Abstract
This study highlights metaphors as ways of articulating the nature of spiritual experiences. A secondary analysis of data from a previous study revealed that spiritual experiences were described using metaphors. A sample of six participants was selected. The study aimed to describe metaphors of inpatients’ spiritual experiences in mental health care. The study had a qualitative design. The metaphors were interpreted as individuals’ embodied meanings of spirituality. These meanings were identified through a hermeneutic phenomenological framework, informed by the approach of interpretative phenomenological analysis. The analysis identified three superordinate themes, to capture the embodied lived experiences of spirituality: the meaning of the immortal diamond, the meaning of the lion-hearted warrior and the meaning of navigating by divine compasses. By acknowledging metaphors as important sources of subjective knowledge, this study reflects on how mental health professionals can use metaphors to gain insight into inpatients’ spiritual universe to facilitate relationships of resonance within a Relational Recovery perspective.
Keywords
Introduction
This study evolved from an ongoing research project exploring spiritual experiences of 12 inpatients in mental health care. A striking feature of the interviews with the inpatients was the abundance and diversity of metaphors they used to capture their spirituality. The researchers found it fruitful to return to the original transcripts to focus on metaphors, which enhanced their insight into the spiritual universe of the participants in a holistic person-centred care perspective. The metaphors in this study refer to musical, figurative and poetic expressions from the participants’ lived experience.
Lakoff and Johnson (2008) suggest that we use our basic bodily understanding as a source of information about abstract concepts of life. This perspective refers to metaphors as experiential phenomena entailing images and felt senses of inner meanings, in which something is imagined or conceived as being something else (Lakoff and Johnson, 2008). In this sense the essence of metaphors is understanding and experiencing one kind of thing in terms of another, and metaphors are thus an important tool for trying to comprehend partially what cannot be comprehended totally (Lakoff and Johnson, 2008: 77, 193).
In this paper, the authors propose an interpretation of metaphors as a source of understanding how patients with mental health issues experience their spirituality. By acknowledging this perspective, subjective knowledge is legitimized as a source to help professionals to facilitate relationships of resonance in a Relational Recovery perspective. The study aimed to describe metaphors of mental health inpatients’ spiritual experiences to gain deeper insight to their spiritual world. The research question was: How can metaphors of inpatients be explored and interpreted as descriptions and sense-making of spiritual experiences?
Spirituality in mental health
Spirituality and mental health is a complex field where several definitions have been proposed. In this study the authors view the distinctive aspect of spirituality as ‘the relationship or contact with a transcendent realm of reality that is considered sacred, the ultimate truth or reality’ (Moreira-Almeida et al., 2021: 21). This realm of reality can be referred to as ‘something other to be sensed’ or ‘transcendent entities in the conventional sense as God, gods, supernatural beings and worlds’ (Moreira-Almeida et al., 2021: 21). All these aspects of spirituality form the basis for the interpretation of the findings in this study. For many people, religion can be a part of the spiritual. The authors understand religion as ‘the institutional or communal aspect of spirituality, as a shared set of beliefs, experiences and practices related to the transcendent and the sacred’ (Moreira-Almeida et al., 2021: 21).
Metaphors as lived experiences of embodied meaning
Experiences of hospitalization in mental health inpatient facilities are highly complex and affect the individuals’ identity and how they embody the meaning of their vulnerable situation. Merleau-Ponty (2004) proposes the philosophical concept of embodiment as one way of attempting to interpret meaning. Here lived experience is understood through meanings, expectations, styles and habits that are articulated and experienced in and through the lived body. This refers to lived experiences of spirituality and mental health issues as highly personal and thus widely diverse. In this way, any notions of reality where everyday activities fall within what society considers normal must be critically deconstructed (Milbourn et al., 2015). To think by means of embodied meaning exceeds all our concepts, distinctions and symbolic forms. Gendlin (1991) discusses the possibility of gaining access to a meaningful order that exceeds formal possibilities. The nature of embodied experience inspires and constrains how things are meaningful to us. In this study this perspective refers to the use of metaphors as embodied and imaginative meaning, suggesting structures of human language and reasoning as irreducibly and pervasively metaphoric and imaginative in nature (Lakoff and Johnson, 2008). Embodied understanding is not merely linguistic; it refers to structures of our conceptual systems, of our inferences based on those concepts, and the language that emerges from those concepts. This emphasizes the term experiential metaphors, as the mode of being-in-the-world of the participants is metaphoric and imaginative. Meanings are embodied experiences as conceptualized by the participants themselves (Lakoff and Johnson, 2008). These perspectives underpin the aim of this study.
