Poetry, Philosophy

Psychology, psychoanalysis

Psychiatry

Psychotic disorders

Mood disorders

Bipolar

Depressive

The use of metaphor is a mental practice as old as philosophy and poetry

Sontag (1989) suggests that people cannot think without using metaphorical images. 

A metaphor is a figure of speech in which a word or a phrase that ordinarily designates one thing is used to designate another, thus creating an implicit comparison (Flexner, 1993)

Metaphors use “symbolic language” to “uncover knowledge” that otherwise might be unrecognized (Kangas et al, 1998; McAllister, 1995)

Metaphors "say a thing is or is like something it is not" (Sontag, 1989) 

Metaphors intend to suggest, and reveal, certain images that enable us to see a likeness between initially different events (Fine et al, 1973)

A metaphor gives you two ideas for one

Metaphors do not add facts to a description; rather, they add depth of meaning to the nature of a phenomenon or experience. 

A new perspective is gained by juxtaposition of seemingly disparate entities

They provide a model of novel ways of looking at behaviour or thinking about a topic.

They simplify events in the terms of a schema, or concept, that emphasises some properties more than others.

They give communications an intimate or personal quality because of the concrete referents of metaphorical imagery. (Lakoff & Johnson, 1980)

William Blake, Songs of Experience, c. 1803

“…become instruments, not answers to enigmas, in which we can rest. We don’t lie back on them, we move forward, and, on occasion, make nature over again by their 
aid”.

[are] “…mental modes of adaptation to reality”

“The truth of an idea is not a stagnant property inherent in it. Truth happens to an 
idea. It becomes true, is made true by events”. 

Modularity hypotheses

Big domain-general purpose computer

Switchboard

Black box mechanical behaviourist model

Freudian school

	analytic-reductive mode of understanding
	tracing back to antecedent causal elements
	(“objective understanding”)

Jungian Zurich school constructive “synthetic” method (“subjective 
understanding”)

	“asks how, out of this present psyche, a bridge can be built into its own future” (Jung)
	to corroborate & validate their inner experience
	“Analysis has to be completed by synthesis” (Ribot, 1900)
	“He who wants to get to know the human soul will find out next to nothing from experimental psychology” (Jung)

The human mind is a product of the human brain

Inadequate consideration as to how to engage psychiatric patients

Need to form a practical, active, collaborative approach, but…

A common obstacle is resistance to engage due to:

lack of insight

reality distortion due to severe symptoms (esp. delusions)

preference for non-medical models 

fear of the stigma of being labelled with a psychiatric diagnosis. 

Assist the doctor & pt to find common ground without colluding with a maladaptive paradigm

metaphorical model need not be equal to a medical model

Enable the patient to progress from a maladaptive paradigm to a less maladaptive one

It is a dynamic process

there may be a spectrum to proceed along 

...how ‘loose’ the metaphor proves to be depends on the patient’s degree of reality orientation

Demystify scientific jargon

Promote therapeutic relationship

Participation

Treatment adherence

Improve illness management skills

Utilise management strategies for relapse 

prevention

Improve long-term outcome

Provide sense of understanding, orientation & insight

Avoid confrontation  

Help make some sense of their experiences using a less maladaptive model to their psychotic explanation

Improve insight

Promote the therapeutic relationship, participation, treatment adherence

describes the ability of a patient to recognise that:

they are ill 

their symptoms are part of the illness

they need medical treatment

often patchily affected, as is judgment 

severity of psychosis

type of psychosis

duration of symptoms 

personality

culture 

education

IQ 

responsiveness to medication

most common metaphor used in psychiatry

simple, effective, acceptable

brains = complex biological machines that can malfunction when the constituent chemicals become unbalanced

If our brains malfunction, our minds become unbalanced: our emotions, thoughts & behaviours may become abnormal

medications right the imbalance by normalising the chemicals

Some people have genetically more vulnerable brains

A psychosis is like a physiological storm raging through the limbic networks of the 
brain

A different 3-dim spread of the storm causes different parts of the brain to be affected and thus a unique profile of symptoms in every patient

Certain types of topography increase the vulnerability of an individual to having these chemical storms in these areas of the brain

Lightning reps: short-circuits producing visions, misinterpretations & erroneous ideas

Thunder reps: voices, apprehension and fear

Rain reps: withdrawal, isolation, lack of initiative & misery

If the land below is flooded for an long period, then it's going to be harder to rebuild & life will take longer to return to normal

Useful when a patient has some insight into symptoms

Usually found in early stages of relapse, onset & in drug-induced psychoses

might reduce levels of frustration, anger or anxiety that others do not support their views

might help them ‘save face’& be spared from humiliation or despair acknowledging two perspectives (theirs & the medical model) may reassure them that their own experiences are not being dismissed

Offering to treat whatever symptoms the patient acknowledges is another face-saving measure

Symptoms may include 

	fear & anxiety
	low frustration tolerance
	racing thoughts
	inability to think clearly
	poor concentration / easy distractibility
	Insomnia
	poor appetite
	Restlessness
	other somatic symptoms

another version of the merging reality metaphor

helpful when the content of the patient's delusions or hallucinations is religious

