People use various types of figurative language to express ideas, abstract concepts, inner experiences, and comparisons.

Aristotle defined metaphor as: “giving something a name that belongs to something else; the transference (“epi-phora”) being either from genus to species, or from species to genus, or from species to species, or on the grounds of analogy … metaphors are constituted on the basis of our ability to see the similarity in dissimilars” (20) p.4 [citing Aristotle (21)].

The Oxford Dictionary defines a metaphor as “a word or phrase used to describe somebody/something else, in a way that is different from its normal use, in order to show that the two things have the same qualities and to make the description more powerful, for example She has a heart of stone” (22).

Thus, metaphors apply a word or phrase to an object or action to which it is not factually appropriate, to convey one thing as representative or symbolic of something else. For example, “pain is a knife stabbing my leg”—pain is not actually a knife; or “there is a gnawing pain in my bone”—pain is not actually gnawing the bone. In metaphor, the properties of one thing are integrated with the other, leaving the observer to interpret the relationship.

Linguistically, metaphors are distinct from other types of figurative language such as: •

Simile—comparing one thing with another thing using the words “like”, “as”, “so”, or “than”. Simile makes explicit the fact that the properties of one thing are alike to the properties of another thing (i.e., the two distinct entities are not the same) e.g. “my pain was like a rat, gnawing at my bone” or “my hand feels like it is a burning glove”.

In 1980, Lakoff and Johnson reasoned that metaphors used in everyday conversation enable understanding and expression of abstract concepts, such as feelings or ideas, by the process of making sense of one type of thing in terms of another (2). Lackoff and Johnson stated:

Thus, metaphors are a conceptual tool for categorising, organizing, thinking about, and ultimately shaping reality; this is known as the cognitive metaphor theory (3). Since 1980, scholarship on conceptual metaphor theory has developed within the larger disciplines of cognitive linguistics and cognitive psychology. Claims of conceptual ambiguities and challenges to the accuracy of empirical evidence means that cognitive metaphor theory has evolved over time, although the central concept remains irrefutable (23).

Importantly, Lakoff and Johnson demonstrated that metaphorical concepts are formed according to the configuration of a human body interacting with the external environment, i.e., as a 3-dimensional object in space acting consciously within the dimension of time. Consequently, conceptual thinking has developed according to the constraints of being human, i.e., a visually dominant, bipedal, upright, mobile human being living on the surface of a spherical planet under the force of gravity. Human concepts develop according to the human body schema and are characterised by front, back, top, bottom, middle (medial), side (lateral), left, right, inside, and outside, and in relation to moving forward, backwards, up, and down. It is unlikely that these concepts would develop in a sentient organism with a spherical body-schema existing in the gravity-free void of space (24). Consequently, the constraints of embodied human existence restricts and obscures human conceptual thinking.

Perceiving, acting and communicating in metaphorical language shapes mental organization and is realised through embodied neural circuitry that encodes signatures of conceptual domains, as described in the neural theory of metaphors [for review see (25)]. Metaphors are at the core of our lived experience, they govern the way we perceive, navigate and gain insight to the nature of the world, creating and describing new realities (26). Metaphor is a tool to project private experiences (sensations, feelings, and thoughts) onto externally located objects and events to understand one's own inner bodily state and to communicate this private inner experience to others.

The process of creating coherently organised experience through metaphor involves the use of a source domain that is shared by others (e.g., an enemy) to understand a target (concept) domain (e.g., pain). Thus, the idea that “pain is an enemy” comprises a concept we are trying to understand (e.g., pain) and a concept from which we draw a metaphorical expression (e.g., an enemy). “Pain is an enemy” is considered a primary metaphor because it forms a “rudimentary theme” that spawns secondary metaphors such as “fighting pain”, “battling pain”, “surrendering to pain”, and “pain killers”.

Pain is a complex, sometimes formless, bodily experience not directly sharable to others. Humans describe formless sensations and feelings by “projecting” the experience to objects and events that have form in the external world. Thus, people borrow from the world of form and meaning to connect bodily symptoms to objects, enabling symptoms to gain a sense of structure, i.e., they apply a word or phrase to convey one thing as representative or symbolic of something else.

