Wisdom is with you always, overseeing your body, even though you may not recognize the fact. Do something against your body and this wisdom will eventually admonish you—Jalāl ad-Dīn Muhammad Rūmī181
You may already have experienced this. You’re in a café in a country where nobody speaks your language. You have an overwhelming desire for a coffee and the waiter is standing by to take your order. If you’re lucky, you can get by with the universal language of gestures (miming sipping from a cup, pointing at the Lavazza machine).
But supposing your needs are a bit more complex. You want half-caffeinated, half-decaf. Skimmed milk, topped up with hot water, but extra foam. And, since you’re watching your weight, you want to know if he’ll bring you some artificial sweetener.
Suddenly, it’s not so easy. On an unequal battle-ground, neither side can win. You may even ‘kiss your teeth’ and throw your head back in exasperation, but if this happens to be in a country where that gesture means ‘yes’, he rushes off to bring you something you don’t want. Or, if your waiter is African or West Indian, where ‘teeth-kissing’ is a supreme insult, you may get a lot more than a sugar substitute for your pains.
This is the position the patient suffering from a complex, chronic ‘functional’ disorder finds herself in. At some level, she knows a lot about her dis-ease, but words just seem to widen the gap of understanding.
Now, put yourself in the waiter’s shoes. He’s confronted by a gesticulating, increasingly angry or frustrated customer, whose mimed gestures are becoming increasingly bizarre (‘What on earth does a little square shape drawn in the air followed by several pats on the midriff have to do with coffee? Oh, good—he’s said, “Yes”. At last…’).
This is the position the practitioner finds herself in when she tries to sort through the avalanche of signs, symptoms, and complaints the patient is sending in her direction. In a world where logical, linear, sequential, digital data are considered superior to feelings, imagery, relationships, and subjective experience, it’s no wonder that the practitioner and the patient in our analogy will attempt to generate even more words in the hopes that some consensual ‘explanation’ will emerge. It’s no surprise that the person who holds most power in the relationship will jump at a piece of information (the head-toss and teeth-kissing) that seems to make sense, in terms of her own map, and run with it. But, as this happens, both parties slide further down the greased pole of the Structural Differential, away from the patient’s experience and into the abyss of ever-increasing inference and abstraction.
There is another way, and this is what this book is about.
But, first, a case history:
Case history: A woman in her mid-30s had returned to the doctor’s practice after the latest, unsuccessful, investigation into a painful allergy that had been making her life miserable for the previous three years.
Because it usually occurred at night, marked by large, inflamed wheals, suspicion fell on possible allergens, such as dust mites, laundry detergents, and synthetic fibers. However, extensive tests had failed to identify the cause, and the patient despaired that her problem would ever be resolved. Depressed, anxious, and suffering from sleep deprivation, she described how her condition was destroying her relationship; she felt ‘cut off’ from her partner, who was becoming increasingly frustrated with her reluctance to have sex. ‘It’s as though we’re living in different worlds and we’re separated by a wall we just can’t get through,’ she remarked bitterly. As always, we suggest practitioners go back to basics when a problem seems overwhelmingly complex. This is similar to what therapist Sheldon Kopp calls going ‘back to one’182—temporarily abandoning theories and assumptions, and returning to the baseline of the Medical NLP consultation: gathering sensory-based information.
Pursuing a conventional investigative approach had, so far, proved fruitless, so the practitioner decided to re-enter her ‘beginner’s mind’ state. Hoping, at least, to be able to restore a more optimistic direction in which they could both work, she asked the patient, ‘When the problem is finally resolved, what will you be able to do that you haven’t been able to do so far? What will be different and better about your life now?’ (These are standard, presuppositional, solution-oriented questions characteristic of Medical NLP. They are usually applied early in the first consultation, but the practitioner should feel free to check back at any point to see if the patient’s outcomes have clarified or changed.)
To the practitioner’s surprise (and, she admits, to her dismay), the patient began to weep. Sensing that the woman needed to dissipate her grief and despair, she resisted the urge to comfort her, remained engaged and present, and did what many health professionals find particularly difficult to do in their busy and pressured world…absolutely nothing. After a while, the woman raised her head, dabbed at her still streaming eyes and said indistinctly, ‘I want a baby. My life is empty without a child.’
