Deepa Ramaswamy, MD

Some of the biggest challenges in clinical practice revolve around patient education: ensuring medication adherence and explaining difficult medical concepts to patients. Analogies can be an effective tool in the therapeutic armamentarium. This paper elucidates steps in discussing analogies and contains several useful analogies for various problems encountered in psychiatric practice.

Patient and caregiver education for psychiatric illness is often referred to as 

. It may also be defined as the education of a person with a psychiatric disorder (and their caregivers) in subject areas that serve the goals of treatment and rehabilitation.

 Psychoeducation can be used for various psychiatric disorders, including 

Psychoeducation is both essential and especially challenging. It improves knowledge, thereby bringing change in attitudes, and (hopefully) behavioral changes that, in turn, affect treatment outcomes.

 Many factors complicate psychoeducation, including cognitive deficits that accompany psychiatric illness,

 poor insight, stigma, lack of laboratory markers, inadequate knowledge of neurological sciences, and prevalence of magico-religious practices. Therefore, it is a challenge to explain difficult or complex concepts to patients so that they may understand treatment decisions or advice, stay engaged in treatment, and follow medical advice and instructions.

Psychoeducation can be improved by use of metaphors, similes, and analogies. Analogies are often preferred, as they are easier to understand and demand less knowledge of the literature. The rationale for the use of analogies can be explained by cognitive development work by 

. His theory states that the ability to relate to tasks directly impacts the understanding of new and complex tasks.

An analogy allows for a comparison between two things; it is especially helpful in explaining or clarifying ideas. Various disorders have successfully utilized analogies as part of patient education-diabetes

An effective analogy should include a common principle that is appropriate to the patient’s background, knowledge, age, gender, and ethnicity. Multiple distinct analogies, including visual analogies and patient-generated analogies, are recommended.

 Presenting scenarios and asking questions allows greater patient involvement.

Use of analogies in psychiatric clinical practice can be broadly categorized into five domains of psychoeducation, all of which are explored in this article 

Assessment, diagnosis, causes, and symptoms

 Most diseases are diagnosed with the help of medical tests. Patients may be dissatisfied or confused when their psychiatric diagnosis is based on a clinical interview.

 Psychiatric disorders do not have straight-forward diagnostic tests.

 Patients gain a great understanding of the differences between diagnosing medical and psychiatric illnesses.

Concern: Shouldn’t you order a cat scan or magnetic resonance imaging before starting my treatment?

Response: If we take a photograph of a cup of coffee, will it tell us if there was enough salt or sugar added to the coffee? We can only comment tasting it, right? Sometimes a scan may help us better understand the situation. However, a good patient interview-a taste of what’s going on-can truly help diagnosis a psychiatric illness.

Concern: How can I be suffering from a disorder when all my medical tests are normal?

Response: Suppose a light bulb is not working. It may be due to a wire or electricity problem. Similarly, in our bodies problems may be due to neurons (wires) or the chemicals they use to communicate (electricity). Current medical tests generally are designed to check for wire-related problems, such as photographing the wires (ie, neuroimaging). Since psychiatric problems are often related to electricity (eg, chemicals like neurotransmitters), they may not be seen in medical tests.

 Psychiatric disorders may be viewed as the patient’s emotional failures by their caregivers.

 Each patient’s experience with mental illness is different and unique.

 The caregiver reattributes the symptoms to the disorder and does not blame the patient. This helps the patient, the patient-caregiver relationship, and the caregiver (eg, reducing burnout).

Concern: Why doesn’t the patient see the world normally like we all do?

Response: If you wear black glasses, the world may appear black, even though it is not black. The disorder similarly distorts the world for the patient. To complicate things, the patient may not realize that they are wearing glasses that distort their world view.

Concern: We are finding it very hard to tolerate the patient’s behavior.

Response: Say you are sitting in a restaurant and healthy, alert, sober adult kicks you. You would be understandably upset, right? Now consider your reaction if you are accidently kicked by a child having seizures. Would your reaction be the same? Would you be upset with the child or would you recognize the kick was an unintentional result of the seizure? It helps to understand behavioral symptoms are part of the illness and not done purposely by the patient to upset you.

Concern: How will knowing the details of the disorder help me in dealing with the patient?

Response: Just as you will be able to differentiate a rope from a snake in the dark with the help of a flashlight, adequate knowledge of the illness can help in differentiating symptoms from normal experiences. We literally need to shine a light on things to better understand what is going on.

Patients achieve results from treatment and want to discontinue treatment.

 Psychiatric disorders like other non-communicable diseases require long-term treatment strategies.

 These examples engage patients and promote long-term adherence.

Concern: Now that we know the diagnosis, what is the way to get well?

Response: A plant requires time and care before it yields fruit. The disorder requires similar care:

- Time and attention (ie, visiting the doctor)

- Fruit takes time to appear (ie, treatment response)

Concern: I have been taking my medication. Why have I yet to experience improvements?

Response: Medical treatment is similar to a farmer’s work. One has to dig the mud, remove the weeds, and then plant the seed. How long do you think it will be before the farmer see any growth? 