Using language to “project” inner states to entities and events in the external world helps people gain a sense of clarity and control of the meaning of their experience. A thematic analysis of interviews with 23 older adults by Clarke et al. (27) revealed that people use vivid stories, metaphors, and similes, rather than using isolated words, to personalise the meaning of their lived experience of chronic pain, e.g., “two bones rubbing together” or ‘the sensation of “running cold water”. Nortvedt and Engelsrud (28) found men used dramatic metaphors to describe the impact of phantom pain sensation on relationships with their self (body), others, and the world, e.g., “being invaded by insects” or “skin being scorched and stripped from the body”.

In the book The Language of Pain, Biro describes metaphors as a powerful means of worldmaking, creating a descriptive language for the often silencing effect of pain (29).

Biro argues that metaphor is the only means available to represent the reality of pain experience.

In this quote, Biro transforms pain into a “thing” that threatens to destroy. Thus, metaphors attempt to objectify the subjective. Bourke describes this as a metaphorical concretisation of pain that brings the nature of private experience into the “knowable, external world” of others.

The idea of pain as a “concrete thing” is contentious and exposes ongoing tension about the nature of pain and the use of literal and metaphorical language (31, 32, 33). Bourke contends that pain should be considered as a “kind of event” or “a way of being-in-the-world” (30, 34). To make sense of “unstable pain-events” people constitute and reconstitute their experiences of the body's behaviour during and after social and environmental interactions using metaphorical language. Thus,

Explaining the experience of pain is likened to making the invisible visible. Metaphorical expression uses a common understanding of words and non-verbal vocabularies e.g., visual art, music, and rhythmic movement, to communicate pain, and to elicit an empathetic response. Semino (35) summarised psycholinguistic and neuroscientific research that supports the premise that detail, creativity and textual complexity of pain metaphor can influence the nature and intensity of an embodied simulation of pain experience, a proxy of empathy, in listeners.

Metaphoric communication of pain enables the expression of disordered and indescribable inner thoughts and feelings providing emotional release and relief. Shinebourne and Smith (36) suggest that metaphors provide a “safe bridge” to communicate emotions too distressing to express literally. Metaphoric expression enables the repair of broken connections of the internal sense of self and with oneself, culture, and society. Sharing experiences creates a sense of “connective liberation”. McFarland et al. (37), argue that living with pain is an “emotional time bomb” and that metaphoric thinking can help to deactivate and reframe inner emotions, and “off-load” the explosive and destructive inner experience of living with pain to oneself and to others.

In health care settings, scaffolding for a person's sense-making of their bodily experience comes from a variety of sources such as the physical and social environment of the clinic, and the consultation with practitioners. During a consultation, patients describe their internal states using stories flooded with metaphors. Thus, metaphorical dialogue between patient and practitioner is the norm, although neither is fully aware that they are talking in metaphor (just as we have done here by instinctively using the term “flooded”).

A thematic analysis of 18 interviews of pain practitioners by Munday et al. (38) revealed that metaphors were used as a communicative tool, a clue, an obstacle and as an adjunct in treatment. Practitioners reported most metaphors used by patients provided insight into the meaning attributed to pain, although some metaphors used by patients were unhelpful for patient recovery. Sometimes interpreting metaphorical meaning in patient narrative was challenging because patients were using metaphors that did not align with the clinician's biomedical paradigm.

Often, healthcare professionals default to structural biomechanistic metaphors when explaining pain, perhaps because it is an easier viewpoint from which to understand the body. However, biomechanistic metaphors may infer, whether intentionally or not, that the body is damaged, fragile, weak, and slow to heal. Metaphorical language can conjure up distressing imagery such as “bone-on-bone” or “wear and tear”. People may interpret metaphors literally, believing that vertebral discs “slip”, core stability has “gone”, or joints have “seized”. These metaphorical misunderstandings and incorrect beliefs may reinforce rumination on sensations of pain and stiffness, attention to crepitus, and fear avoidance of movement. Medical imaging used to confirm pathology and anatomical models used to explain pathophysiological processes may inadvertently strengthen negative rumination. The use of a destructive pain metaphor is insidious and generally goes unnoticed.

Historical analyses of pain metaphors provide useful insights into how the societal meaning of pain has changed through the ages (30). A prevailing view throughout early history, as described by the Greek physician Galen AD 129–216, was that pain was “of the soul”, associated with illness and disease resulting from an imbalance of internal humors.