‘And, have you talked about this with your partner? What does he think?’ The woman drew a long, shuddering breath, and then let it out. ‘He wants one too—very much…but, I don’t think it’s possible.’
On reflection, the practitioner admitted that she responded according to what she believed the woman was saying, rather than to what was actually meant. She said, ‘You might have to approach it differently, especially if making love is painful, but I don’t see any reason why you shouldn’t be able to have a baby.’
The patient paused, then leaned forward and spoke softly, but emphatically. ‘You don’t understand. It’s not that. It’s that I know he’s not the right one. I want a baby, and he’s willing to have one, too, but I don’t want it with him. I’ve never admitted that to anyone, not even myself. The idea of having a baby with someone I don’t love makes my skin crawl.’
It took a moment or two, the practitioner later admitted, ‘but, then it was as if all the lights went on’. Some gentle questioning fleshed out the picture. The ‘allergic response’ occurred only at night, and only when she was with her partner. She hadn’t noticed it before (and nor had any of the specialists she had consulted), but on the few occasions she’d been away from home on a work assignment and sleeping on her own, the symptoms hadn’t appeared.
‘What do you think that means?’ the practitioner asked. The woman smiled faintly. ‘That it’s all in my head? That’s what the other doctors think. I can see that from the way they talk to me.’
‘Of course it’s in your head,’ the practitioner said. ‘But, it’s also very much in your body. It can’t be in one and not the other.’ The remark seemed to resonate with the patient, so the practitioner continued. She explained that the function of the immune system was essentially protective. Its role was to distinguish between ‘me’ and ‘not me’, and to defend against anything it perceived as threatening the boundary between the two. ‘It’s just a guess,’ she added, ‘but could it be that your immune system knew something you hadn’t really thought out clearly for yourself. What do you think?’
The patient’s words tumbled out. She had known ‘at some level’ that the relationship had to end. She realized she was being unfair to her partner by not telling him that she didn’t love him. She thought she had to be open with him. She was nervous about his response, she said, but added, without a touch of irony, that she needed to ‘grow a thicker skin’.
The premise that unresolved emotional issues can be expressed as physical symptoms is almost as old as the practice of medicine itself. But, the search for the ‘deeper meaning’ of ‘psychosomatic’ disorders has traditionally been long, arduous, and often unrewarding. This is further complicated by the abundance of theory-driven schools and models of therapy, each of which competes for supremacy over the others.
Our proposal, then, is that the process of helping the patient to restore both physical and emotional balance can be substantially quicker and easier when we learn to defer less to dogma and more to the expertise and communication style of the undisputed expert in the problem at hand: the patient who is presenting it.
When permitted to speak freely, the patient usually presents a narrative rich in detail and meaning. But, unlike the logical, linear signs and symptoms that traditionally govern clinical investigation, meaning emerges in a form of description that is usually overlooked. This is densely packed with words, phrases, imagery, actions, and behaviors that represent (present again) the problem state in a more dynamic form.
More than mere linguistic and behavioral artifices, these ‘stand for’ a much more complex inner landscape. This is what linguists refer to as metaphor.
Traditionally, a metaphor is a figure of speech which, normally used of one class of object, action, etc, is extended to another. In everyday conversation, and, especially in consultations, metaphors are everywhere—so much so that we rarely notice them.
If we return to our analogy at the start of the chapter, we can point to a number of examples: the health professional as ‘waiter’, the patient as ‘customer’; their communication problems as a battle’ fought on an ‘uneven battleground’ where there could be no ‘winners’.
Then there are the non-verbal metaphors: the little square packet of sweetener ‘drawn’ in the air, the patting of an expanding waistline, representing, ‘I’m watching my weight’, the ‘kissing’ of the teeth and the ‘tossing’ of the head.
Similarly, imagery used by the patient whose case history is presented above includes various forms of walls and barriers that, nonetheless, create ‘emptiness’. She craves something to fill the emptiness, but ‘part’ of her is repulsed by the idea of that happening with someone she does not love. Failing to speak out about and resolve this inner conflict, her immune system takes over the job. In evolutionary adaptive terms, we might even propose that it is preventing her from reproducing with an unsuitable mate. Her skin, literally, ‘crawls’ to prevent that happening.
