative, constitutive, and transformative of meaning and experience. Metaphor is not simply a colorful or fanciful representation of what already exists but the presentation and enactment of what is possible or conceivable. The potential meaning may involve resituating experience in a different frame, world, or ontology.⁶² A theory of symbolic meaning built on metaphor emphasizes the inventive, evocative, and performative powers of language and imagination, which are central to individuals’ efforts to understand and cope with distress, as well as to the symbolic logic and evocative power of healing systems, rituals, and interventions.

(4) The metaphors we use to make sense of experience can be systematized as schemas or models based on analogical mappings. When a metaphor is schematized or systematized, it can become a model of experience but, unlike a formal analogy or explicit mapping, the metaphor need not conform to its initial target domain, and this may lead to divergent meanings. While analogies may provide the basic structure or mapping that prompts metaphor, metaphors have excess or supplementary meaning reflecting the wider or deeper search for associations, correspondences, or connections. This search may involve picking out one or other aspect of the source to attach its quality (or entailment) to the target in a focal way, or it may involve constructing possible worlds or situations in which the extended metaphor makes sense.

When metaphors offer new ways of looking at or “taking hold” of familiar objects or events, they can be viewed as cognitive tools or gadgets.⁶³ New metaphors can be readily fashioned, yielding new tools. In this way, metaphor provides a highly flexible, granular modularity of mind. In a sense, metaphors can function as temporary cognitive modules assembled to do specific types of information processing, regulation or transformation of action and perception. Each metaphor becomes a jury-rigged module that serves the generative/constructive nature of cognition. But metaphors have lives of their own, both cognitively and socially. As a cognitive tool, every metaphor has its own affective resonances, affordances, and limitations that leave marks or traces on the concepts and experiences to which it is applied. Socially, every metaphor provides a particular perspective or way of seeing the world, framing situations, identifying goals, and organizing action for individuals and groups.⁶⁴ Crucial to this autonomy and constructive power of metaphors is the extent to which metaphoric meanings can be stabilized and put to use. This stabilization can occur through a metaphor’s connection to embodied experience or discourse, its elaboration in narratives that are shared with others, and by its embedding in a web of social practices and institutions. This points to the need to understand metaphor (and its narrative elaborations) in terms of the dynamics of social-ecological contexts.⁶⁵

Metaphor in Ecosocial Context

The chief problem with putting metaphor at the center of a theory of meaning is that, in metaphoric worlds, anything goes. While individual metaphors bias and constrain our associations, they do so in partial and flexible ways that can be easily subverted or transcended by the production of new metaphors. The coherence of metaphors is like the organization of a tool kit: though they may be carried together in the toolbox, each tool, when taken out, encourages hand and eye to approach a problem in a particular fashion (of course, a tool can be used in unintended ways). While a degree of continuity occurs because each tool must work with the material left by its predecessor, each tool affords new possibilities and allows radical departures. In a similar way, when different metaphors are used to explore a region of experience, we can try to make them fit with each other or take off with a train of associations at an oblique angle. The use of multiple metaphors may yield no overarching coherence, because the polysemy of metaphor imposes no necessary or rigid logical order, unless there is some reason to grant a particular metaphor primacy or centrality and use it to corral, constrain, and hierarchically structure the rest of our cognitive constructions and inventions. In many cases, the central metaphor remains unclear. Instead, we achieve coherence by imposing the formal constraints of logic and the pragmatic constraints of practice. In addition to logical coherence, these constraints may be based on the trajectory of our personal history or biography or the demands of adapting to particular situations, social norms and institutions. Coherence and consistency of meaning then usually come not from within the field of potential metaphors but from the subordination of metaphors to features of the world relevant to specific goals.⁶⁶ The goal or use constrains the choice of metaphor even as the metaphor can reframe or modify the goal. In particular, it is grounding in bodily experience on the one hand and the social order on the other that provide constraints and norms and, in so doing, a sense of aptness, epistemic authority, and cognitive or rhetorical efficacy that promotes some metaphors to the status of central, core, or root metaphors that come to dominate our symptom perception, illness narratives, and medical models.