Coming to the position with the patient that they are having a religious experience but one that is causing negative consequences for them or others and therefore they need to be brought back down to Earth

Patients with grandiose delusions are often the most insightless into the fact that 
these symptoms are part of a mental illness, but may well accept they are not thinking or 
acting like they usually do or that they are overwhelmed by their situation

Pruning is a developmental stage occurring in late adolescence to the human CNS with 
regard to synapses volume of synapses in parts of the brain have been found to be reduced in 
schizophrenia

Many patients with psychotic disorders were premorbidly high functioning in school, sports or artistically & rates of psychotic disorders higher amongst artisans

Positive natural selective pressure for humans to become smarter and more creative

Strength of this model is that it is positive, focusing on potential strengths & benefits of the same genes

Having bipolar disorder is like having a loose emotional switch:

	Flick the switch up and mood becomes elevated
	flick down and mood becomes depressed.

The switch tends to flick from north pole to south (b/w black and white) without any shades of grey.

As if there is an absence or diminution of inhibitory process to prevent the emotional momentum from building in a particular direction.

Mood stabiliser medication is like using glue to stiffen the switch

discouraging the switch from flicking to one pole, and discouraging mood instability.

Having bipolar disorder is like being trapped on a runaway Rollacoaster ...  

without  brakes or a steering wheel.  The track swings high and low and the sufferer is taken along for the ride.

Medication is like adding brakes to the front carriage, slowing the train down enough to permit the rider to take some of the cars off the tracks to spread them amongst other paths

Losing touch with reality is common when in the manic phase and often in the depressive phase.

Even when manic, the subject is often distressed by mood instability, interpersonal friction, paranoia, sleep disturbance,  lowered frustration tolerance, racing thoughts, disorganisation and unproductive overactivity.

They may be aware that they are functioning differently to their normal state: "riding too high in the clouds"

Anti-manic (mood stabiliser & atypical antipsychotic) medication may assist the sufferer to be brought down to earth more gently than will otherwise be the case if they should wait, in which case they may well come plunging down and crashing (i.e. phase change into depression).

Treating the manic phase may prevent depressive episodes, especially when mood stabilisers are used prophylactically, for relapse prevention. 

Bipolar genes may be related to capacity for achievement and creativity, attraction of the opposite sex, leadership qualities (e.g. increasing group stability),  risk taking & exploration.

These qualities are positive human attributes that may have evolved for the benefit of the species, and have therefore been retained by Natural Selection.

Increased risk to developing bipolar disorder may result from an excess number or particular combination of the genes that code for these attributes. 

Mood stabilising medications may dampen the expressivity of genes that are pushing and driving the mood too far in one direction

Or they may be increasing inhibition of the escalating mood state, by activating genes and proteins controlling this activity

Mood stabilising medications often take some weeks before obtaining maximal benefit, reflecting likely gene modulating effects

Falling into a depressive disorder is like falling down a slope and into a hole that you cannot get out from.

Once you are in the hole it is all dark... 

	you become disoriented, isolated, frightened and apprehensive.
	If you fall in deep enough, you become disoriented and cannot see the light at the end of the tunnel.
	You feel helpless, anxious, confused, agitated and eventually hopeless

Environmental triggers in childhood and personality attributes increase the vulnerability to develop depressive disorder by reducing emotional reserve

This emotional reserve is like an emotional fuel tank.

The fuel tank has the capacity to gradually expand, if excessive demands are not made on the tank, constantly bleeding it dry

Past traumatic issues occurring in the construction yard can create baggage that the ship takes along with it on its voyage, weighing it down, but not so much as to sink it.

Sinkage may be threatened by extra baggage that is accumulated along the voyage, or rough waters, such as a torrential storm, tidal wave, or tsunami that the ship confronts during the voyage, spilling water over the sides into the ship adding extra strain and weight.  Panic may ensue as the ship falters. 

The water needs to be pumped out with buckets.

A mechanical pump may be necessary and should be installed by a professional.

The ship needs to keep moving along, to pass through the rough waters.

The baggage may need to be sorted through, reorganised, redistributed through the ship, important elements brought up to the deck for examination in the light of day and selectively discarded.

The ship might need to deviate from the course it was on, to the closest shipyard for maintenance.

Manual car drivers are well aware that 'low' gears (one and two) are designed for parking, starting the car from park, going up hill, through city traffic or over rough terrain.

Depression is like your gearstick getting 'stuck' in gear one or two.

In two, it is a very uncomfortable ride, with the car over-revving & engine whining.

If you were stuck in one, you would pretty much be at standstill

When waves of depression pass through the individual, these episodes must be survived.

Methods of coping with the distress must be found.

Strategies to manage the experience: distress tolerance, visualisations, self-reassurance, distraction, breathing exercises and reaching out for support if necessary.

When experiencing a depressive wave, the sufferer should remind themselves that it is a wave passing through them, which will pass through and then begone.

Medication acts like a sand-bar, buffering the waves, and hopefully re-sculpting the beach