The metaphoric content of communication cannot be ignored if we truly mean to practice ‘whole-person’ healthcare. In either screening metaphors out or dismissing them as verbal flourishes that have nothing to do with ‘fact’, we lose information that could considerably increase our understanding. We choose text over context, facts over story, left brain over right. We drain off the lifeblood of subjective experience, and then blame the corpse for its lack of co-operation.
The truth is: we cannot communicate without metaphor. It is not merely the way in which we add color, depth, and poetry to bald facts, but it is how we organize and make sense out of our experience, express the inexpressible, and seek resolution when our complex homeostasis becomes dangerously upset. Above all, the symptom itself can function as a metaphor—and, as such, can help practitioner and patient uncover the structure, origin and meaning of the presenting problem, and therefore arrive significantly more quickly and easily at resolution.
Elsewhere in this book (see pages 77 to 81) we look at the component parts—the ‘building blocks’—of subjective experience. The sensory modalities and their distinctive qualities, the sub-modalities, are to our sense of ‘reality’ what bricks and mortar are to a building. But what gives meaning and purpose to the building is metaphor.
If the building is a house, is it also a ‘home’, or perhaps a ‘sanctuary’ for you and your family, or perhaps a ‘showpiece’ that places you in a particular position in your society? Size and shape may expand the possibilities for its use, but the concept driving its design and construction dictates how we will relate to it.
Linguist George Lakoff and philosopher Mark Johnson believe that our language and thinking are both metaphoric in nature.183 Additionally, they suggest that both our verbal and non-verbal actions are metaphorically structured. We cannot accurately describe our inner world in linear sequential terms, simply because our experience of that unique landscape precedes its arrangement into the grammar of communication. And we cannot act without in some way expressing the greater complexity of that inner world.
Some cognitive linguists believe that our primary metaphors are unconsciously acquired in our early years, largely by associating experiential domains (say, the closeness of your mother’s embrace with enjoying ‘close’ friendships in later life).184
Metaphoric constructs, each with its own neural network, both trigger and shape our physical and emotional responses in hundreds of different two-way interactions. The fact that they usually function below the level of conscious awareness is significant. The neural circuits that allow us to operate on both literal and figurative levels leave their traces indirectly—through certain words, phrases, actions (such as distinctive gestures), and, as we have already said, the appearance and development of symptoms themselves.
Traditionally, NLP uses practitioner-generated metaphors adjunctively with other techniques. These are usually isomorphic—that is, stories or anecdotes that follow the structure of the problem but with a suggested solution appended. Derived from the work of Milton Erickson, who had a vast repertoire of therapeutic stories, they are intended to bypass conscious awareness to be embedded in and acted upon by the patient’s unconscious mind.
Practitioners trained in Medical NLP use metaphors in this manner wherever relevant; telling a story about ‘someone else’ who solved a similar problem can be immensely encouraging to a patient. However, our focus in this chapter is on another class of metaphor—that spontaneously generated by the patient.
The metaphors that emerge spontaneously in the patient’s story and during information-gathering fall into two distinct categories: linguistic metaphors, and the symptom itself.
Although from our earlier discussion about sub-modalities, it is easy to understand that metaphors derive from the way we use our sensory modalities, all problem-based metaphors have at their core a kinesthetic, or ‘felt sense’. This is almost a truism; all patients seek help because, in one way or another, they ‘feel bad’. In Korzybski’s model, there is an awareness of some neurological disturbance at the Object level. It is this felt sense which disturbs them and from which they seek respite. However, unlike conventional medicine that may seek reduction or elimination of the felt sense, Medical NLP regards it as an entry-point to the silent, flowing level of the Event. Integrating transformational approaches into the regular consultation process requires that the practitioner works at ‘tuning’ his senses to listen for and observe the patient’s metaphoric communication.
Some years ago, Western medicine recognized and paid attention to what was then called ‘organ language’. Phrases such as ‘pain in the neck’ and ‘heart-broken’ were given equal weight along with objective signs and symptoms in arriving at diagnoses.