Early bodily experiences provide preconceptual templates for subsequent knowledge and experience.⁶⁷ These templates may be what George Lakoff and Mark Johnson call “image-schemas”—that is, combinations of images and propositional knowledge about situations⁶⁸—but they may also involve forms of procedural or embodied knowledge (skills, biases, stances, propensities to respond) that cannot be easily articulated or described. More elaborate metaphors that structure both concepts and the syntax of language may be built on these rudimentary sensorimotor schemas.

Social structures and patterns of interaction shaped by cultural beliefs and practices influence our bodily experiences of the world from their inception.⁶⁹ Social practices conjoin disparate bodily experiences in familiar sequences that, however contingent, have the experiential quality of immediacy, of occurring in the moment without any mediation, which is easily mistaken for necessity—that is, the sense or conviction that things could not possibly be any other way. These seem to be basic building blocks of experience that cannot depend on the mediation of language and cultural history. Yet, insofar as such experiences are apprehended through a culturally shaped consciousness or habitus and articulated in common language, the basic qualities and elements of bodily experience are never free of culture.

At another level of organization, social models, myths, and ideologies that circulate through many forms of discourse provide narratives that constrain the choice of metaphor. In formal terms, a narrative structure imposes a partial ordering or lattice on experiences and events.⁷⁰ The operators that relate one node to the next in the lattice of narrative can be based on implicit metaphors. For example, for English speakers, the passage of time—which is fundamental to narrative structure—is often based on spatial metaphors in which we move forward along a path toward the future (e.g., “i look forward to tomorrow”); in parallel, we metaphorize events as entities that move toward us from the future and disappear behind us into the past (e.g., “all things must pass”); these structures vary by language and culture, with effects on how we process, perceive, and evaluate events.⁷¹ Metaphors lie at the basis of both such simple narrative structures and the more complex stories that imbue our lives with emotional and historical meaning. But the bridge from metaphor to narrative is not unidirectional: narratives, in turn, may suggest metaphors, and the framework of a familiar narrative allows us to use many disparate, even incompatible metaphors, without obvious incoherence.

The higher order conceptual structure and self-referentiality made possible by narrative practices is key for understanding how metaphors are stabilized and extend their reach into the social world. Narratives come in many shapes and sizes, some concocted for a transitory occasion, others drawn from a common fund of stories that circulate within and between communities. Some of these stories are tentative, the result of casual bricolage, while others are highly valorized, deeply held, and defended. Certain dominant, socially constructed narratives can be called “myths,” not in the sense that they are false beliefs or a special genre of story, but in recognition of their function as unquestioned truths and master narratives or frameworks that we use to order and explain vital aspects of our worlds.⁷² The classical myths of Greece or India are stories about gods who are human-like actors with intelligible motivations, if sometimes awe-inspiring powers. The more mundane stories invoked in illness narratives describe the motivations, conflicts, and concerns of ordinary human lives. Some of these become exemplary as models for suffering, endurance, and moral personhood. We use these narratives to justify, order, and make sense of our lives and, in so doing, we constitute our selves. In this sense, ordinary narratives draw from cultural templates that are similar to grand myths: they are story-forms that convey central values and concerns. Like classical myths, the origins of the mundane myths provided by secular society remain largely unexamined and unquestioned in everyday life; that taken-for-grantedness is part of their rhetorical power.⁷³

There is a triadic relationship between bodily experience, metaphoric constructions, and overarching narratives in the production of meaning- and sense-making. Figure 1.2 depicts the interaction of these processes. Social forces work at all three of these sites (body, metaphor, discourse), though they are most explicit and conspicuous in the process of constructing discursive formations. Exclusive attention to one site gives an incomplete picture of the process of meaning-making and leads to predictable distortions in our picture of the forces that shape experience. Research on embodiment shows how the body undergirds and constrains perception and thought, just as critical anthropology and social constructivism expose the self-confirming realities maintained by political economic structures and ideologies. The study of the role of metaphor in mediating transactions of embodied and socially situated selves offers a way to move beyond some of the limitations of disembodied and apolitical theories of illness experience and healing.