Perspectives on recovery
The recovery approach promotes person-centred care and holistic interventions in mental health. This implies the expertise of subjective experiences to promote health (Slade et al., 2012). Anthony (1993) defined recovery as ‘a deeply personal, unique process of change, a way of living a satisfying, hopeful and contributing life even with limitations caused by illness and a process involving the development of new meaning or purpose in one’s life’. Spirituality and recovery are thus interrelated concepts, involving a view of recovery as the process by which people affected by mental distress reclaim their lives and rebuild their connectedness with themselves, others and their environment, while developing a new sense of meaning and purpose in life (Bassett et al., 2008) The concept of recovery involves philosophical and existential ideas, which may not be easy to translate into the caring context (Milner et al., 2020). There has, however, been little research to examine how patients construct the meanings they give to their actions within these constructions (Milbourn et al., 2015). In particular, there has been little focus on patients’ use of metaphors (Lawn et al., 2016). This suggests that the concept of recovery is arguably a deeply personal notion involving ideas and experiences that might be difficult to put into words, underpinning the relevance of this specific study.
In recent years, the recovery perspective has developed from an individualistic perspective of recovery into a Relational Recovery (RR) perspective. RR implies a social, humanistic and contextual tradition underpinning human beings as relationally dependent on each other, where human life is created in relationships and connected to our social conditions (Price-Robertson et al., 2017). The human mind is understood as a social phenomenon that is manifested and developed through dialogue and relationships (Sidis et al., 2023). In this study, the authors propose aspects of the perspectives of both recovery and Relational Recovery as a framework of care.
Metaphors in a Relational Recovery perspective
Understanding an individual’s lived experiences of spirituality in the caring context of mental health suggests a focus on the person’s narrative. A narrative approach acknowledges the association of spiritual experiences and mental health problems and the personal ways of constructing meanings out of the embodied lifeworld. In light of the aspects of Relational Recovery, the use of metaphors can shape the lifeworld and small stories can act as windows into the process of creating meaning. Persons struggling with mental issues often use figurative language to express experiential states. Literal forms of communication in these instances often fail to represent adequately the richness and complexity of the experience, which supports the use of metaphors in mental health care contexts (Coll-Florit et al., 2021; Malkomsen et al., 2021; Mathieson et al., 2017). The achievement of shared understanding of a metaphor can help clients feel deeply connected to the professional. Working to ascertain the nature of the abstract often entails difficulty in finding words to describe experiences, sensations, emotions and psychological states (Tay, 2016). In mental health care, the use of metaphors can expand and deepen the language within the complex and varied form of embodied meaning and create meaningful dialogues leading to a healthy change outcome (Lawn et al., 2016; Tay, 2016). Metaphors are ways of constructing powerful realities in subjective and psychological ways. This highlights the relevance of music and art as metaphoric resources of non-verbal communication (Samaritter, 2009). The use of metaphors in the context of mental health can thus shape therapeutic work (Mathieson et al., 2016, 2017).
Methodology
Objective
This study was guided by the following research question: How can metaphors of inpatients be explored and interpreted as descriptions and sense-making of spiritual experiences?
Design
The study had a qualitative design with a hermeneutic phenomenological approach. The aim of hermeneutic phenomenology is to evoke lived experience through the explicit involvement of interpretation (Finlay, 2011). This study draws on expressive phenomenology, which portrays research findings using poetic and aesthetic representational forms to capture lived experience and hidden meanings (Galvin and Todres, 2009). Expressive phenomenology seeks to slow down researchers and readers to enable them to dwell on the lived experience (the phenomenon) (Finlay, 2011: 111).
Participants
This article evolved from an ongoing research project describing spiritual experiences of 12 inpatients in mental health care. The study was initiated at two mental health hospitals in Norway. The attending psychiatrists had the ethical and legal responsibility for the recruitment processes. The following inclusion criteria were adopted: inpatient in one of the two hospitals, age range 18 to 64 and capable of completing an interview and sharing spiritual experiences. The researchers were not concerned with any specific diagnosis. The context was a treatment setting for inpatients with mental health issues identified as psychosis, schizophrenia, bipolar disorders, anxiety and severe depression from the perspective of ICD 10 (World Health Organization, 1993). Those that agreed to participate were contacted to provide them with more information verbally and in writing. Before the interviews started, the participants had the opportunity to ask questions about the project and sign an informed consent. Informed consent implies that the participants are aware of the content of the study, what is being asked of them, their right to withdraw at any time and the purpose of the research. The interviews were conducted during 2022.
Participants’ biographical details (N = 6) (page 8).
Data collection
All participants were given pseudonyms. They were interviewed once, drawing on a reflective lifeworld research approach (Dahlberg et al., 2008). The interview guide was thematic with broad and open questions. The interviews took place in the units where the participants were admitted, and they were reminded that they were not obliged to answer any questions that could make them feel uncomfortable. No participants reported being distressed; instead, they stated that it was vital to be part of the study. Each interview lasted from 40 to 60 min, and a Dictaphone was used to record the dialogue. All interviews were transcribed verbatim.
