Metaphor and debates

To the Editor

I am grateful for Dr Smith’s concurrence on a conceptual debate (Smith, 2017) that reprises issues that appear to have fallen out of the mainstream since we left behind 1970s arguments about the reality and nature of mental illnesses. Those arguments rejected the ‘medical model’ and promoted an anti-medical psychiatry and a ‘social construction’ of disease. The arguments were left behind rather than resolved. However, not only has psychiatry moved on but so has the rest of medicine that has had to deal with problems that refuse to fit into the old medical mould. Some branches of medicine have been less anxious about their medical status and have been more flexible about the models they use. (What models accommodate end-of-life care or gastric banding?)

How to approach a debate again is ticklish. To re-open the debate with talk of ‘ideology’, ‘fixed beliefs’ and ‘constructed beliefs’ risks casting debate in the terms of the old debate and that argument tended to place psychiatry outside the medical fold and closer to politics. We are, above all, doctors and our practice, ethics and language will remain within that widening fold. For that reason, I might better have stuck with ‘model’ and not use the larger term ‘metaphor’ which is not yet so commonly used in medicine, although it is a term that connects to a wider intellectual world. We use metaphors and models to make sense of the uncanny in terms of concepts that are more familiar. Those models can mislead as well as inform us. Above all, we need to acknowledge the metaphorical nature of our concepts and to keep revising those concepts in the light of what people suffer today. I am grateful to Dr Smith for underlining that, although we may not use the same language in the debate.