Figure 1.2

Embodiment and enactment in experience

This figure outlines the cyclical processes of embodiment and enactment that mediate experience. There is two-way traffic between bodily processes and individual experience mediated by cognitive processes of metaphor, imagery, and imagination. Similarly, there is traffic between experience and social discourse or institutional practices mediated by interpersonal communication through narratives, self-presentation, and positioning. Embodied experiences give rise to metaphors, which structure and shape individual experience, and to narratives, which are amplified, stabilized, and extended through collective enactments. In turn, discursive practices give rise to new metaphors and modes of embodiment. These cycles of enactment and embodiment occur on multiple timescales: (i) in the historical process of producing culture, novel metaphors become the building blocks of common sense; (ii) over the course of individual development, collective narratives and modes of cooperative enactment structure individual autobiographical narratives and identity; and (iii) in the ongoing improvisations of everyday life, extended metaphors and narratives are tools for self-fashioning and positioning. All of this occurs in a field of cultural affordances provided by local niches and larger social contexts

(adapted from Kirmayer & Ramstead, 2017, with permission of MIT Press).

Some Notes on Method

There are many ways to study metaphor, reflecting both disciplinary interests and the multiple uses of metaphor as linguistic trope, pragmatic speech act, rhetorical device, and conceptual structure.⁷⁴ The approach to metaphor analysis in this book is informal and unsystematic but adequate to the task of showing some of the hidden meanings and unintended consequences of our models in medicine and psychiatry. There are three steps to this informal method: tracing and tracking, analysis and critique, and integration. Tracing and tracking explore the uses of a metaphor as well as its origins, applications, and extensions. Critique is based on clarifying the assumptions inherent in the production or use of a metaphor, both implicit and explicit, identifying alternative metaphors for the same domain of interest, and considering the consequences of the use of the metaphor, both deliberate and unintended. Integration aims to identify or invent larger frames or ecologies within which multiple (even contradictory) metaphors can coexist.

While any metaphor easily generates polarities (hard/soft, concrete/abstract, inside/outside), the possible contrasts are endless, and the narrative strands implied by metaphor are always multiple and tangled rather than constituting a simple binary opposition. The goal of analyzing multiple metaphors is not a synthesis that transcends differences but a pluralism that recognizes the unique virtues and limitations of particular metaphors and stays with the generative tensions of difference, contrast, and invention. The methods of metaphor analysis borrow from cognitive poetics and critical discourse analysis.⁷⁵ This allows us to uncover and trace some of the connotations or implications of specific metaphors presented as words, images, or actions. Tracing connotations can be done in several ways, each informed by a set of pragmatic concerns.

The most basic metaphors have their roots in sensory analogy. This level of metaphoric meaning can be recognized by considering personal, conventional, and cultural associations to the sensory qualities invoked in describing or expressing an idea. Many basic concepts make direct appeal to these sensory qualities but they are also present in abstract discourse. More elaborate sensory associations are found, for example, in the work of the philosopher Gaston Bachelard, though in his reveries on matter, the passage from common or conventional sensory associations to personal, often idiosyncratic meanings is quick and unannounced.⁷⁶ Linguistic research on metaphor often relies on the intuitions of the author as native speaker, but it can also engage more systematically with a corpus of language drawn from particular discursive contexts like books, newspapers, and conversations (increasingly captured through social media). Of course, context shapes discourse, and that includes the medium through which metaphor is conveyed. Some metaphors may reflect the sensory qualities of the medium (speech, written text, electronic media) itself rather than the specific topic, interlocutors, or occasion. And, while one’s own associations can be a guide to common experience, they must be tested for generality both within and across cultures. Intuitions about metaphoric meaning must be treated as hypotheses rather than final truths.

