Does ‘mental illness’ work as a metaphor?

February 15, 2020


Suggesting that mental illness is a metaphor is not intended to disparage psychiatry. Rather, it is an attempt to answer Thomas Szasz’s (1974) now infamous critique that psychiatry has no medical or scientific basis, but is purely descriptive, grounded, rather, in legal, ethical and philosophical issues.

Szasz’s view might be that ‘schizophrenia’ as a diagnosis a medical fiction but is a great label for a set of behaviours and experiences that are not widely tolerated as normal.

Be clear, of course, there is something important going on with those experiencing, for example, schizophrenia, autism or ADHD, which is very real for those who suffer from the symptoms. The impact of such symptoms is high: one in four people in the UK suffer from a mental health episode each year, which commands poor resourcing for intervention in comparison with high-profile physical illnesses such as heart disease and cancers. Mental illness still attracts stigma and is hidden in the fabric of culture.

For PositiveWays, metaphor is a more imaginative way of communicating the impacts of mental illness. In fact, some metaphors themselves can appear irrational; What is the meaning of ‘their goose is cooked’.

The paradox being, for example, those living the delusional world of a ‘schizophrenic’, seemingly fail to distinguish the metaphorical from the literal or real world. The schizophrenics may be collectively defined as taking metaphor literally, or embodying (being an expression of or give a tangible or visible form to) a metaphor while in a disembodied (or separated from reality) state.

Psychiatrists seemingly use metaphors, such as ‘the body as machine’, to make sense of and communicate their patient’s angst and experiences. Ironically, a symptom reported by patients suffering from schizophrenia is that machines place thoughts into their heads by ‘thought insertion’ or in hypnotherapeutic terms, auto suggestion.

The very imaginative qualities we associate with literary use of metaphor, transferred across to rational human behaviour, and were seen or interrupted as abnormal. With the arrival of the DSM, now in its fifth edition, conditions became concrete representations.

Slowly, the DSM became more excessively intricate or elaborate as it attempted to classify a messy social world of complex and context-dependent psychological behaviours, while the same behaviours were systematically reduced to commonly shared brain mechanisms that collapse the historical, cultural, social, and local or idiosyncratic. This is not to say that neuroscience has simplified brain mechanisms. Rather, the simplification comes with the reduction of difference in the social world to self-versus-same in the brain’s anatomy and functioning.

Psychiatry has been described as using a system of knowledge ‘that is not a copy of facts but a representation of them’ (Martinez-Hernaez 2013, p. 1019) – a culturally specific ‘folk knowledge’ disguised as objective science.

In the process, actual folk People or patients’ individual differences and experiences have been eradicated and may be lost to us all.


The language of DSM makes claims for an asocial and universal character of mental illness categories (at the same time as it multiplies up those categories, or fine-tunes them into a complex almost statute state) for clinical practice and judgement as neutral and non-moral

Categorization of mental illness then proceeds, paradoxically, as ‘the concealment of metaphor’ and these metaphors, in turn shape psychiatry.

At the cultural level, psychiatry has bought in to the general metaphors of the body as machine and medicine as aggressive and competitive (‘let’s beat mental illness’).

Rosenman (2008a, p. 391) suggests that a category such as (by exposing the metaphors) assumed:

  1. chemical imbalance (metaphorical because there is an assumption about what a normal ‘balance’ of neurotransmission in the brain might be – balance then becomes a metaphor rather than a measure);
  2. degenerative (based on assumed wasting away of specific brain structures – a metaphor of the ‘unseen’);
  3. ‘toxicological’ (assumed exposure to an abstract ‘noxious’ psychological environment, and not measurable chemical changes such as nitrous oxide levels in the air);
  4. material damage to the brain as a result of psychological stress (again based on the unseen);
  5. deficiency of neurotransmitters such as serotonin (based on a metaphor of lack without any measurable baseline);
  6. reference to a ‘medical mystery’ paradigm-shifting breakthrough (a metaphor of pending ‘discovery’);
  7. evolutionary benefits (it helps us adapt to poor circumstances)

Metaphors are helpful. They teach us to tolerate uncertainty. We should be pleased to find a medical specialty that trades in metaphors without embarrassment

We must warm to, or befriend, metaphors – we cannot afford to leave them out in the cold, they cannot simply be applied cold, and they do not drop into our laps as cold calls. Metaphor works only if there is intention and audience reception and understanding.

So, ‘my husband is a clown’ appears to be a metaphor, yet in this case Mrs Jones’ husband does in fact put on make-up, a wig, a funny nose and huge feet and apes around entertaining children at parties as a paid professional. Nobody would laugh at Mr Jones’ clowning if his intentions and his audience’s expectations did not match – all through the medium of metaphor. Mr Jones throws a bucket of confetti ‘as if’ it were water and the kids duck; he hits himself on the head with a hammer, but everybody knows the hammer is made of rubber; he mimes climbing a ladder and we all agree that the ladder is not there.

We then co-create metaphors as a common social endeavour – again, they do not simply fall out of the sky, and they do not work solo in front of a mirror. Brains alone do not do this – language and performance, along with the use of artefacts (such as cooking utensils, shelter, spectacles, books, computers and transport), knit brains together.

Yet, it can be argued that the expression and the reception of mental illness do not work in this co-creative way of shared production. In fact, their dynamic may be entirely different. A mentally ill person might indeed stand in front of the mirror and, in misrecognition, circulate metaphors amongst herself and her alter egos.

Studies of dissociative identity disorder (DID) suggest that multiple identities, or subpersonalities, are metaphorical in nature.

Imagine a contemporary scene update:

Macbeth Act 5, Scene 3, page 3

MACBETH: ‘How’s my wife?’

DOCTOR: ‘She’s overwhelmed by visions that will not allow her rest.’

MACBETH: ‘Can you not treat an ill mind by taking away her memory of sorrow? Can you not use some drug to erase the troubling thoughts from her brain and ease her heart?’

DOCTOR: ‘In that respect, the patient must heal herself.’ So, the patient must indeed look in the mirror and ask, ‘Can I make sense of this – or, in what way might this make sense?’


Adapted from; Bleakley, Alan. Thinking with Metaphors in Medicine: The State of the Art (Routledge Advances in the Medical Humanities) (p. 112). Taylor and Francis.