Today, we (the authors) prefer the term ‘somatic language’, which should not be confused with what physicians often refer to as ‘somatization’. Somatic language comprises figures of speech, used unconsciously, but semantically related to the physical and/or psychological problem presented by the patient. When practitioners begin to pay attention to this phenomenon, they are often astonished by the layers of meaning present in the patient’s speech.
Here are just a few examples of somatic language phrases encountered in our own consultations:
‘My boss makes me so hot under the collar. I’m scared one day I’m just going to blow my top’ (from a man with high blood pressure).
‘I’ve had enough. I’ve had a gut-full of things’ (from a patient diagnosed with irritable bowel syndrome).
‘I’m always there for other people, but they don’t give me the support I need’ (from a woman whose rheumatoid arthritis reduced her to walking—when she could walk—with sticks).
‘I know I should leave my husband, but each time I think about it I get cold feet’ (from a woman diagnosed with Raynaud’s disease, a condition ‘of unknown cause’ marked by highly reactive arteries of the fingers or toes, painful spasms and unduly cold hands and feet).
‘People always expect me to mother them, but nobody ever asks about what I want’ (from a woman faced with a diagnosis of breast cancer and the prospect of a mastectomy).
‘I feel as though I’m going to drive off a cliff’ (from a car salesman with agitated depression).
‘My father always told me to keep my head down and not draw attention to myself’ (from a golf pro who developed the ‘yips’—a term used by golfers to describe a nervous response that causes them to lose form—each time he came near to winning a championship).
It should be emphasized that patients never consciously use true somatic language. The words and phrases occur without any discernible awareness or irony. We caution against drawing them to the patient’s attention lest we abort the unconsciously driven communication process, or embarrass him with his ‘Freudian slip’. Equally, guard against jumping to conclusions. Without supporting evidence, it would be presumptuous and potentially damaging to attribute a specific meaning where meaning may not exist.
Patients will often report feeling ‘really listened to’ when the practitioner simply matches the somatic language used. But utilizing it therapeutically requires exploring and expanding the imagery to include the potential for solutions. Sometimes a simple reframing of the patient’s metaphor is sufficient. Here is the practitioner’s response to the golfer who had lost his form:
‘Well, “keeping your head down” when you swing is a good thing, isn’t it? So, your Dad gave you some good advice there.’ (This is said lightly, and the patient gets the joke.) ‘But, we know he wanted the best for you, so what else could he have intended by telling you not to draw attention to yourself?’ (Here the father’s positive intention is presupposed; contrary to some psychoanalytical theories, we believe very few parents deliberately set out to make their children miserable.)
Patient: ‘…Maybe not to take risks in case I failed? Perhaps, in his way he was trying to keep me from getting hurt…’
‘Maybe. And, you mentioned earlier that he’d never had the experience of really achieving anything important in his own life. Did I understand that correctly?’ (The patient agrees.) ‘So, I wonder how that will change for him when he experiences real success through his son’s achievements.’
This reframing simultaneously suggests that the patient will return to form and that his achievements will serve both him and his father. The conversation continues in this direction with some further tips about managing stress, etc, as a win-win solution for everyone, and is negotiated without recourse to, or even any suggestion of, antidepressants or betablockers to deal with the golfer’s nerves.
Taken as a whole, the patient’s story, including his language patterns, provides the practitioner with tools further to explore the condition.
All of the above presupposes a kind of ‘enfoldment’ of all the characteristics of the problem—including its history and biology—into the symptom. Attempts to ‘unfold’ the complex nature of this complex state have, thus far in Western medicine, been essentially linear, left-brained, logical and, clearly, incomplete. By alternating this essentially left-brain approach with the creative, right-brain, relationship-detecting talents of your cognitive processing abilities, a ‘bigger picture’ will begin to appear.
The questions to bear in mind when reviewing the totality of the condition as presented are:
How the condition ‘works’ is discussed at some length elsewhere in this book (see Chapter 6, pages 69 to 81 and Appendix D, pages 367 to 369). The way the patient structures his experience—his preferred sensory modalities, sub-modalities, and the sequences involved (strategies)—may be elicited (chunking down) directly by questioning, or indirectly by noting eye accessing cues and sensory predicates. Be sure to calibrate and test to ensure that your observations match the patient’s internal experience.