Data analysis
In this study, creative forms of expression such as poems, song lyrics, pictures and linguistic metaphors were used to capture vivid senses of lived experiences of spirituality. The transcripts were analysed using the six steps of interpretative phenomenological analysis (IPA), which increased the robustness and rigour of the findings (Larkin et al., 2021). The phenomenological perspective of IPA stems from a focus on Husserl (1962)’s work, which argues for the importance and relevance of lived experience and its perception from a first-person perspective, which is a property of relationships with the world. Such an approach involves the uniqueness and richness of individuals’ senses as embodied and situated in relationships with the world. Hermeneutics and interpretation are vital to efforts to make meaning out of experiences (Gadamer, 2013; Larkin et al., 2021). The strength of IPA lies in its ability to identify meanings and develop understandings which emerge out of sustained interpretative engagement, which refers to an idiographic sensibility in the commitment to the particular in the approach (Larkin et al., 2021).
In the first stage, the first author read and reread each transcript to identify possible metaphors related to the participants’ lifeworld experiences of spirituality, and underlined the metaphors and wrote comments and notes in the right-hand margin of the transcript. The next stage consisted of examining the metaphors and clustering them together based on conceptual similarities. Each cluster was then given a descriptive label that conveyed the conceptual nature of its themes. As the clusters of themes emerged, each transcript was checked to ensure that the connection with the participants’ statements was maintained. In the final step, a table of themes was produced. The above steps were repeated for each transcript. The tables of themes of all transcripts were compared and a master table of themes for all metaphors was created (see Figure 1 for an example). The process was iterative and required repeated returns to the data to check meanings and coherence. When constructing the final table of themes, it was necessary to prioritize and reduce the data included. In this selection process, the authors considered the prevalence of the data and the richness of the metaphors and their capacity to highlight the themes. In the final step, the authors interpreted the superordinate themes in terms of metaphors that captured the metaphors in the subcategories of the data. For an example of the analytical process, see Table 2, where the themes have been reduced and prioritized as superordinate themes, subcategories and emergent themes. In selecting the authors considered the prevalence of data and the richness of the metaphors to highlight the themes. An example of IPA analysis. Metaphors of spiritual experiences (page 12).
Reflexivity
Exploring experiences and subjectivity involves the researchers bringing themselves into the research. Understandings are inevitably based upon situatedness (Finlay, 2011). This highlights the need for a reflexive journal, which was written to ensure awareness of the authors’ pre-understandings of the phenomenon investigated and to enable maximum transparency regarding reflections. The journal ensured bracketing of past knowledge and reflection on the analytical process. To increase trustworthiness of the findings, an open attitude to what appeared was adopted, along with consciousness of and sensitivity to the descriptions from the first-person perspective. Validation of the results consisted of systematically comparing content and invariant meanings. The analysis was validated by the authors in close reflection.
Developing an ability to dwell on and wonder about the raw data will help the implicit meanings, nuances and texture to emerge (Finlay, 2011: 230–231). Wertz (1985) highlights the content of a focused act of discovering the meanings by referring to the attitude of stopping and lingering with the text to enable the full significance to be amplified. The first author strove to have a sensitive, moving, empathizing, responsive and resonating whole-body attitude to the text and metaphors. After the first analytical step, the first author in close reflection with the second author aimed to empathize by repeatedly listening to the participants’ descriptions of their lifeworld and trying to sense their common situation by including their metaphors. The authors then lingered with the text by dwelling on specific songs, poems or pictures to engage in the lifeworld of each participant to feel his/her sense of embodiment. Next, the authors reflected on questions such as: What does it mean to be this person? Is he/she closed in? Is there a feeling of insideness/outsideness? What is this person’s subjective sense of embodiment? How does he/she relate to others? Is there a language used that seems significant? What existential feelings are expressed? and Is there something that drives this person? Then the first and second author reflected on the metaphors in each transcript to integrate the metaphoric expressions in the interpretation of the lifeworld of each participant. After this, the third author was invited to join analytical step 6 of IPA (Larkin et al., 2021). The whole research team made every effort to achieve a genuinely curious attitude involving self-awareness and self-reflection during the analytical process (Finlay, 2011).
Issues of rigour
The recruitment process was assigned to the attending psychiatrists in each unit. This meant that study information may have been communicated differently than originally intended, which could have influenced the participants. Another factor that may have affected some participants was the fact that they had to bring their primary nurse into the interview setting. This may have impacted how they behaved and what they shared, and thus some of the findings. The professional background of the first author as a mental health nurse and her knowledge of the field enabled relationships that provided good communication and a sensitive attitude. All the participants were offered a conversation with their primary nurse after the interview to ensure that any difficulty related to the topics discussed could be shared with a professional.
Ethical considerations
It was essential to conduct the study in a caring manner. The attending psychiatrists had ethical and legal responsibility for the recruitment process. It was stressed that participation was voluntary and that the participants could withdraw from the project at any time without giving any reason and without any consequences. The participants were assured that anonymity and confidentiality would be respected throughout the research process and in publishing. The project was pre-approved by the Regional Committee for Medical and Health Research Ethics (68608). In addition, the Norwegian Agency for Shared Services in Education and Research authorized the study (697344). The hospital ombudsman in close collaboration with the hospital leaders also authorized the study and the content of the informed consent.