 How about before the farmer sees any fruit? 

(Elicit the answer “Several months.”)

 Exactly. Some medicines are like seeds; they take time to grow (ie, act) in the body.

Concern: I am doing well now. I feel that I have recovered, and I no longer need medication.

Response: Let’s think about a person wearing eyeglasses. When the patient wears glasses, they see clearly. If they throw away their glasses, will they continue to see as well?

Similarly, you are well because you are taking your medication regularly. If you stop the medication (ie, throw out the glasses), you will not be as well (ie, won’t see as clearly).

Concern: Why do you insist I continue to take my medication, even though I no longer have symptoms?

Response: Did you lock your home when you left for this appointment? Did you do so because you knew that thieves were waiting?

Just as locked you home to avoid the risk of getting robbed; regular use of the medication keeps you safe with a smaller risk of becoming ill again.

Concern: I have not taken my medication for a few days, and I am still doing well. Does that mean that I do not need medication anymore?

Response: When you stop watering a plant (ie, nonadherence), the plant does not die immediately (ie, experience immediate relapse). But once the plant dies (ie, relapse occurs), you will have to start with a new sapling (ie, go back to the first step/restart treatment). You also will have lost a healthy, flourishing plant (ie, the progress you made).

For that reason, does it not make sense to continue the medication?

Concern: I have not followed your advice regarding medication, but nothing happened. Does that mean you are wrong?

Response: If you successfully cross the highway blindfolded, would you attempt it again? Similarly, you may be lucky once or twice without relapse, but that may not always be the case. Therefore, it is better to follow your treatment regimen.

Patients or their caregivers often raise difficult questions comparing their treatment to others.

 Each person is unique and requires a unique approach.

 Patients and caregivers will better understand the need for various approaches for the same disorder.

Concern: I noticed that another patient with the same diagnosis is receiving a different medication. Why is that?

Response: Let’s look at our hands and appreciate our fingers. The thumb is small and stout. The little finger is thin and small. The middle finger is thin and tall. They all are fingers, yet they are different from one another. Similarly, each individual is different and requires a customized approach. The medicines are given as per the individual’s profile, side-effect profiles, and other factors unique to each patient.

It can be difficult to explain the process of psychotherapy. This results in poor retention and poor results.

 Psychotherapy is a structured, goal-oriented, time-consuming professional approach to psychological issues.

 These examples engage patients, increase understanding of the treatment modalities, and increase retention in therapy.

Concern: Can you keep the duration of my therapy sessions shorter, please?

Response: Psychotherapy is very much like surgery. If the surgeon said the surgery should take two hours, would you bargain to finish it in a half hour? Would it serve the purpose? There also is a process involved, and each step takes time. For example, if you have an abscess, first the dentist needs time to drain the infection (provide ventilation and establish relationship), and only then can the dentist address the tissue (ie, therapy).

Concern: How can what we do here in the office help me in real life situations?

Response: Don’t we all learn to use a bicycle through practice in empty, open grounds before we enter the streets with traffic? Similarly, therapy in a comfortable setting helps you develop skills when you are calm. With practice (ie, therapy sessions), you will be able to rely on these skills even during your busy routines and stressful situations.

Concern: I have been in therapy for a while now. I know that I am making progress; but why haven’t I actually achieved the end result?

Response: In football, the players all want to score goals. But they recognize not every play will result in a goal. Still, as they rush down the field, they are making progress towards that goal, and they believe they will eventually be able to score points. Same thing for therapy. With each session we are getting closer to the goal. With time and patience, you will be able to score, too.

Concern: I know all about anxiety, so why am I still suffering from it?

Response: No matter how good a surgeon is, he still cannot pull out his own appendix. Similarly, you may be aware of your symptoms and treatment, but expert guidance is still needed.

Concern: I feel terrible. There was some initial improvement, and then nothing more. What do I do?

Response: The path to the destination at the top of the hill is often serpiginous and not a straight, short one. Similarly, at times it may look like you are not making any progress, but with every step you are closer to your destination.

Patients may be reluctant to be admitted to a psychiatric hospital; once admitted, they may demand swift discharge.

 Good rapport built on honesty and collaboration remains the keystone to resolving these issues.

 These examples engage patients and support admission for their treatment.

Concern: Why do I need to stay longer than my last admission?

Response: Have you ever spoken to someone who had a repeated fracture-or who broke a bone a second time? As you might imagine, it takes longer for the bones to heal properly after repeated injury. Similarly, a brain with repeated insults might need a longer time to heal.

Post-operative preparation and premature discharge

Concern: My medication dosages have stabilized, so why are you not recommending discharge?

Response: After a patient has surgery, we allow the sutured wound to heal and for the patient to stabilize. Surgeons do not just sew up the patient and send them on their merry way. Even after discharge, they may make additional precautions, like advising patients to avoid lifting heavy weights.

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The use of analogies can improve the patient-clinician relationship, foster the therapeutic alliance, and open a dialogue for psychoeducation.

Author | Deepa Ramaswamy, MD

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