Díaz Vera (39) appraised metaphorical language in Middle English medical writings from the period 1350–1500 and found that pain was described as a process of commencement, treatment, and cure, rather than a permanent state, i.e., as a type of event [c.f (30, 34).]. Often pain was described (metaphorically) as a gas entering the body (“being in motion”) to affect bodily organs, or as living entities with hostile intentions e.g., a living creature that grows within the body or as an angry person outside the body. Thus, medieval physicians described “fighting pain” with an arsenal of weapons (treatments); this contrasted with religious treatises and homilies that pain needed to be endured for relief in the afterlife (40).

By the 17th century, warmongering language underpinned beliefs that relief of pain depended on correct medical treatment. The prevailing view was diseases were caused by discrete pathological entities (objects) that were “the enemy” and could be “targeted” (treated) by interventions that “eradicated”, “annihilated”, “attacked”, “battled”, and “destroyed”. The development of Germ Theory in the late 1800s, engrained warmongering metaphors within the medical discourse and people with disease began to be viewed as “clinical research material” within a “metaphorical medical battlefield”. Bourke's historical analysis of metaphorical language within medical texts of the eighteenth and nineteenth centuries reveals the attitudes of many physicians to wage war on diseased tissue with little compassion towards the person in pain (41). Thus, medical practice involved decontextualising a person's lived experience of pain.

By the 20th century, warmongering language was ubiquitous in medical literature, with healthcare practitioners (the soldiers) encouraged to “wage war” on communicable and non-communicable diseases (the enemy) such as AIDS, Covid, cancer, diabetes, obesity, and pain. The success of “an arsenal of weapons” such as antibiotics, vaccination, medication, and surgery has conceptualized the body in metaphors of warfare that are so pervasive they go unnoticed, e.g., “a battle against disease”, “winning or losing the fight”, “pathogens invading or attacking”, “the body”s defences”, “doctor”s orders”, “the magic bullet” and “fighting disease”.

Warmongering metaphors easily unite with the metaphor “pain is damage” in common language about; sensations (e.g., “attacks of pain”, “stabbing pain”), emotions (e.g., “the horror of pain”), thoughts (e.g., “tortured by pain”), treatments (e.g., “pain killers”), strategies for relief (e.g., “fighting pain”) and personnel (e.g., “victims of pain”). Pain assessment tools to capture the quality of pain are dominated by metaphors of damage and warmongering. A case in point is the McGill Pain Questionnaire (MPQ), designed to “measure” sensory, affective, and cognitive dimensions of pain. Patients are invited to describe how their pain “feels” by selecting from a list of words, examples of which include “throbbing”, “stabbing”, “shooting”, “gnawing”, “lancinating”, “burning”, “scalding”, “searing”, “stinging”, “suffocating”, “killing”, “blinding”, “penetrating”, “piercing” “tearing” and “torturing”. An online survey of 247 people with various persistent pain conditions by Munday et al. (42), found pain metaphors to be characterised by the overarching theme of “damage”, with source domains including electricity, insects, rigidity, causes of damage, bodily misperception, and death and mortality. Damage dominates the lexicon of pain.

Leading pain organisations define pain within a framework of tissue damage (e.g., the International Association for the Study of Pain (IASP), the European Federation of International Chapters of IASP (EFIC), American Pain Association, and the British Pain Association). The IASP's definition of pain is “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (43). Pain organisations emphasise the complex relationship between tissue damage and pain experience, i.e., it is not one-to-one; rather pain is a multifaceted sensory, emotional and cognitive experience influenced by ecological, sociological, psychological and biological factors. Thus, serious tissue damage may occur without pain (44), and pain may occur without tissue damage (45, 46, 47), although this is often counterintuitive to patients.

Warmongering metaphor is often used for motivational messaging, e.g., the British Pain Society's 2022 Pain Awareness Month campaign “I beat cancer. Now I am fighting pain”. There is, however, an insidious side to damage and warmongering metaphors. Fighting pain may encourage unrealistic expectations that recovery is associated with how hard you fight. Fighting fosters an ever-expanding arsenal of weaponry (e.g., painkillers) leading to the medicalization of issues that may be socially rather than biomedically rooted; instigating overdiagnosis and overtreatment (20, 48, 49, 50). Fighting pain could misdirect efforts; for example, by therapy shopping for “quick fix cures” at the expense of interdisciplinary biopsychosocial-based treatment and salutogenic approaches that promote living well with and without pain (51).