Medical NLP is less concerned with ‘causes’ than with solutions. Nevertheless, understanding how the problem was established (or is perceived to have been established) and its purpose or intention can provide a useful starting point for restructuring the experience. Our intention in establishing a symptom’s origin is not to dwell unnecessarily on a stressful experience, but to understand how the patient set up his response to the experience.
Here is an important Medical NLP presupposition: it is not what happened in the past (injury, etc) that is the problem but how the individual is responding in the present to what happened in the past.
Here are some useful guiding presuppositions:
The origins—real or perceived—of the problem may be simply detected by a process known as ‘Affect bridging’ (explained in full in a later chapter).
Once the origins of a problem have been identified, we may need to explore its purpose or intention and the sequence of actions involved in its execution. One process for achieving is the NLP principle of ‘chunking’.
Chunking is a term borrowed from computer programming. It refers to how we group and organize ‘bits’ of information. The technique linguistically shifts a subject’s consciousness, either deeper into the details and sequences of a particular experience (chunking down), or towards a more generalized, experiential ‘core’ state (chunking up). Chunking down can also be seen as the molecular approach, and chunking up as the molar approach.
‘Chunking across’ reveals similar examples of the same experience.
Metaphors, similes and analogies are examples of chunking across. We will discuss the therapeutic application of chunking in greater detail in later chapters (notably Chapter 16–pages 223 to 226). For now, though, we can apply chunking to access the purpose or intention of a symptom, and to explore alternative means of satisfying that need.
To do this, simply ask the patient, ‘If [the symptom] had a positive intention, what would it want to accomplish for you?’ Whatever the patient answers, respond with, ‘So, if you had [the reply], what would that want for you that’s even more positive?’ Repeat the question until the patient is unable to access any more levels. The word or phrase she uses will usually be a nominalization, with somewhat abstract or even ‘spiritual’ connotations.
Examples given during a consultation about excessive drinking are:
‘It relaxes me.’
‘I’m better able to cope.’
‘I feel less of a failure.’ (Reframed by the practitioner to, ‘I feel more successful.’)
‘More fulfilled.’
‘More at peace.’
‘More connected.’
Solutions are often self-evident, once the origins and purpose have been disclosed. For example, the woman with the mysterious allergy decided to review her relationship with her partner; following through with her decision to leave him was enough to resolve her emotional distress. The ‘allergy’ was still absent a year later.
The practitioner can also assist the patient by chunking across to explore alternative responses. All questions in this class are variations of in what healthier and more resourceful way can the purpose or intention of the symptom be met?
Here are some ‘solutions’ to a few of the cases mentioned earlier:
Please remember that the interpretation must be generated by the patient, not by the practitioner.
1. Start by keeping a metaphor log. Pay attention not only to your patients, but to newscasts, television programs, and conversations with your family and friends. Listen for words and phrases that suggest something is ‘like’ something else (see our comment at the end of this chapter). Notice when someone doesn’t feel ‘grounded’, or is ‘off center’, or whether they see life or their work as a ‘battle’, a ‘journey’, or a ‘bowl of cherries’. How much of a match can you detect between the metaphors they present and the way they lead their lives?
2. Write a mini-saga (no more than 50 words) about patients’ symptoms. Start with the words, ‘I am X’s symptom. I want…’
3. Without necessarily applying an intervention, gently probe for the unspoken, unmet need of a patient’s symptom. Use the questions suggested in this chapter, or ask yourself, ‘What could this be doing for X? How is it protecting her? From what?’
A final message to our more pedantic readers: yes, we do know the difference between a metaphor and a simile. We simply use the word ‘metaphor’ as a convenient…well, metaphor.
First the patient, second the patient, third the patient, fourth the patient,
181. From a translation by Rafi Khan. Used by permission.
182. Kopp S (1977) Back to One. Palo Alto, CA: Science & Behavior Books.
183. Lakoff G, Johnson M (1980) Metaphors We Live By. Chicago, IL: University of Chicago Press.
184. Lakoff G, Johnson M (1999) Philosophy in the Flesh. New York: Basic Books.