This Week at Team Talk… Escalator, Kaleidoscope, Car, Glasses: Life in 4 Analogies
This week at Union Square Practice, Dr. Michael Dulchin provided an interesting perspective on using analogies in clinical practice. Here is an abridged version of his talk.
I use analogies endlessly in clinical practice. Probably because it is just the way my brain works, but when I stop to think about it, I realize I use them clinically for a number of different purposes:
- Helping clients understand and contextualize their experiences and help discuss the experiences of others.
- Helping clients understand how I am thinking about the issues and problems as their psychiatrist.
- Help clients understand the goals of therapy and some of the processes of treatment.
- Help develop a short-hand language for complicated concepts.
So, here are some of the analogies I find useful:
“For some people, life can feel like trying to walk up the down escalator.”
- People often become depressed when they look to the future and don’t think that they have enough energy and wherewithal to succeed in life by their own standards. They can imagine that they have enough energy for a while, but when they finally run out of energy, they will inevitably end up right where they started. This analogy can be helpful for patients who are trying to understand what appears to be a lack of motivation. The lack of motivation is their brains assessment that energy spent is ultimately energy wasted.
“For others, not only is the escalator descending but the speed changes as well.”
- One of the other things that is thought to lead to depression and anxiety is an inability to predict the environment. Here the analogy is modified and the escalator is envisioned as still descending but now the speed of descent is variable and unpredictable. This analogy can be helpful for patients with Attention Deficit Hyperactivity Disorder who find that sometimes they can concentrate and be efficient and effective while at other times just the opposite is the case. It can be difficult for patients with ADHD to know when their brains will concentrate and when they won’t and thus difficult to know when it makes sense to put in sustained effort.
“For some people it is as if the world is coming at them very quickly and they are trying to navigate it while looking through a kaleidoscope.”
- There is 1. the world– life events that happen to a person, 2. the underlying qualities and sensitivities of the person these events happen to, and 3. the cognitive and perceptual brain functions through which someone understands and experiences the world. It could be that someone is depressed, anxious and overwhelmed because the world has been particularly difficult—trauma. It can also be the case that someone is depressed, anxious and overwhelmed because of a direct genetic predisposition or they are particularly sensitive, often to rejection or humiliation, which in turn can lead to depression and anxiety because events that would not be experienced as traumatic to others are experienced this way by them. Others, and this is where the kaleidoscope analogy is used, don’t realize that the information that comes at them from the world in everyday life doesn’t get into their brains as easily as it does for others. It is as if these patients see the world through a kaleidoscope when others have clear vision. The kaleidoscopic vision would be caused by difficulties including ADHD, Learning Disorders and Executive Functioning problems. In this scenario I ask patients to imagine trying to catch a baseball while looking through a kaleidoscope as a visceral understanding of cognitive issues leading directly to anxiety.
“Imagine that life is a landscape that you are driving through and your cognitive difficulties can be thought of as a cracked windshield, a non-functioning GPS or an inability not to look at the windshield wipers when they are turned on.”
- Cracked windshield. Driving with a cracked windshield is harder but the problem is unchanging and thus can be accounted for. This would be analogous to having a learning disorder—it makes things harder but in a predictable and learnable way. It takes more effort to achieve but the amount of effort is predictable ahead of time.
- No GPS. Having no GPS is like having an executive function problem—hard to know where you are and what is around you and thus hard to plan. People with executive function problems have difficulty organizing information in a way that allows them to plan and triage.
- Watching the windshield wipers. Here I imagine someone having to drive more slowly and with more effort—less efficiently–because they keep becoming distracted by the wipers. This is analogous to ADHD.
I find the car analogy particularly helpful because people can have all or some or none of the above and imagining them singularly and then all together can be helpful both to patients and to family members of people with these issues in order to give a sense of how difficult and frustrating it must be to exist with these problems.
“While I would prefer to not need them, I have learned how to put up with wearing my glasses because my life goes so much more smoothly when I do.”
- Wearing glasses in this case is analogous to taking medication. Everyone would prefer not to if they do not need to but learning how to put up with it if it is needed is often worthwhile.
“Optician, what is your average prescription? Please make me a pair of glasses with those lenses!”
- Patients often ask about typical dosages of medication and I am often helping people understand that the process of finding the right medication, for better or worse, is a process of trial and error. Standard dosages are good initial guesses at what will work for any patient, but much like at the optician who tries different prescriptions and asks “better or worse,” continued treatment is an effort to optimize the dose for maximum effectiveness and minimum side effects.
These are merely a small sample of the endless analogies that can be used in the context of therapy to help inform the client and therapist and facilitate communication and understanding.
Team Talk at Union Square Practice takes place on a weekly basis. It is an open forum for both the USP team and guest speakers to discuss topics including psychopharmacology, therapeutic developments, and other relevant material in the field.
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