A clumsy metaphor, not a diagnosis: Language psychiatry often uses can hinder patient progress, argues paper

It is time to rethink metaphorical brain talk in psychiatry, according to a new essay published Molecular Psychiatry. Metaphorical brain talk refers to a word or phrase literally denoting one kind of object or idea that is used in place of another in order to suggest a likeness or analogy between them. In psychiatry, patients are commonly diagnosed with major depression and told it is due to an imbalance in their brain serotonin. They are told if they take the medicine prescribed it can correct the imbalance. “While certainly more false than true, this example of metaphorical brain talk remains a common story in psychiatric culture. Some of us tell stories like this to our patients, in part, because it may make them feel better and also perhaps because it is a story we like to tell,” writes Dr. Kenneth S. Kendler, a professor at Virginia Commonwealth University in Richmond, Va.Metaphorical brain talk has been used in psychiatry for centuries with terms such as “broken brain.” In this essay, Dr. Kendler reviews the history, meaning and significance of this phenomenon. He theorizes that metaphors, such as the “due to an imbalance in the brain,” and the use of simplistic and empirically poorly supported explanations of psychiatric illness, are causing harm. His criticism of metaphorical psychiatric brain talk is not a critique of the rigorous scientific reductive agenda in modern psychiatric research. His concern is to the degree to which the profession of psychiatry has “impoverished its conceptual foundations” with a strong brain-focused bias in discussions with patients. Many clinicians may feel more comfortable with the reductionist approach of brain metaphors. Metaphorical brain talk can be seen as the “promissory note” by the psychiatry profession, a pledge that one day it will be possible to explain accurately the brain basis of psychiatric disorders, according to Dr. Kendler.In reality, patients with so-called ‘mental illnesses’ are really individuals with illnesses of the nerves and brain. This realization needs to be discussed and much larger investigations are warranted to investigate the effects of metaphorical brain talk. Dr. Kendler writes that in order to replace metaphorical brain talk, there needs to be scientific consensus. Further, mental health problems need to address issues of anatomy as a physical function. So, what suggestions does Dr. Kendler have to improve the situation? “I don’t because I am not sure whether the issues you describe were ever discussed in DSM (Diagnostic and Statistical Manual of Mental Disorders) circles,” Dr. Kendler told the Medical Post.Metaphorical brain talk attempts to explain the complex phenomena of the biological and the physical environment on the basis of simpler physical constituents. Nicholas Haslam, a professor of Psychology at the University of Melbourne in Australia, said this is a very important but under-discussed issue. “Kendler shows that psychiatrists and other doctors often offer brain-based explanations for psychological problems that are scientifically unfounded. They’re metaphors for those problems, not genuine explanations. It would be better if we didn’t present these metaphors as if they were explanations,” said Haslam.Because some of these metaphors are inaccurate, they can have undesirable consequences. Some patients may believe that their problem is deep-seated in their biology and that only brain-targeting treatments can be effective. “So, patients shouldn’t be told they have a chemical imbalance because there’s no solid scientific evidence that any psychiatric condition is well explained by such an imbalance, no evidence that it’s true in their case, and that explanation can discourage them from taking an active role in their own recovery and from engaging in non-pharmaceutical treatments,” Haslam told the Medical Post.Physicians may provide these metaphors to patients because these pseudo-explanations seem simple and easy to grasp. It is common for patients to bring these explanations to their health care provider seeking their endorsement. “Doctors should be aware that these metaphors can have undesirable effects and that they lack a solid empirical basis. It’s better to be honest with patients that we still don’t fully grasp the causes of mental health problems and that many factors can contribute, rather than resorting to pop neuroscience,” said Haslam.He said moving forward researchers should be careful not to oversimplify mental illness by offering reductive brain-based explanations. “A mature attitude of scientific humility should make us skeptical of ideas such as the chemical imbalance explanation of depression. It’s not well-supported scientifically and we should be grown-up enough to acknowledge complexity and the limits of current understanding,” said Haslam. Dr. Philip R. Muskin, who is a professor of Psychiatry at Columbia University in New York, said while this essay is intriguing, he doesn’t agree with Dr. Kendler. “I don’t think it is a fair paper, quite frankly. Many of his examples are old. He is going back a century or more to criticize how psychiatrists have conceptualized the mind and mental illness. He is right, but we are not that different from other medical illnesses. Can your cardiologist tell you why you became hypertensive. Can your neurosurgeon tell you why you got brain cancer?” said Dr. Muskin.A significant problem in psychiatry is there is so much that is still unknown. Dr. Muskin said it is not acceptable to say to a patient 'I have no idea what is wrong with you.' Patients need explanations even if they are not perfect. “Patients deserve explanations. You don’t want people being told they are weak or less than someone,” said Dr. Muskin. “There is a stigma with mental illness.” He said when you don’t give patients concrete answers, it creates its own stress, anxiety and it can fuel depression. “Existentialism is stressful. You think you are a bad person,” said Dr. Muskin. While some of the common jargon used in psychiatry may not be completely accurate, He said the profession has done its best based on psychiatric science. References:Kenneth S Kendler. A history of metaphorical brain talk in psychiatry. Molecular Psychiatry (2025)

A clumsy metaphor, not a diagnosis: Language psychiatry often uses can hinder patient progress, argues paper

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