Beyond the sensory qualities conveyed by metaphors, there is a layer of meaning associated with affect or emotion. Some of this can be captured through Charles Osgood’s device of the semantic differential, in which a respondent is asked to rate various words, concepts, or experiences on bipolar scales anchored at each end by semantic opposites (e.g., hot/cold, fast/slow, pleasant/unpleasant).⁷⁷ It is easy for people to do this—showing our facility with cross-modal sensory analogies, emotional valences, and metaphoric thinking. Factor analyses of answers to many such scales yield a small set of common dimensions of affective or motivational meaning.⁷⁸ We all have the capacity to recognize such simple meaning and can use our bodily and emotional responses to identify some of the affective connotations of a particular metaphor. In effect, our capacity for affective response allows us to unpack some of the potential meaning of the metaphor. However, while some simple or basic emotions may be closely tied to particular bodily states or dispositions to respond, more complex emotions or sentiments depend on specific social scenarios or situations. Interpersonal or intercultural understanding of more specific or fine-grained aspects of emotional meaning then depends on greater levels of shared experience with the kinds of social scenarios, scripts, positions, and predicaments encoded in the emotion.⁷⁹ Complex feelings that involve cognition extended over time and space to include personal and collective history and geography will require the same sort of unpacking as abstract concepts.

Everyday affective meaning may be communicated not only through the content and connotations of a metaphor but also (or, in some cases, exclusively) through its paralinguistic expression in voice, tone, and gesture. Listening to the tone and other pragmatic features of a speaker’s utterance may yield metaphoric connotations that supplement, contextualize, or even contradict other levels or layers of meaning. This is part of the pragmatics of the use of metaphor to convey irony or sarcasm.

By relating two different domains of experiences, metaphors can generate affective meaning simply by juxtaposition. The activation of two different image-schemas or sets of associations creates a superposition, interaction or blending in which each modifies the other.⁸⁰ This can occur without an explicit model, awareness, or understanding of the connection between the domains. To understand the content of a metaphor, we construct an image, action, model, scenario, or story implied by the metaphor. From this image, model, or story, we can then reason analogically to explore the implications of the metaphor. We can return to the initial metaphoric image repeatedly and move out along other arcs of associations. Of course, this kind of cognitive engagement and elaboration works within the metaphor and cannot reveal all of its connotations. To get beyond or behind the assumptions conveyed by the metaphor, we need to compare and contrast the image or story invoked by the metaphor with alternative metaphors. This comparison of alternatives can make it clear why “the fight against cancer,” for example, is not the only way to think about the search for a cure, public health efforts, or one’s personal struggle.⁸¹ “Fighting” can be contrasted with “taming,” “treating,” or “controlling” or “living with” in terms of its sensory, affective, and conceptual connotations. This generation of alternatives is a basic way to open up the meaning of metaphor and is especially revealing when metaphors have become entirely conventional and, hence, hard to recognize as such.

Clearly, metaphors are grounded not only in bodily experience but in the social world. Exploring the social and cultural connotations of metaphor then involves reconstructing the scene, setting, or scenario where action and experience unfold. This requires detailed knowledge of cultural particulars. While bodily experience tends to be single if not singular—occurring to you or me in this moment, though experiences of intersubjectivity and intercorporeality are common⁸²—social experience is characterized by its multiplicity of voices. The social connotations of metaphor include the invocation of or allusion to these other voices. This heteroglossia may involve other voices from history, oral tradition, literature, or communities.⁸³

Meanings may lie buried or sedimented in layers of metaphors that link a word to its historical origin and changing contexts of use. Etymological analysis can expose the historical roots of metaphors that are obscure or that have become entirely conventional. This archaeology of metaphor can reveal whole systems of meaning and metaphysics that may have been elided or suppressed by changes in cultural models and ontologies. Some of the historical connotations of a metaphor may be lost, but other connotations may leave traces that can structure whole conceptual domains. There is a rich literature exploring the history of metaphors for mind and psychological functions that provides the undergirding for contemporary academic and folk psychologies and concepts of self and personhood.⁸⁴