Results
Three superordinate themes were identified by the research team as overarching metaphors, as presented in Table 2. The researchers wanted to capture the content of the metaphors in the subcategories. The first metaphor is ‘the immortal diamond’, the second is ‘the lion-hearted warrior’ and the third is ‘navigating by divine compasses’. A report summarizing common and distinctive features was created for each theme. As seen in Table 2, the findings are organized in three sections comprising the subcategories of the three superordinate themes.
Central to the participants’ use of metaphors was their longing for their spiritual experiences to be acknowledged by the professionals during treatment. The participants found that there was no room for talking about their spirituality during hospitalization. Further, they were unable to reflect on their spiritual experiences to increase understanding and integrate these experiences as aspects of embodied sense-making on their way to greater wholeness. Some participants feared receiving an extra diagnosis by sharing their spirituality. These experiences gave rise to an increasing feeling of loneliness. The first superordinate theme, the meaning of the immortal diamond, will now be elaborated.
The meaning of the immortal diamond
The metaphor of the immortal diamond is anchored in three subcategories. Firstly, the burning hell; secondly, the damaged soul; and thirdly, the bleeding heart. Implicit in the metaphor of the immortal diamond lie experiences of subjectivity, and thus sources of what drives the person through life, that felt damaged. The metaphors show increasing feelings of alienation and doubting one’s sense of self. The superordinate theme refers to the core of human subjectivity which possesses sources of power, an immortal part of human existence. The participants were longing for this part of being human to be addressed and acknowledged by the professionals. In the next section, the subcategory of the metaphor of the burning hell will be presented.
The burning hell
Metaphors of the burning hell were evoked by several of the participants. Anna (P4) used the image of hell when she shared experiences of being subjected to coercion when hospitalized. The metaphor of hell refers to being controlled by the system and how these experiences led to a sense of disconnection: “It was awful to be hospitalized. Like hell. We were raised with coercion and strictness.” (Page 3)
The above quote articulates an experience where Anna felt vulnerable, threatened and objectified. She also expressed a need to hide her spirituality because she feared an extra diagnosis. By materializing the people in care as objects, their vitality and thus the core of their breath of life may be overlooked from a professional perspective.
Nina (P6) also shared experiences of hospitalization as visiting hell, when she felt reduced to a ‘mental disorder’: “I felt like the Nazis were taking care of us. It was like visiting hell.” (Page 4)
The metaphor of hell holds images of how the participants yearned to be treated holistically, while they were subjected to coercion.
The damaged soul
Several of the participants pointed out that admission to a mental health hospital was a terrible experience. In their encounter with this hospital world, they felt the need to protect their souls to mitigate their feeling of being destroyed. Implicit in the metaphor of the damaged soul are descriptions of protecting one’s subjectivity and hiding ‘the inner person’. Ruth (P1) stated: “My damaged soul needs to be protected and the staff must be kind to it now. I will never let them take my soul.” (Page 4)
Listening to Ruth gives the impression that her subjective sense of embodiment is deep suffering. Her sense of being human is not capable of handling any more. Despite this, Ruth emphasizes how she makes meaning out of the situation, by pointing out that she can protect her soul and alleviate her painful state of being. By emphasizing that the professionals cannot take her soul, she highlights her ability to take care of her innermost self. She possesses strength to protect her intersubjective parts to handle her being.
Nina (P6) described another perspective of how she protected her soul. Humming the song ‘Eternal wandering’ (Rabalder) gave her a sense of meaning: “I was born to wander forever. You can join now or say goodbye. I can’t be changed, so don’t ask me to change my soul. I’ll go up the mountain and down the valley…” (Page 13)
The metaphor of the song refers to her journey of life as a lonely walk. Listening to Nina’s story suggests that her subjective sense of embodiment is loneliness. There is no relational contact with the outer world. The lyrics refer to an invitation to the professionals to be her travelling companions, which implicitly means to become accepted and acknowledged for who she is. If there is no acceptance, then ‘say goodbye’. The lyrics refer to the power of the soul, as a driving force, which ‘can’t be changed’ and thus needs to be respected. By humming the song, Nina underlines that she experiences an empowered state by protecting her soul and believing in her innermost self. Implicit in the metaphor of the soul lies a life force that is immortal, that has the ability ‘to shine like a diamond’ if acknowledged in a holistic care perspective.
