Have you ever had a visit with a patient or their family member where you just can’t reach them? Where you can feel them walling off, staying safe, not sharing?

Awkward, right? I don’t know anyone who works in healthcare who can answer “no” to this question.

In providing hospice care, we are pressed to meet regulations, sending multiple professionals to the patient’s home within a week of signing onto hospice or palliative care – and understandably so – they are a bit overwhelmed by the number of people coming to meet them to provide services.

The shock of limited life expectancy, the burden of caregiving and feelings of overwhelm sometimes leave those who are experiencing the terminal illness and their loved ones in a state of constant protection. Many people find they search for and still lack the vocabulary to adequately describe their emotions, and many use denial and avoidance to protect themselves from the pain. Even though this is an understandable attempt to help themselves feel better, not speaking of the emotions associated with the grief (or anticipatory grief) may leave them feeling isolated and misunderstood.

That said, there will always be those who don’t want to open up about their emotions, and our job is not to force conversation, but to be a willing participant who can hold emotional space for them – by just being present, reminiscing, discussing current events, sharing things in common, and building rapport and trust.

Sometimes we feel we aren’t “getting anywhere” with a patient or family member – but each time we visit, we are building a relationship of consistency, trust, familiarity, and rapport.

So for all of those times when you thought you didn’t get very far in the visit with your patient or their family member – rest easy. Establishing trust and rapport is the foundation of a therapeutic relationship.

It makes little sense to build a house without pouring a foundation. Most people don’t openly share without trusting the person they speak to. Take the time to pour your foundation first (It also helps to share this concept with your coworkers and supervisors who need help understanding what you do during your visits. We build service on relationships and trust.)

So how do we assess their needs and meet them when they clearly aren’t ready to open up? We aren’t there to change communication patterns used for decades at the end of life – that’s not our goal. Our goal is to create a safe space where sharing could happen should they choose.

When someone is “shut down” how do we create that safe space for them – so that when and if they choose to share their feelings – they feel supported and heard?

Metaphors to the rescue.

What is a Metaphor?

According to literarydevices.net, a metaphor is a figure of speech that makes an implied comparison between two things that are unrelated but share some common characteristics. In therapy, the use of metaphors can help the patient or family find a language or vocabulary to talk about difficult topics comfortably. Almost every culture has metaphors and stories that provide an alternative way of seeing something. Accessing the client’s language creates trust and rapport and allows the client to see that you “get it” by joining in on the use of their word choice, phrasing, and language.

For example, I was seeing a client named Dave who sought grief therapy when his son died. Dave was a carpenter, and I noticed his choice of words related to construction, so to develop rapport, I used the phrase “you hit the nail on the head” to affirm his understanding of the grief process. I made reference to “building resilience” and “tearing down old internal negative messaging and constructing new positive internal messaging.” Any chance I received to mirror and relate to him with his personal choices of language, I would do so.

By the time he left our first session, he had shared that his wife couldn’t understand how he could go back to work so soon after the death, and opened up by explaining that the only way he could actually get in touch with his emotions was through physical work, i.e. swinging a hammer and lifting lumber. This allowed me to explain the difference between intuitive and instrumental grief, and he could go home and explain to his wife that they are both grieving – but they are doing so in different ways.

What Can We Achieve by Using Metaphors?

The use of metaphor can be a guiding light in your work with patients, caregivers, and clients. End-of-life care requires us to build trust and rapport quickly. We are in patient and caregiver homes, in a time that is overwhelming/traumatic, and we are usually complete strangers to them. We visit with the best intentions, but those intentions aren’t always met with open arms. While it may seem foreign to you initially, with some reflection, you may find that you are already using metaphors in your daily work with your own hospice patients and families. With intentional application of a few basic concepts, you can increase your use of metaphors to build connection and trust, which is crucial when most caregivers are feeling very alone with low levels of confidence that they can survive the caregiving process.

Metaphors use words, visualization, and experience to create a deeper sense of understanding and connection.

Metaphors can:

• create a connection between the known and the unknown by helping the patient or caregiver; absorb new ideas into a framework that is already familiar;
• highlight similarities between you and the patient or caregiver, establishing connection;
• clarify an idea and help the patient or caregiver understand an idea more clearly;
• diminish resistance to psychosocial/spiritual/medical care;
• encourage new ways of thinking;
• use story and illustration to see something differently;
• remind and reinforce earlier connections and teachings;
• help the patient or caregiver retain important information;
• create a language that feels safe so they may express emotions and feelings.

How Do You Begin Using Metaphors?

Start by listening and observing the patient and caregiver. Does he enjoy fishing, hunting, or the outdoors? Does the caregiver relate to a particular family role, like mother, or family household manager? Perhaps the caregiver is a career-minded person who refers to technology often? These are all clues in how to relate to them. Did they grow up on a farm? Do they enjoy travel? Start listening carefully and getting to know them at their core level. Metaphors will evolve from knowing your patient and caregivers.

What are some examples of metaphors?

• It hit me like a ton of bricks.
• I’m a puddle of tears.
• You hit the nail on the head.
• They had a stormy relationship.
• He was like a fish out of water.
• She would play outside until the cows come home.
• Her tears were flowing like a river.
• He is my sunshine.
• Her temper is a volcano.
• We were two peas in a pod.
• You are a true angel.
• She let the cat out of the bag.

Metaphors can also be used by assigning meaning to a physical item. For example, suggest carrying a stone in the client’s pocket to remind them of their strength, or a poem or letter in their wallet to remind them of their connection with a deceased loved one to give them solace and courage.

Using metaphors in the therapeutic or supportive process comes from listening well. Your client will give you, over time, the language to reach them.

How Metaphors Help Patients & Caregivers at the End of Life

Over here at Wings of Change Publications, we craft our words carefully. We put a lot of planning and research into our topics, our style, and our intended purpose.

If you lean on what you know from your experience as a clinician, you undoubtedly have observed, at some point, as an end-of-life professional:

Patients, and families, after learning of a poor prognosis and experiencing many changes in a short period of time, experience shock, energy fatigue, and overwhelm. We as professionals are informing and educating, but the patient’s and family’s inability to retain information is very limited at this time.

Neurobiologically, we know that when we are functioning in fight-or-flight mode, we are primarily being guided by our limbic system. We physiologically cannot be in touch with our prefrontal cortex, which is the center of reason and logic in the brain. As EOL professionals, we must remember that we are supporting and educating people who are highly stressed, overwhelmed, and trying their best to digest the information you are offering – but they cannot fully comprehend it if they are being managed by their limbic system.

This is the primary reason we write our booklets using nature metaphors. Metaphors are memorable, helping the patient retain information and hear the support. Metaphors soften the message with understandable similarities to which everyone can relate. And nature metaphors are universal, providing comfort, connection, and information to people of all religions, cultures, and backgrounds.

If you haven’t experienced our booklets in your EOL professional practice, we offer free samples to EOL professionals. We encourage you to read them yourself, and offer them to those who are part of the life transition, grief, or loss experience. Let the power of the metaphor work with you in your practice.

Questions? We’re here to help you help them. Reach out anytime.