All of these layers of meaning coexist with and contribute to the social significance and rhetorical force of any speech act. As shown throughout this book, metaphors are grounded in both bodily and social experience. Thus, metaphoric connotations can be traced inward to bodily, interoceptive, sensorimotor, and experiential roots, and outward to social context and interactions, including both discursive practices and material circumstances. Explicating what seems to be going on in the body and in social interactions clarifies the meaning of metaphors derived from these experiences. This explication builds on insights from phenomenology and mechanistic accounts of the physiology of the body, the dynamics of the social world, the history of individual experience, and collective culture sedimented in language, institutions, and practices.

Metaphor analysis reveals that meaning includes dimensions that are essentially connotative rather simply denotative. These connotations may be received as part of the everyday use of a metaphor, or excavated from its etymological history, but they can also be generated de novo by the new linguistic and social contexts in which the metaphor is deployed. While acquiring new metaphors may begin with ostension—pointing to an object or event—and hence depend on a primitive concept of denotation, the things of the world are not logical atoms but scenes, situations, and opportunities for action that, by virtue of how we interact with them, yield many different sorts of experience. While a conventional metaphor like she gave him an icy stare may seem to have a relatively narrow or specific meaning associated with its sensory qualities of coldness, transparency, solidity, and slipperiness, ice can be mined for deeper affective and metonymic meaning. Ice as metaphor can conjure a whole season (winter), a physical state (solid water) or phase transition (freezing, melting, sublimating), and a wide variety of sensations and actions: ice can crack or craze, be shaped into a cube that can be plunked in a glass, crunched between the teeth, skated on, scraped from a car windshield, or carved by a chainsaw into ephemeral sculptures. The word “ice” can generate rich metaphoric connotations drawn from the bodily, social, and abstract consequences of all of these potential modes of interaction. We might say these meanings are latent in the metaphor of ice.

To say that meanings are latent in a metaphor, however, is not to claim that every individual who encounters or uses the metaphor has access to all of those meanings all of the time. The salience of meanings depends on having had particular experiences and background knowledge. Some meanings are available to most people by virtue of the many existential universals of human experience: being born, discovering one’s body and becoming self-aware; being dependent on the care of others for comfort and survival; learning and acquiring new skills; experiencing attachment, motivations, and desires like thirst and hunger and emotions like fear and anger; experiencing pain, injury and sickness, and loss; growing old; and facing mortality.⁸⁵ Other meanings depend on living in a particular kind of body, a specific social environment or niche, occupying a certain social position or having had certain life experiences.⁸⁶ Whatever one’s own position and life trajectory, many of the latent meanings are available in the larger social world, distributed among people and places where the metaphors are used and circulate. This means that, whether or not an individual knows, intends, or has access to a particular connotation of a metaphor, that meaning may become important for some participants at some point in the circulation of the metaphor. In a sense, then, the potential meanings travel along with the metaphor, whether or not they are taken up and responded to by anyone, ready to spring to life, provided that the bodily experience and cultural knowledge needed to elaborate their meaning become available.

Systematic study of metaphor shows that there are certain key words or root metaphors that structure larger domains of thought and experience.⁸⁷ These key words may be identified by their high frequency of occurrence in speech, by their central role in organizing a conceptual domain, by evidence that they are concrete terms or “logical atoms” that cannot be further decomposed, or through their status as socially authorized truths or certainties. In many cases, however, root metaphors may be hidden or implicit, buried under a complex superstructure of abstraction and habitual use. Such core metaphors form part of our background knowledge—tacit assumptions, habits of thought, and skills we use to take hold of the world. We may find it hard to identify these root metaphors because they are implicit, involving procedural knowledge or ways of doing things that are viewed as natural or inevitable and, sometimes, because bringing them to light might reveal biases or raise issues that threaten or destabilize the status quo.