The damaged soul also refers to lived experiences of an inner discrepancy which led to longing for death and suicidal ideation. The objectivization and control of the mental health system was too much to bear. Metaphors of being labelled as crazy and being forced into being what the system wanted you to be were unbearable for Nina (P6). She reflected on how she felt forced to behave normally to be discharged. With a tearful voice she described a deep sense of existential suffering through not feeling acknowledged by the professionals: “I am who I am. We need to share experiences. That is a basic human need. Not being pathologized for who we are.” (Page 13)
The bleeding heart
For Ruth (P1), her bleeding heart refers to the treatment setting as a place totally without a holistic perspective. She emphasized feeling forced into a state of alienation by only being treated as a diagnosis. There was no room for reflecting on spiritual experiences during treatment. The image of the bleeding heart highlights the heart as the life-giving source that was ebbing away: “I feel like the splinters have been taken out and my heart is bleeding.” (Page 4)
The image of the heart shows its vital task in sustaining life that cannot be maintained any longer. Ruth’s subjective sense of embodiment is an existential affliction. She expressed how her innermost self felt neglected and reduced to an illness. Several of the participants used the metaphor of the heart as an image of their basic breath of life. They all emphasized a longing for love and respect by the staff for ‘their hearts to stop bleeding’. What they were missing was genuine warmth and acceptance to experience healing. A healing heart is a picture of how the life force can be brought forth in terms of being acknowledged and then become ‘a shining diamond’.
Anna (P4) also emphasized a longing to be treated holistically: “They only focus on medication here. It’s impossible to feel like a whole person.” (Page 15)
The metaphor of a bleeding heart shows a longing to stop pretending to be others than yourself. This was emphasized as a challenge by Nina (P6): “I live in my own body. I know who I am.” (Page 2)
Several of the participants pointed to the vital need of being accepted as whole persons for their hearts ‘to stop bleeding’. Implicit in the metaphor of the bleeding heart lie experiences of not being recognized for your innermost self. This is an image of the spiritual. There was only room for being materialized as objects in the treatment setting.
The meaning of the lion-hearted warrior
The second superordinate theme, the meaning of the lion-hearted warrior, is rooted in two subcategories, filled with contrasts and the battlefield of thunder. Implicit in the meaning of the lion-hearted warrior are metaphors that describe how the participants feel drawn into a tug of war between forces of darkness and light and how they fought these battles on their own. The metaphor of the lion-hearted warrior emphasizes how the participants possessed power to fight and how in these battles they were longing for relational support and someone by their side to help them through. The metaphor refers to strength, courage and bravery, deeply rooted in a heart that is longing for help. The first subcategory, filled with contrasts, shows how the participants strove to hold on to forces of light when faced with darkness.
Filled with contrasts
This metaphor holds a contrasting picture, which was evoked in Karen’s (P5) image of ‘longing for goodness on the path of evil’ and Ruth’s (P1) image when referring to the famous song by Madonna, ‘Like a prayer’ (Madonna, 1989). This song illustrates a state of being filled with dark forces during the night and a longing to receive help to gain more control. The song also refers to a deep lack of power to handle the dark forces. Other participants used to write poems to calm their mind and body when experiencing such contrasts. Karen (P5) explained how writing was the language of her soul and helped her to grasp the darkness. The content of her poems dealt with feeling torn between darkness and light, as in a tug of war. When filled with evil, she received strength from a divine power: “God is the way and the life; I dance with you on the path of pain.” (Page 15) “You and my father laughing, as we were waiting for the sweetness of summer and the spring of paradise.” (Page 15)
These quotes refer to a state of longing for something bright and sweet while in the dark. They further highlight the image of a warm father and the relationship between father and daughter as a vital element of life. The sweetness of summer and the spring of paradise also show her longing for warmth and safety in her situation. For Karen (P5) ‘the father’ was a picture of God, her divine power that gave her strength and courage to hold on to goodness. The divine relationship was her greatest source of vitality and enhanced her sense of connection.
The battlefield of thunder
This metaphor implies experiences of being trapped in a battlefield that the participants had to fight on their own. For Ruth (P1), musical metaphors were helpful to express aspects of her spiritual universe. She hummed the song ‘Thunder’ which illustrates a desperate state of being. The lyrics of the song show a desperate need for help, and a longing for ‘the thunder’ to go away to be capable ‘to go to the other side’. The battlefield contains a longing for a stronger will to feel empowered to handle one’s situation. Ruth also described a longing to extricate herself from the victim role and to be able to find her way back to her inner resources. She experienced a state of helplessness: “If I had my will to do what I wanted, I would go to the other side.” (Page 8) “I am a fighter. I want to focus on the good side.” (Page 21)
The image of the battlefield shows the inner life as uncontrollable. All the participants used different images to express their embodied battles. Nina (P6) used the famous painting The Scream (Munch, 1893) to describe her experience when she attempted suicide: “The Scream. That was how I felt when I jumped. I wanted them to find me, so I left my shoes on the edge of the ferry.” (Page 17)
The statements show different battles between existential despair and sources of something lifegiving. Nina (P6) felt pulled towards death, but she still hoped someone would find her. The Scream refers to a desperate state of being, without control. The woman carries an unbearable fear. The famous painter Edvard Munch experienced darkly troubled times when he painted The Scream. Nina seemed to be able to relate to Munch’s situation when she described her battles. At the same time, The Scream shows that there is hope. Men are coming towards the person on the bridge. The sky is filled with warm colours. Here lies the contrast in the metaphor of the battlefield. Parallel to darkness, there are also flashes of light and something powerful to focus on.
