Home > Public Resources > Trauma Blog > 2023 - March > Military Matters: Veteran Psychotherapy and the Use of Military Metaphor Military Matters: Veteran Psychotherapy and the Use of Military Metaphor Kenneth J. Thompson, PhD March 30, 2023 The use of military metaphor in the health sciences has been a topic of recurrent interest and debate for several decades. In that time, writers have decried how “wars” against such scourges as cancer, drugs, and, more recently the COVID-19 pandemic, can shape conceptualizations of these maladies and their treatments in unproductive ways (see, for example, Hauser & Schwarz, 2020; Nie et al., 2016; for an earlier and seminal statement of this position, see Sontag, 1978). Fuks (2010) cautions against this militarized language, in which providers wage war against disease, concerned not only that the disease might supplant the patient as the focus of attention but also that providers themselves might be adversely affected: “it is not simply for patients that medicine must create new metaphors. What is also at stake is the very persona of the physician whose own identity cannot be rooted in warfare and assaults” (Fuks, p. 64). Other writers have readily embraced war metaphors. War metaphors can bespeak a shared knowledge, garner attention and invoke a sense of urgency (Flusberg et al., 2018). Indeed, through their ebook of the same name, Nold and Nold (2021) offer a review of adjunctive treatments marshalled in support of a Total War on PTSD. In psychotherapy, “agonism”—i.e., struggle—has long been part of the theoretical language. Heide (2010) reviews major schools of clinical theory, demonstrating how their proponents have incorporated the language of combat. There is a certain inevitability that providers working with current or former service members will pick up some Veteran-inflected language. A clinician’s familiarity with aspects of military life, along with an understanding of military terminology, can help to build rapport. However, such language can begin to infuse other areas of the work, leaving open the extent to which military metaphors shape thoughts about and attitudes toward therapeutic work, even outside of sessions. For example, I have heard a clinician remark that, in enforcing Prolonged Exposure homework, one had to “pick one’s battles,” noting that a particular problem under discussion was “not a hill I’d choose to die on.” In a treatment team meeting, another provider referred to an irrigation procedure for loosening ear wax as “waterboarding” the veteran. Such casual references to battlefield death and the use of torture betokens a glibness that contrasts sharply with the lived experience of combat and cruelty. More importantly, if clinicians are imagining their interactions as battles or faux-torture sessions, are they damaging, fundamentally, the therapeutic relationship? Agonistic metaphor could also be counterproductive within particular therapeutic contexts. For example, in Acceptance and Commitment Therapy work, or when teaching mindfulness, language involving battling one's thoughts would seemingly work against efforts to foster nonjudgmental awareness and acceptance. Conversely, part of building the rapport necessary to optimize treatment effectiveness involves using language that veterans will readily relate to and understand. For instance, an 18-year-old infantryman, successfully finished with military occupational specialty training and subsequently traumatized during a combat deployment, may opt to use the military terms, concrete representations and metaphors with which he has become conversant. It would be important to consider what purposes metaphors serve. Because agonistic language could represent a vernacular with which the veteran is most familiar, the provider might lose an important avenue of connection and communication by not engaging with the veteran through such metaphors. Distinguishing between description and abstraction is important here. Gold standard treatments for PTSD, such as Prolonged Exposure and Cognitive Processing Therapy, acknowledge the necessity to confront the traumatic events themselves and the beliefs derived from those events. It is thus entirely appropriate to use military terminology to describe the concrete details of, say, a firefight. Less clear, however, is whether military terminology is appropriate at the level of illustrative abstractions, regardless of whether a particular trauma is war-related. It would appear beneficial to the veteran as well as the therapeutic relationship for the clinician to understand the role such language serves. In “meeting veterans where they’re at,” military metaphor may contribute to an individual remaining stuck in patterns of speech (and, therefore, thought) by remaining immersed in a military vernacular; in such cases, helping the veteran rediscover a broader metaphorical language could serve the function of re-expanding a world shrunken by posttraumatic avoidance. Fortunately, questions regarding the use of military metaphor are beginning to be addressed more directly under experimental conditions. In a series of experiments, Hauser and Schwarz (2020) found that battle metaphors increased the perception of treatment difficulties and fatalism while also gaining no increase in vigilance. Landau et al. (2019) explored the level at which a metaphor is meant to operate in a given discussion. Their research was built on Conceptual Metaphor Theory, in which metaphorical thinking necessitates identifying similarities between concepts at a structural level (i.e., aligning concretism with the concrete, abstraction with the abstract). In a study concerning ultraviolet (UV) sun exposure warnings, 186 college students were primed for either abstract or concrete thinking. Participants were then exposed to metaphoric messages (e.g., the sun is the enemy) or concrete messages (e.g., the sun’s rays create a health risk); the participants’ subsequent intentions toward UV protective strategies were then assessed. Individuals primed for abstraction and exposed to the abstract message were significantly more likely to endorse an intention to engage in UV protection. The work of these researchers thus suggests that military metaphor can be put to beneficial use. Such work demonstrates that military metaphors may have utility and should not be dismissed out of hand. In our attempts to understand and treat posttraumatic stress disorder—and other stress-induced conditions—the language we use to communicate warrants scrutiny. In the interest of creating a broader or more uplifting therapeutic vocabulary, providers might cast about for metaphors beyond the military in order to introduce and model other useful abstractions; at the same time, complete elimination of military metaphors may arbitrarily remove a common and useful abstract frame, one that is potentially deeply engrained from current or prior service. The use of military metaphor—and, more generally, of violent figurative language—represents a fruitful space for the provider to develop self-awareness and measured application. About the Author Kenneth J. Thompson, PhD, is a postdoctoral fellow in the Substance Abuse Residential Rehabilitation and Treatment-PTSD Track within the VA San Diego Healthcare System. In addition to research and clinical practice related to trauma and substance use, he is interested in fostering Veteran cultural awareness among healthcare providers. References Flusberg, S. J., Matlock, T., & Thibodeau, P. H. (2018). War metaphors in public discourse. Metaphor and Symbol, 33(1), 1–18. https://doi.org/10.1080/10926488.2018.1407992 Fuks, A. (2010). The military metaphors of modern medicine. In The meaning management challenge: Making sense of health, illness and disease (pp. 55-68). Brill. Hauser, D. J., & Schwarz, N. (2020). The war on prevention II: Battle metaphors undermine cancer treatment and prevention and do not increase vigilance. Health communication,35(13), 1698-1704. Heide, F. J. (2010). The agnostic metaphor in psychotherapy: Should clients battle their blues? Psychotherapy Theory, Research, Practice, Training, 47(1), 68-82. https://10.1037/a0018839 Landau, M. J., Cameron, L. D., Arndt, J., Hamilton, W. K., Swanson, T. J., & Bultmann, M. (2019). Beneath the surface: Abstract construal mindset increases receptivity to metaphors in health communications. Social Cognition, 37(3), 314-340. Nie, J. B., Gilbertson, A., de Roubaix, M., Staunton, C., van Niekerk, A., Tucker, J. D., & Rennie, S. (2016). Healing without waging war: Beyond military metaphors in medicine and HIV cure research. The American Journal of Bioethics, 16(10), 3-11. Nold, C., and Nold, D. (Eds.). (2021). Total War on PTSD. [Ebook]. Barnes & Noble Sontag, S. (1978). Illness as metaphor. Farrar, Straus and Giroux