Metaphors reflect categorical knowledge, but metaphors also allow the creation of new categories.⁸⁸ In this way, metaphors populate the world with new entities and, to the extent that these give rise to new ontologies, some philosophers have argued that there is a sense in which metaphors impel the construction of whole new worlds.⁸⁹ Metaphors may be taken as literal statements if we view them as initiating the construction of worlds (local or global) in which the metaphoric relation finally obtains because it has recognized or brought into being a new ontology. If metaphors create whole worlds, and if these worlds can only be accessed or inhabited by those who live within a particular regime of metaphors, then it is a small step to the claim that these worlds are incommensurable—that is, there can be no Archimedean point from which to compare them, or, still worse, no easy traffic or exchange between them.⁹⁰ In fact, we see constant traffic between disparate metaphoric “worlds” both within and between individuals and communities, with borrowing, blending, and hybridizing, suggesting that any incommensurability we perceive is only as large as the limits of our imagination and ability to create communicative situations of openness, equity, intimacy, and prolonged engagement.⁹¹ Indeed, metaphor itself invites intimacy and enhances our understanding of others’ experience.⁹² When they challenge or unsettle conventional worldviews, metaphors serve as modes of inquiry that can lead to the recognition of similarity as well as difference. This points to the fundamentally social and political nature of metaphoric constructions and their implicit ontologies.

Indeed, as much as metaphors structure our world, the claim that metaphors create worlds is overstated: metaphors create worlds of imagination or possibility, not this world, which—in its fullness, complexity, and intransigence—escapes any encompassing metaphor.⁹³ Metaphors allow us to take hold of the raw materials of the world to fashion shelter, build bridges, and enter into dialogue with others. To do this, we must recognize the material exigencies that lie beyond the metaphoric frame. Metaphor can be enacted in ways that create new structures and processes that transform our world. It provides us with tools to negotiate a larger reality that is, at least potentially, shared with others with whom we enter into relationships of mutual recognition. This results in a hermeneutic circle or cycle in which meaning is co-constructed. On one side of the cycle between imagination and reality, we have the piecemeal constructions of metaphor based on experiences with the world, on the other side, the calling into being of a shared world through narratives and imaginative constructions in which metaphor finds purchase, makes sense, and solicits both serious and playful engagement.

An Outline of This Volume

Reflecting the way that hermeneutic circles are actually cycles that unfold in time, this book spirals around the central theme of metaphor and healing, first addressing the embodied nature of metaphor, then various models of healing, and finally issues of meaning, truth, and transcendence central to the politics, ethics, and pragmatics of metaphor in individual and social rhetorics of transformation.

Chapter 2 explores the developmental psychology of metaphor and its significance for illness experience. Illness experience is articulated through metaphors that are grounded in—and constrained by—both bodily experience and social interaction. The bodily grounding of metaphor is based on the elaboration of sensorimotor equivalences, as seen early in development in synesthesia and cross-modal analogies. The social grounding of metaphor resides in the pragmatics of language where context and goal are inseparable from meaning. Metaphors allow for inventive play, despite the dual constraints of body and society, by requiring only piecemeal correspondences to the world through ostension. The meaning of metaphors is then to be found not in representation but in presentation—modes of action of ways or life. Clinical examples illustrate how a semantics of metaphor can clarify the tensions between the essential irrationality of illness experience and the biomedical presumption of rationality. Notions of embodiment are central to this analysis, but the body itself appears in these reflections in many ways: as the primary locus and vehicle of experience, as our means of engaging with the world, as the material substrate of cognition and action, as footing for the scaffold of metaphoric meaning, and as itself a metaphor.

Chapter 3 illustrates the poetics of illness experience by examining the clinical conversation during a psychiatric assessment of a patient with “psychosomatic” complaints. The narratives presented by patients in clinical contexts are often fragmentary and contradictory, reflecting their ongoing struggle to make sense of inchoate experience and position themselves in ways that elicit care and concern. Metaphors of illness experience open up narrative possibilities, but these may be blocked by the conflicting agendas or cross-purposes of clinician and patient. As a result, in place of an overarching integrative narrative, we find interruption, miscommunication, and mutual subversion of accounts. Focusing on narratives in their pragmatic context, with close attention to the speakers’ rhetorical aims, can identify situations of tension and misunderstanding that are common kinds of clinical impasse and that point to structural problems and ideological conflicts in the institutions and practice of biomedical care.