Henni (P2) used the metaphor of purgatory to express how she dealt with her battles. The image of purgatory offers a place to maintain goodness and let go of the dark forces: “Purgatory is a place of letting darkness go and holding on to goodness.” (Page 13)
The metaphor of purgatory includes experiences of seizing onto something positive in the heat of the battle. Her story bore the mark of deep desperation when she spoke of pulling against dark forces. The metaphor emphasizes transformation, revealing an inexhaustible source of strength to fight which Henni drew on.
The meaning of navigating by divine compasses
This superordinate theme was evoked by Christopher’s stoic way of thinking (P3), Anna’s (P4) talking to God as an everyday activity and Henni’s image of grace as a ‘hug’ (P2). Common to the metaphors in this superordinate theme are how the participants were in deep need of connection to something bigger than themselves during hospitalization. The need for connection was emphasized as a counterforce during the battlefield, and a source of power ‘to get through’. Within the metaphor of connection lies also a need of belonging to something outside oneself during a feeling of embodied disconnection. Implicit in this lie sources of something bigger that the participants could navigate towards. For Anna (P4) and Henni (P2), God and Bible texts were their main compasses. Reading the Bible implied feeling deeply rooted in a hopeful state. For Christopher (P3), a stoic way of thinking was his ideal compass to navigate towards. This thinking was a way of pushing himself in the right direction to gain greater control. Common to the metaphors was the participants’ capacity to create anchors during darkness to help them maintain a hopeful state. The two subcategories ‘to hold on to an anchor’ and ‘in the arms of angels’ will now be presented.
To hold on to an anchor
Within the metaphor of ‘to hold on to an anchor’ lie experiences of enhancing connection through relational anchors as counterforces to embodied isolation: “The Gospel of Matthew gives me comfort. It’s about grace. Grace is like having done something wrong, but there’s a warm hug waiting for you.” (Page 2)
Using this construction, Henni (P2) shows that the book of Matthew gives her a sense of hope to counteract darkness. By using the metaphor of grace as a warm hug, she refers to something that provides her with security and belonging, which is the relational aspect of the metaphor. The hug provides a feeling of being warmly comforted and lifted up. The metaphor of an anchor includes various sources that the participants used to increase their sense of holding on.
Christopher (P3) longed for his stoic way of thinking. In this mindset lay an ability to let go of difficulties to increase hope. This attitude gave him a sense of security on his path of life: “It’s like a power that leads you.” (Page 1) and “The thinking calms my mind and I feel safe. It’s a counterforce to fear.” (Page 4)
Several of the participants used metaphors of divine anchors as sources of help from a greater power.
For Nina (P6), believing in God helped her to stay rooted as a foundation of life. She emphasized: “My faith in God cannot be shaken. Praying comforts me.” (Page 5)
This quote reveals her religious belief as an embodied source of anchoring. It also shows the importance of navigating towards a divine power to increase one’s sense of rootedness.
In the arms of angels
In the participants’ suffering and despair lay a longing to be able to rest and feel peace and security during hospitalization. The subcategory ‘in the arms of angels’ is evoked by the symbolism of Anna (P4) when she talked about feathers as greetings from God, Henni’s (P2) nightly ritual of praying to angels and Nina’s (P6) reflections on how praying to angels protected her during the night. Common to the metaphors is their function as sources of a sense of security. At night the participants felt filled with darkness and were longing to encounter such sources.
Anna (P4) shared the symbolism of feathers, which she viewed as greetings from God. This metaphor contains proof of something divine to hold on to and increase one’s sense of security. Implicit in this metaphor is also the relational aspect, as the feathers symbolize the existence of angels as God’s helpers. This is thus an image of experiencing an embodied connection to God and a divine community: “Angels are God’s helpers. They watch over me. I feel comforted. Occasionally I find small feathers, which are greetings from God.” (Page 4)
For Henni (P2), praying to angels was an important ritual to feel a sense of security at night. At night she needed to hold on to something bright to counteract the darkness. She used the metaphor of ‘the angel of trust’ to express her embodied safety at night: “Praying to the angel of trust at sunset lets me hope that a new day will come. At night it’s worst.” (Page 2)
Nina (P6) felt a sense of security from reading her evening prayer: “Jesus let your angelic host protect me in this night, look after the little ones and the big ones, let your angel stand with me.” (Page 8)
This quote emphasizes the need to be able to rest and feel protected from dark forces during the night. It implicitly refers to angelic power that increases the sense of safety.
Discussion
The study reveals that people with mental health issues may engage in spiritual perspectives to cope with their complex situations. Metaphors are likely to be used in situations where ordinary language seems inadequate, such as in the context of specialized mental health care. The participants were longing for professionals to engage in their spirituality. Metaphors can provide a way of talking about experiences that are difficult to convey to others. The metaphors of spirituality can act as a bridge to understand the understandable from a professional perspective. In what follows we will reflect on the significance of creating meaning, using the metaphors as ways of understanding the spiritual universe of inpatients.