Corkhill (52) suggests that “fighting pain to the end” may be a feisty attitude but thoughts of fighting your own body may trigger psychophysiological stressors that may make pain worse. Warmongering language creates “battlefields” rather than “safe havens” and this is not only contrary to the goal of alleviating suffering and aiding recovery, but reveals issues such as “where are the safe havens and how do people get to them?” So, metaphors of damage and warmongering may harm health, well-being, and recovery by: •

Generalising conceptual (mis)understanding of pain as always being due to tissue damage resulting in constant vigilance, e.g., of an “attack” of pain

Scarry (53) argues that reducing pain to a sign and symptom of illness, disease, or trauma places the person within a paradigm of disability, disorder, and diagnosis, reinforcing biomedical discourse and decontextualising a person's lived experience. At the core of biomedical discourse is a neuro-mechanistic model of pain conceptualised in metaphor that often goes unnoticed, is insidious in nature, and motivates patients to constantly search for medical solutions. Biomedical discourse was not always the norm.

In many so-called “traditional societies”, the language used to describe pain and discomfort has its roots in “biophilic metaphors”. These are figures of speech that draw from nature and natural processes to convey abstract ideas or emotions such as phrases that invoke images of the land, weather, or local flora and fauna. Such metaphors were not merely poetic expressions but reflections of deep-seated cultural beliefs and understandings of the human condition (54). Over time, the spread of Western mechanistic medicine in conjunction with the pervasive reach of global media, began to mould and, in some cases, outright replace these indigenous understandings of pain. Research by Halliburton suggests that traditional interpretations of mental illness that reference spirits with names and personalities in Kerala, India, have been replaced by psychological idioms such as “tension”, “stress” and “depression”—concepts that, while perhaps more standardised, lack cultural specificity or veracity (55). Halliburton advocates salutogenic approaches that incorporate traditional and biomedical modalities (56, 57, 58).

Our viewpoint is that the erosion of biophilic cultural beliefs and understandings of the human condition may foster a necrophilous mindset. A person with a “biophilic” lens sees growth, function, and the spirited intricacies of living beings, with a love for life, whereas a necrophilous person is “entranced” by static and mechanical aspects of life, drawn to the unchanging, lifeless, and inanimate, seeing living beings as objects, devoid of spirit or agency (59, 60). Interpreting pain through a necrophilous lens replaces the rich tapestry of cultural nuances with a cold, clinical uniformity. We contend that the biophilic spirit of humankind, which thrives on understanding, empathy, and the celebration of life in all its forms, is eroded by this mechanistic view, leading to a world where pain, and by extension, life, is understood not in its vibrant, multi-faceted entirety, but as a mere malfunctioning of physiological machinery.

In fact, biomedical pain language has encroached upon human activity unrelated to potential or actual tissue damage, i.e., unrelated to so-called “physical pain [sic]”. This is often termed “psychological pain” or “social pain” and refers to unpleasant experiences such as grief, sadness, anguish, embarrassment, shame, and hopelessness that arise from social situations such as the death of a loved one, rejection from a social group, or bullying. Shneidman (61) devised the neologism “psychache” to describe unbearable psychological anguish, soreness, hurt, “pain” and aching and theorized that unresolved psychache due to an unfulfilled psychological need caused suicide. This demonstrates the pervasive nature of biomedical pain language in the development of scientific concepts of the human condition.

The need to adopt constructive metaphorical language that reflects contemporary understanding of pain experience has been acknowledged, e.g., “The malleable magic of metaphor” by Moseley and Butler (78). Moseley and Butler advocate societal strategies to adopt positive pain metaphors within a psycho-educational model that re-contextualizes pain from the primary metaphor “pain is damage” to “pain is protection”. This spawns constructive metaphors such as “pain as a gift”, “sore but safe”, “hurt's not harm” and “pain is an alarm” (78, 79). “Pain is an alarm” and “Pain is a protector” have become dominant metaphors used in public health initiatives and by pain education providers to assist people reconceptualise pain, e.g., Live Well With Pain (www.livewellwithpain.co.uk), Pain Revolution (www.painrevolution.org), Flippin' Pain (www.flippinpain.co.uk), and Neuro Orthopaedic Institute Australasia (Noigroup, https://www.noigroup.com/).

