Renewing Empathy With Imagery and Metaphor

My colleague tells me, her voice quivering, of her husband’s first day of chemo for newly diagnosed lung cancer. I think of her twin 2-year-olds who come to the office and lift everyone’s mood with their smiles and giggles. We sit in her office, where the collage of memories of a young growing family is just beginning to fill the walls. I try to imagine how she must feel to envisage the horror of her experience. Yet after years of practice I have treated many patients with cancer, seen it cause pain, disability, and death, and witnessed its devastating impact. I am struggling to identify my feelings to get past my cognitive understanding and break through into an emotional realm. Then I recall a vivid image from Nina Riggs’s heartfelt memoir of her struggle with terminal breast cancer:

I am reminded of an image…that living with a terminal disease is like walking on a tightrope over an insanely scary abyss. But that living without disease is also like walking on a tightrope over an insanely scary abyss, only with some fog or cloud cover obscuring the depths a bit more—sometimes the wind blowing it off a little, sometimes a nice dense cover (1).

This nonmedical imagery offers a vivid portal into her experience of advanced illness which I’m not sure a clinical description can. With this technique, she is also able to help both herself and the reader view the state of good health, which we all take for granted, as the precarious adventure which it more accurately is. My ability to empathize can now reach its fuller potential.

Jane O. Wayne’s poem Intensive Care uses a sea storm metaphor to describe the agonizing experience of watching a loved one’s daily progress in the intensive care unit (ICU):

…In such a storm, we might have been villagers Waiting for a lost ship We could never rest Which is worse then—waves beating On an empty beach or the throbs of that device Working for your heart…(2)

Reading this excerpt, I am once again transported from the professionally familiar ICU routine to a scenario where I possess no emotional self-protection. The desperate hope expressed herein helps me better imagine the suffering. Metaphor, on one hand, can bring in something familiar in order to understand a complex idea. Here, the opposite is true—the metaphor moves me away from the familiar to a place where nothing impedes my gut reaction. It opens a much wider door to empathy and human connection.

Metaphor also has the potential to stigmatize illness and the sufferer. In her seminal essay “Illness as Metaphor,” writer and philosopher Susan Sontag, who died of myelodysplastic syndrome, argues that metaphor is not useful in referring to illness. She argues, citing tuberculosis and cancer as examples, that metaphor may unfairly connect illnesses with certain personality traits that unfairly characterize the sufferers. This may imply that their personal traits may have somehow invited these diseases. Although our modern understanding of pathophysiology has helped to dispel unfair associations of disease with personality, her admonition about the power of metaphor to inflict emotional wounds is powerful and remains relevant. As a clinician though, I find that patients’ own metaphoric self-descriptions are very enlightening, as are those from literature or my own imagination, when they are born out of a desire to connect rather than categorize. Sontag’s own metaphor which comprises the very first sentences of her book is a wonderful example:

Illness is the night-side of life, a more onerous citizenship. Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place (3).

Imagery to fuel empathy is not limited to the written narrative. Visual illustration of the sufferer’s experience can be similarly enlightening. Graphic novelist Harvey Pekar, author of the autobiographical comic series “American Splendor,” published “Our Cancer Year” in 1994, cowritten with his wife Joyce Brabner and illustrator Frank Stack (4). It tells the story, in comic form, of his struggle with lymphoma. The illustrations help me better understand how his illness impacted him. Frida Kahlo’s paintings depicting her own struggle with illness reveal a side of suffering which transcends words.

Desensitization, as much as we try in our medical schooling and practice to limit it, is unavoidable and self-protective. Clinicians get used to witnessing suffering, much as police detectives or soldiers get used to seeing the residue of human rage and brutality. Knowing how important empathic connection is to patients and families seeking my care, I have looked for new and more effective ways to be thoroughly genuine in providing it. Visual imagery and metaphor have helped a great deal. The coincident nurturing effect on my own well-being as a physician is a welcome treasure.