Embodied metaphors in a Relational Recovery Perspective
The participants used linguistic images of embodied experiences of spirituality when talking about their spiritual lives. We argue that a focus on metaphors in the caring context can help inpatients to create meaning in a subjective reality and improve the quality of the therapeutic alliance. Metaphors can help clients to reach deep into issues of human existence. In a caring context, the exploration of metaphors can help to elaborate on understandings of spirituality and create new healing narratives (Finlay, 2015).
Relational Recovery emphasizes that all aspects and needs of the client must form the basis of care. This implies a biopsychosocial-spiritual approach in mental health (Moreira-Almeida et al., 2021). RR implies a humanistic, social and contextual tradition, which assumes that human beings are relationally dependent on each other (Sidis et al., 2023). RR involves processes of care that can address an exploration of what is helpful for the patient. Experiences of hope and meaning can increase in significant helping relationships. Through such processes clients can find new ways of being present to the emotional world, which can prove to be empowering.
Metaphors emphasize expressions of embodied experiences and can transport the patient and the helper into a common universe of shared meanings (Finlay, 2015; Lakoff and Johnson, 2008). This demonstrates the power of metaphors as reflections of embodied experiences which in terms of RR can offer a reflective tool to help the person in care into sense-making and new understandings (Finlay, 2015). Experiences of hospitalization in mental health care are highly subjective and complex. This calls for professionals to give voice to the patients’ lived bodily experiences in intersubjective terms (Buber, 1992). An intersubjective relationship is emphasized by ‘a mutual insertion and intertwining of one in the other’ (Merleau-Ponty, 1964). This perspective reveals the transformative potential of metaphors (Finlay, 2015). The mode of being in the world in the study context strongly suggests using experiential metaphors to create meaningful relationships. Open spaces where patients can find language to create a sense of meaning can have a healing outcome. Løgstrup (2020) points out that there is rarely a direct path to the other, but that it is through a detour via mediation that a human encounter and dialogue can take place and provide redemption. Metaphors can form responsive relationships of resonance where helper and patient can come together and touch and transform each other (Rosa, 2019). Such spaces are the essence of Relational Recovery.
The metaphor of ‘the meaning of the immortal diamond’ is emphasized by experiences that represent the core of human subjectivity. The participants were longing for this part of being human to be addressed. Metaphors within this theme underline embodied sensations of existential suffering. Ruth (P1) explored her embodied suffering by referring to the need to protect her damaged soul. This metaphor may act to explore and articulate Ruth’s ‘being-in-the-world’ (Heidegger, 1977). The metaphor of the damaged soul refers to a bodily sense; she creates it by drawing on the use of a familiar symbol (the soul) that she feels is damaged. The metaphor of the soul already has some other familiar meanings (Finlay, 2015). In the caring context, this metaphor of Ruth (P1) may help professionals to empathize and create a bridge of understanding to her embodied sense of suffering. The metaphor can act as indirect language of the soul that enables a poetic body to emerge in intersubjective terms (Buber, 1992). The professional enters into a dynamic mirror through which patient and professional helper meet and transform in terms of resonance (Romanyshyn, 1982; Rosa, 2019). A resonant relationship involves really listening to what the patient brings to the conversation and staying with the meanings that emerge to achieve deeper understanding and insight. Merleau-Ponty (1964: 155) underlines such an engagement of “dwelling” by pointing out: “It is the totality of what is said… it is given with the words for those who have ears to hear.”
To linger on the embodied meaning in a therapeutic encounter implies seeing with the heart’s eye (Martinsen, 2006). This is an eye which does not rob the other of his own understanding of himself and which does not reduce the other to an object. The ability to wait, to be in the unknown, the mysterious, without yearning for facts or questioning what is said or feeding the ‘appetite’ of symptoms must form the basis of care. This is important to help inpatients in their process of sense-making.
Metaphors as anchors to the world
Metaphors are ways of positioning and using the body in the world. This refers to embodied experiences of images, poetry and music as bodily capacities (Lakoff and Johnson, 2008). Metaphorical knowing is a form of feeling back at home in the world, where distancing collapses and intimacy abounds, and here the psyche finds an anchor in the world and in itself (Romanyshyn, 1982: 41).
‘The meaning of navigating by divine compasses’ holds metaphors emphasized as anchors to higher powers. From a professional perspective, these metaphors can help clients to increase their sense of security in a resonant relationship. Christopher (P3) used the metaphor of a leading power as providing a helpful direction as a clue to navigate through difficult times: ‘It’s like a power that leads you’. The quote shows the relational aspect of the divine power. It is a strengthening anchor. In a Relational Recovery perspective, this metaphor can create inner strength if acknowledged by the helper. Sharing metaphors can also facilitate a deeper understanding of resonance (Rosa, 2019).