Contemporary constructive metaphors concur with evolutionary theories that pain serves to warn of stimuli that cause potential or actual disruption to the integrity of the body, including stimuli that may hinder tissue healing achieved by making injured body parts “sensitive” (80, 81, 82). Pain commands attention and utilises cognitive resources to elicit behaviours that attempt to minimise physiological disruption to alleviate the pain. In situations where pain persists with no clear underlying condition or out of proportion to any observable injury or disease (primary chronic pain), metaphors of “alarm” and “protection” can be developed and stories created to assist understanding of socio-psycho-bio factors that influence pain and its persistence, e.g., “an oversensitive alarm” and “an overprotective brain” [see (83) for examples].

Storytelling is an essential characteristic of human beings (84). Stories with metaphors that include visual and verbal cues are increasingly being used to aid health communication and literacy, e.g., in acceptance and commitment therapy (ACT). The therapeutic effect of metaphor has been shown to improve when people imagine themselves as a protagonist of a metaphorical story compared with the story presented in the third person (85). Stones and Cole (86) developed a primary metaphor-based visualisation called the “bus of life”. The person (reader) is described as on their “bus of life” when, one day, the pain got on as a passenger; the bus can be driven by the pain or by the reader. The “bus of life” metaphor enables a sustained and coherent “big picture” narrative of emotional qualities and meaning and can spawn secondary metaphors, e.g., “direction of travel”. If pain drives the bus, a persistent “red Pain wheel”, indicating a persistent pain cycle, is in control of the direction of travel, whereas if the reader drives the bus, a persistent “green Gain wheel” is in control alluding to a virtuous circle (86).

Vilardaga et al. (87) offers other examples of storylines: •

The Football Player and the Robbery Victim to Pain: To describe 3 distinct features of chronic pain, i.e., personal relevance, complexity, and unpredictability of pain—to address hopelessness and lack of connectedness to others.

Padfield (88) reported the benefits of using visual metaphors to facilitate dialogue in clinical consultations. Patients selected a photographic image, from an assortment, that best represented their pain experience, enabling a “shared narrative space” for practitioner and patient to negotiate the meaning of pain. Padfield et al. have found that metaphoric images catalyse memories of experiences to construct meaning, increase disclosure of emotional information from the patient and increase empathetic engagement from the clinician (88, 89, 90).

Stilwell et al. (91) created five paintings of pain-related metaphors from a study of sense-making of pain during communication between patient and clinician. The paintings were then used to catalyse deeper levels of reflection on the language, action, meaning, and experience of pain. This process revealed how practitioners may accidently reinforce overprotection through inadvertent use of threatening metaphors, thus, increasing pain and disability. Stilwell called for practitioners to be sensitive to how pain-related metaphors are used, reinforced, and reconceptualised when co-constructing meanings of pain for patients.

Enactivism is a theory for sense-making grounded in the idea that people are embodied and action-oriented beings. Enactivism is defined as “… a relational and emergent process of sense-making through a lived body that is inseparable from the world that we shape and that shapes us.” (98) p. 637. Enactive metaphors bring metaphors into existence through actions. Metaphors are expressed via movement such as play to facilitate the embodiment of the metaphor through “full-body engagement”. Thus, enactive metaphors could aid the conceptualisation, construction, and internalisation of positive meanings of pain.

Constructive metaphorical language reflecting contemporary understanding of pain that extends beyond a neuro-mechanistic lens is continuously growing through pain education initiatives by public and privately owned providers. Here, we demonstrate how pain metaphors can be reconfigured to assist people in pain acceptance: •

Pain as a journey: Instead of “Fighting pain” consider “Navigating pain” or “Every day is a different path on my pain journey”.

We advocate the development of metaphors mirroring modern concepts of embodied and embedded pain that utilise notions from non-biomedical disciplines (104). This provides opportunities for new perspectives and paradigm shift. For example, informational or quantum metaphors might better resonate with the subjective nature of pain, offering a less rigid objectivity. For instance, quantum superposition, where particles exist in multiple states, can be likened to patients observing all their life's temporal moments as “now”. We have used this perspective to develop a framework called Past Adversity Influencing Now (PAIN), showcasing how some people may become “ensnared” by their temporal perception of pain (105). We believe that our PAIN framework offers practitioners a chance to use quantum metaphors to help patients reframe their pain experiences. For instance, suggesting “pain arrives from the past” might prompt patients to reconsider their past experiences in their present, possibly liberating them from their previously “fixed time-lines”—a concept in time travel theories where events are predetermined and unchangeable as an outcome.