The Broken Metaphors of Treating Mental Illness


Psychiatric medication prevents you from drowning.

I love Acceptance and Commitment Therapy and third-wave psychology. I love how it is a full-circle throwback to ancient wisdom traditions, reconfigured without all the confusing esoteric, and presented so that an everyday person in the 21st century can understand and use practically.

It sounds simple, but the meaning and application of Acceptance and Commitment Therapy is profound.

ACT teaches you skills such as defusing from your thoughts and feelings without repression, how to develop a sense of self built on your core values, and how to accept the things you cannot change. It shows you how to develop a worldview based on peace and empathy and compassion. It teaches that experiential avoidance – of fear, sadness, panic, anger or unwanted thoughts – is what compounds the problem, and the remedy is to be openhearted and welcoming to commonly perceived “negative” private experiences. Instead of finding ways not to have panic attacks, just have the damn panic attack, and sit inside it with a brave, curious heart. It is to accept that you are human, to have compassion and forgiveness for yourself, and to push forward with what you want to do in life anyway – get on that plane, host that meeting, give that speech, walk out the door to your house. ACT is the existential cousin of Exposure-Response Prevention. It is absolutely brilliant.

But, like my Dad loves to say, “People only tend to meet the middle when they cross it.”

I fight hard for the middle. I try to be a moderate in principle (an extreme moderate? :/ )  I believe the healthiest, and yet most challenging and complex, place to be is in the middle. The middle is really the straddling of ideologies, the ability to have one foot planted on seemingly opposing sides of an issue. It is like standing on the tip of a pyramid – it’s hard not to feel like you will be pulled in two. You feel compelled to pick a side. But when you do, what inevitably happens is a gradual sliding descent to ground zero. To me, the middle – while resisting the forces of gravity that pull you in an extreme direction there on the summit of that very slippery iceberg – is where true acceptance of human reality is to be found.

Because the curious thing about “the opinion” – that the ONLY WAY to mental health is by radical acceptance and openness to experience with no shortcuts whatsoever (and we’re talking the no-taking-of-medication), is counterintuitively what tips you toward extreme thinking.

Mental and philosophical muscles are not made while sliding further away from the other side of the human experience coin.

And the problem with Acceptance and Commitment Therapy advocates is their tendency to be so impressed with its efficacy that they risk slipping into evangelicalism. They become ACTivists. This beautiful philosophy built on time-tested wisdom becomes rigid and separated, and even troubled or phobic, towards more than one approach to getting better.

This is a problem with any value system that looks down its nose on the use of “quick” or man-made” answers to address a problem in society. Secularism looks down on religion. Liberals with their flexible points of view look down smugly on the perceived narrow-minded dogma of conservatives. Generations of yore shake their heads at millennials and mutter “in my day we didn’t give kids the iPhone when they misbehaved at the table” (irony: we spanked them). Paleo and Atkins dieters roll their eyes at carbohydrate-consumers. Every member of society at one point or another, consciously or unconsciously, holds the opinion that people who are homeless, or addicted to drugs or alcohol or tobacco, are doing it because they are lazy and lack the “cobbles” to be resolute against their desire to use. An anti-crutch or anti-quick-fix attitude, in the absence of openness to multiple truths or ways of being, begins to feed upon itself. It becomes its own crutch – even sometimes its own delusion.

And then there is the so called quick answer that everybody loves to hate and prohibit and finger-wag at: psych drugs. And despite all of the disapproval and admonishing – one in ten people uses an antidepressant. Just like the War on Drugs or Sex in the Media – what is resisted persists. Isn’t that precisely what Acceptance and Commitment Therapy has been trying to get across?

Not that taking antidepressants gives you a quick fix anyway – most take up to four weeks or longer to have an effect. And considering that the initiation of medication is something that is fraught with stigma and difficult emotions, especially if you are pregnant or breastfeeding, it is neither quick nor easy.

The neurosis over medication in some drug-free human-to-human therapy circles is best encapsulated by the gigantic error in the following analogy:

Giving somebody medication for mental illness is like giving medication to someone drowning in the ocean. It’s not addressing the root problem, therefore it doesn’t make sense.

Well, for fuck’s sake. You thought they would be saved if a psychologist leaned over the side of the boat and covered “The 12 Thought Distortions” with them?

Because one problem with this metaphor is that medication is still being used in its literal sense. It is not being translated into a metaphorical device, and so what happens is the integrity of the entire analogy is broken – and the use of medication for a drowning person ends up looking ridiculous – because it is ridiculous!! Even counselling someone on how to resist coping and checking compulsions looks ridiculous in the context of a drowning person – because you are not translating it into a metaphor first.

The other problem with this metaphor is that “drowning” is being substituted interchangeably for 1) the subjective feeling of suffering with mental illness and 2) the specific behaviours you are engaging in to perpetuate the illness. These things are causally linked, but not the same exact thing. So “drowning while medicated” doesn’t really make sense if the problem (suffering) is supposedly being remedied by the medication in the first place (something that is lifting your head above the water).

If the metaphor for suffering from compulsive shopping was “drowning” in one’s “ocean” of problem spending, teaching them how to make a budget and stick to it would be like “teaching them how to swim”. But you can’t just tell them that over the side of the boat! They’ll scream “How?!” and go under and leave nothing but bubbles.