Nina’s (P6) angel metaphor refers to a sense of togetherness with the words: ‘let your angel stand with me’. The divine relationship creates a sense of steadfastness in the world. The metaphor underlines companionship. The physical feeling highlights a way of feeling empowered and anchored. This aspect is also shown in the metaphor of Anna (P4) when she refers to angels as God’s helpers that watch over her. Here a safe relationship with God through angels is emphasized. She creates a sense of meaning by pointing out how the divine relationship comforts her, which also underlines the anchoring aspect. By picking up feathers she feels that God can see her. The activity gives her a calm bodily felt sense: ‘Angels are God’s helpers. They watch over me. I feel comforted’. From a professional viewpoint, this is a question of having the courage to dare to enter the subjective world of metaphors to address relationships of resonance (Rosa, 2019). In a holistic care perspective, professionals can gain understanding of patients’ embodied intersubjective worlds (Buber, 1992). Engaging in metaphors creatively and reflexively can help professionals to engage in and relate to patients’ very being. We need to seek out patterns that connect, and be with the other in his world (Bateson, 1972). This calls for allowing the other to emerge through his bodily felt senses, images, reveries and intuitions even if we feel uncertain. In such a space Merleau-Ponty (1964: 97) points out: “To the extent that I understand, I no longer know who is speaking and who is listening.”
It is about being open-minded and letting oneself be affected. In this process of being affected, the professional gives back a response that can have a transformative outcome of resonance (Rosa, 2019).
The poetics of the mind
‘The meaning of the lion-hearted warrior’ includes experiences of embodied felt senses of being drawn into a war and battle against dark forces while longing for the ‘bright side’. Through a professional lens, an exploration of such metaphors can be a way of transcending what appears to the person in care and exploring multiple meanings. This can strengthen a resonant relationship (Rosa, 2019). Karen (P5) used to write poems to create embodied meaning out of her situation. By pointing to her felt senses of dancing with God on the path of pain, she experiences a divine embodied power (a dance partner) that leads her (she feels safe and navigates towards something greater) through her life of suffering. The word ‘dance’ underlines a strengthening relational aspect as a way of being in the world (Heidegger, 1977). It also holds an experience of togetherness which increases her sense of safety: ‘God is the way and the life; I dance with you on the path of pain’ and ‘You and my father laughing, as we were waiting for the sweetness of summer and the spring of paradise’. The above metaphors refer to a more inward-turning state of reverie. Here the truth of the soul of Karen (P5) is given room to express itself. The speaking of the heart never obscures the search for the truth of the soul (Romanyshyn, 1982). The creation of meaning through poems shows how the poet herself has the felt meaning before she invents the metaphor. The poet seeks to put symbols together in a new meaningful way to enable these symbols to create the particular experience in the helper in intersubjective terms (Buber, 1992). This refers to the process of becoming as representative of living beings in dialogue. The dialogical perspective emphasizes collaboration as a unique description of the way in which movement is experienced by the other and mutually influences the parties involved (Andersen, 1997).
Metaphors like the psyche itself are an autonomous realm where the metaphoric mind bridges the abyss between nature and consciousness, and in this regard it re-animates the world (Romanyshyn, 1982: 41). These perspectives emphasize the role of bodily sensations in the experience of emotions. They are the primary source of information about a person’s needs and relationships with both self and others, which can give direction to the care provided. On an existential level, metaphors can be viewed as a mode of entry into a primary knowing of how one ‘finds oneself’ in the world (Heidegger, 1977). In metaphors, the language of the body and the language of relationships intersect. The metaphors provide ways to express, work on and transform difficult life experiences through collaborative resonant relationships (Rosa, 2019).
As humans we are directed to express ourselves through a ‘third element’, which refers to stories, symbols and poetic language that create bodily forms (Løgstrup, 2020). In order for human encounters to take place in therapy, professionals are responsible for understanding and accepting patients’ tones and achieving attunement (Rosa, 2019). If human encounters are to have a redemptive effect and contribute to a client’s recovery, arrangements must be made for a common understanding of how the client embodies her situatedness. This requires an ability to listen to the patient’s point of view and dare to stand with the patient in her suffering and receive her tone to create resonance. This ability can give rise to courage and hope in the context of Relational Recovery.
Implications for practice
By acknowledging spirituality as an aspect of coping with mental distress in terms of the elements of meaning, connection and transcendence (Moreira-Almeida et al., 2021; Murgia et al., 2020), this study is of particular relevance to professionals in mental health care. Within a holistic care perspective, exploration of spiritual metaphors can help to create understanding of the patient’s being and create relationships of resonance. Such an exploration can increase feelings of acceptance. The use of metaphors is a creative approach for the conceptualization and interpretation of spiritual experiences in mental health care settings. Consideration should be given to a focus on metaphors to understand and present people’s rich lived experiences, which can make a valuable contribution to the knowledge of the spiritual aspects of mental health care clients.
Footnotes
Author contributions
All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Camilla Christine Holm, Åse Holmberg and Bengt Karlsson. The first draft of the manuscript was written by Camilla Christine Holm and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by VID Specialized University Norway.