Having looked at meaning construction in the clinical encounter, we then turn to a closer examination of the dynamics of transformation. Healing rituals use metaphoric language and symbolic actions not only to represent experience but also to change it. How do symbols alter social, psychological, and physiological processes? Chapter 4 applies recent work in cognitive neuroscience to explore plausible models for a physiology of metaphor as imaginative enactment. Examples drawn from ethnographic studies of Indigenous healing practices, including shamanism, illustrate how metaphors and images may entrain and transform affliction through parallel processes at the levels of bodily feelings, emotional states, cognitive maps, and mythic narratives.

The narrative construction of the self is the pivot between embodied experience and the social world. The key argument of Chapter 5 is that a theory of meaning adequate to account for the effectiveness of symbolic healing and psychotherapy requires some variant of the three concepts of myth, metaphor, and archetype. Here, myth stands for the over-arching narrative and discursive structures of self and society, produced and lent authority by cultural tradition. Archetype stands not for preformed ideas or images, but for bodily and existentially given structures in experience that undergird specific images, metaphors, and imaginative constructions. Metaphors then occupy an intermediate realm (as depicted in Figure 1.2), linking overarching narratives or discursive formations and bodily given structures and through imaginative enactments that allow movement in sensory-affective quality space. This multilevel perspective itself constitutes a middle ground between constructivist and realist approaches to meaning that can integrate causal and interpretive models of symbolic healing.

Autobiographical narratives link past, present and future in the service of making sense of the world and anticipating and adapting to its many challenges. Life events and changes to the social world can disrupt existing narratives and demand a reconstructive process that recapitulates elements of the original developmental process through which the narrative self emerges. In Chapter 6, I discuss the representation of memory in narratives of trauma. The accounts of victims of childhood trauma are contrasted with the testimony of survivors of the Holocaust. These accounts differ strikingly in the contours of the struggle to remember and forget. For the childhood trauma victim, the violence of traumatic events makes them difficult to remember, while, for the Holocaust victim, violence makes events impossible to forget. I argue that that the distinctive qualities of trauma narratives can also be understood as differences in the culturally constructed landscapes of memory that shape the distance and effort required to remember affectively charged and socially defined events. Landscapes of memory draw from implicit models of memory that influence what can be recalled and warranted as accurate. Narratives of trauma, then, involve cultural models and metaphors of personal and historical memory.

The ethics of storytelling has an essential counterpart in the ethics of listening and this involves particular forms of temporality (being present with and in the story) and ways of participating in a cultural community. Chapter 7 explores some ways in which the psychological dynamics of trauma shape the experience of the self and temporality. I distinguish two meta-narratives or concepts of the self in terms of their implicit root metaphors and associated temporalities: the endurance of the adamantine self, characterized by its integrity, coherence, autonomy, self-definition, self-determination, and self-control; and the flexibility of the relational self, characterized by its fluidity, sensitivity to context, multivocality, interdependence, and responsiveness to others. These two implicit models of the self are associated with different ideologies of the person and forms of social life that shape trauma memory and experience.

The intersubjectivity through which experience emerges involves encounters with others that confront us with difference.⁹⁴ Chapter 8 considers the politics and poetics of alterity, of understanding the other when they have experiences or use modes of expression that are radically unfamiliar. Some forms of psychopathology can render people strange and difficult to understand. Communication can lead to empathic understanding, which, in turn, can guide compassionate action. But communication depends on a shared conceptual world. How can language convey meanings that are not shared, that mark a divide between human beings or whole communities? The work of the poet Paul Celan sheds light on the power of language to bridge disparate worlds and on the ethical stance needed when empathy fails. Celan’s poetics of alterity have implications for our efforts to understand individuals’ illness experience as a grounding for the ethics of the clinical encounter.