You can’t teach someone to swim – who has never swam before – in the midst of drowning.

First you need to pull them out of the water.

Sometimes that means the water is actually not so deep. Sometimes you can tell them how to swim over the side of the boat and tell them to just stand up. And it turns out their problems actually have solutions – in metaphor: there is a sand bar beneath their feet and they can stand up and breathe.

But sometimes (many times) those problems are not little. Mental illness happens to intelligent people and can even haunt exceptionally intelligent people the most. Sometimes it’s not the shallow end of the ocean – sometimes it’s grief and trauma and upheaval and the deep dark mire of existential human problems.

And you can’t literally throw pills at a drowning person. No one would do that anyway. It’s stupid so let’s not even talk about it.

So to preserve the integrity of the metaphor we have to convert “pills” to a device in the metaphor.

Which would be:  a flotation device.

Giving someone medication when they are drowning is like throwing them a pool noodle.

I feel this is apt because you can directly compare aspects of floating on the noodle (a life-saving “crutch” -and here I’ll even highlight the stigmatizing of the word “crutch” when in fact it is referring to something that helps you walk and perform in your life when one of your legs doesn’t fucking work).

The pool noodle is doing spectacular work – it is keeping this person’s head above water long enough that a plan of rescue can be made. They can be pulled out of the lake and reintroduced into a swimming pool (and eventually a lake or an ocean) where swimming lessons can occur.

But the pool noodle without “counsel on how to swim” has limitations. The water can have swells that may eventually capsize the inexperienced swimmer. If you hang onto the pool noodle for too long and float, your swimming muscles may atrophy and become useless, and you may slip off the pool noodle (this can be remedied by throwing out a bigger pool noodle or one that supports you from a different angle and switching things up from time to time). You find when you are not expending energy you start to become cold and hypothermic in the water. Other swimmers pass by you – floating on their own – and you realize you could never travel as fast as they can through the water because of this stupid pool noodle you push everywhere.

But drowning is a crisis. No matter the amount of very correct and wise swimming instruction in the most compassionate of manners you deliver to a drowning person (whether you the therapist are swimming in the water next to this person or still sitting in the comfy-ass boat they fell out of – the boat being a metaphor for the privileged position in the genetic, financial, gender, race, or socioeconomic lottery of society).

And I can still hear the “but, but, but” of the anti-medication crowd. They are now clamoring that the metaphor should never have been used in the first place. Because you can die from drowning and water inhalation but you can’t die from mental illness.

I can’t even type that sentence without cringing. People absolutely die of mental illness. In the United States, someone commits suicide every 15 minutes. I am forced to use an image of Kermit to convey just a tiny portion of my disdain for the opinion that years and years of struggling with mental illness is not the suffering equivalent of drowning in the freezing waters of the ocean.



Let’s examine another metaphor. One that anti-psychiatry proponents bully people over constantly when it’s used in debate:


You wouldn’t withhold insulin from a diabetic, so why shame people for using psychiatric medication?

“Because, dummy,” says XYZ Internet Couch Skeptic. “Mental illness is fixed by addressing your thoughts and behaviour. Mental problem = mental treatment. Physical problem = physical treatment (pills or insulin, you know, because you can physically see them).”

So if it’s something we “can’t see”, you treat it with something else we “can’t see”? If it’s a problem with abstract roots, then the intervention has to be similarly abstract? ‘Fix your thoughts, if the thoughts are giving you problems’, right? And wow, don’t we all wish we could fix stupid.

I can’t even begin to cover the number of physical diseases like Metabolic Syndrome (Type Two Diabetes, Heart Disease, High Cholesterol) in one post that have roots in a person’s thoughts and behaviour.

Dismissing someone with mental illness who is asking for medication is about as unethical as dismissing someone with type two diabetes asking for medication, on the grounds that the Diabetes was not caused by an inborn genetic defect, but because “fatty just needs to put down the fork” and then they would get better.

Yeah, but they’re in crisis now. They’re in diabetic ketoacidosis. Why are you sending them off in a wheelchair to nutrition counselling when they need insulin, they’ve been wasting for days, and now they can’t remember their last name or keep their eyes open.

“But there’s no blood test for mental illness.”

Yeah there is. It’s called fMRI.


Image Source: Disparity between dorsal and ventral networks in patients with obsessive-compulsive disorder: evidence revealed by graph theoretical analysis based on cortical thickness from MRI (2013), Seung-Goo Kim, Wi Hoon Jung, Sung Nyun Kim, Joon Hwan Jang and Jun Soo Kwon.
Column A = Healthy Control. Column C= OCD-affected person.


Those who feel psychiatric medication has no place in mental health are inclined to make prejudicial errors by using broken metaphors and oversimplistic analogies, without even being consciously aware that they have done so.

Avoiding and pushing away subjective experience in yourself is a sign of mental illness. The widespread systematic repressing of the subjective experience of others… is still mental illness. It is cultural anxiety. It is grief – and denial – in the heart of our communities over the fact that without medication some people just can’t get better. Having to rely on help outside ourselves feels like a threat to our wholeness, and reminds us how imperfect and human we are.

The healing begins when we are able to move past our hesitation to accept the place medication has in mental health treatment, to mindfully expand our awareness and, in the words of Thich Nhat Hanh, make a “serene encounter with reality”.