Illness itself constitutes a primordial form of otherness that structures the process of healing. Chapter 9 considers the ways the “other” of illness shapes the dynamics of the healer–sufferer relationship through the archetype of the wounded healer. Shamanism and other elementary systems of medicine are built on an ethos that identifies healers’ calling, authority, and effectiveness with their own initiatory illness experiences. This chapter argues that the ethos of the wounded-healer provides an underlying affective logic to contemporary medicine, psychiatry, and psychotherapy. Developmental changes during psychiatric training in the relationship of a healer to his wounds are illustrated by a series of dreams. The ethos of the wounded-healer has implications for understanding the epistemic authority of healers, the training of clinicians, and for addressing basic ethical and pragmatic issues in intercultural health care.

The final chapter returns to broader issues of the cultural politics of metaphor, examining the tensions between ethics and aesthetics in illness experience and healing. While the focus on language allows us to mobilize the richness of literature to explore illness experience and healing, in doing so, we may inadvertently downplay the material circumstances that determine health disparities and inequities. Against this apparent opposition, I argue that attention to the aesthetics of language and to the creative functions of imagination and poeisis can help us understand the mechanisms of suffering and affliction and devise forms of healing that better respond to the needs of individuals within and across diverse cultures and contexts.

Toward a Poetics of Illness and Healing

The epigraphs from Francis Bacon and René Char at the start of this chapter speak to a basic tension in approaching experience through metaphor. Bacon stands for the value of scientific empiricism and objectivity, knowing the world as it really is, apart from our wishes and self-serving distortions or the collective myths and ideologies that hide us from inconvenient truths. The surrealist poet Char reminds us of the deeper layers of meaning sedimented in language as dead metaphors, idioms, forgotten etymologies, and formulaic accounts waiting to be brought back to life by close attention to language, and by the playful, oneiric refiguring of conventional forms of speech in poetic imagery and art. This backcountry of meaning is also part of reality—the reality of the imagination. As Simon Critchley puts it: “Absolute fact is not absolute, in the sense of being absolved from any relation to the imagination; it is simply the arrière-pays of the imagination and therefore relative to its power.”⁹⁵

Metaphor theory shows how symbols and things—imagination and reality—live in the same world. Medical anthropology, psychology, and psychiatry must steer a course between realism and constructivism, somehow integrating the useful features of both perspectives. Perhaps this is not so quixotic as it first appears. The philosopher Ian Hacking has laid out some of the many meanings of social construction, each associated with different modes of looping between human cognition, action, and the social world.⁹⁶ If experience, identity, and the social world emerge from a cyclical process in which we invent and are reinvented by our own metaphors, the opposing arms of the process are then part of a great hermeneutic circle.⁹⁷ Metaphor is a site for the social construction of embodied experience. At the same time, metaphors are grounded in bodily experiences that appear to be universals—so metaphor is also shaped by bodily givens and projects them into the social world through physical and symbolic action or enactments. There can be no sharp demarcation then between the bodily given and the socially constructed, since both bodily constraints and social practices shape experience from its inception.

Beyond the microdynamics of symptom experience, work on metaphor has implications for the larger project of understanding the biomedical system of knowledge/power. The metaphors that arise in individuals’ struggles to apprehend and make sense of their predicaments borrow from and contribute to the political language of power, resistance, and dissent. Every choice of metaphor lends power to a particular view of the world. We must judge the value of metaphors therefore on ethical, aesthetic, and pragmatic grounds. Certainly, the ability to become aware of metaphor qua metaphor (“only a figure of speech”) is a valuable corrective to blind acceptance of our current models, to which we owe, in part, the advances of science. Yet, this self-critical awareness always occurs within a skein of unexamined metaphors generated anew with every effort to take hold of the world. There is no end to uncovering the metaphors of the cultural implicit. Instead of naive efforts to replace metaphors with literal descriptions of experience then, we need constant attentiveness to the taken-for-granted language of experience, continued creativity in the invention of metaphors, and steadfast commitment to thinking through their implications.