The Leaning Tower of Pain:

A brief case study in dialogical metaphors

Is it just me, or are some of the most useful and curious moments in clinical practice born out of those unexpected, yet necessary conversations?

Donald Schon (the Godfather of reflective professional thinking) considers practice to be like a never ending muddy swamp where we occasionally grasp at a bit of firm ground and, just as you think you’ve reached that moment of enlightenment, you’re unceremoniously thrown back in with your clinical vision of utopia covered in mud once again!

Welcome to the wonderful muddy swamp of the biopsychosocial model of pain! It somewhat mirrors Schon’s notion of professional artistry (PA). The contrasting end of Schon’s continuum (The technical rationale – TA) viewpoint of practice is far more knowing and certain. Schon terms this the ‘high, hard ground’ of professional thinking.

Here, the professional has perfect 20:20 clarity at all times from on top of the mountain. Everything makes sense from this height and, unlike those of us down in the swampy lowlands, an accurate diagnosis and clinical reasoning model can be easily observed.

Of course, all professional thinking sits somewhere along the continuum between PA & TA. This is true of all reflective professionals from estate agents to carpenters and teachers. It’s also true of all reflective healthcare professionals and clearly has a role to play in how we approach pain education.

Anyway, at this point you’re probably thinking, “Right. Ok. What has the leaning tower of Pisa got to do with all this?”

Let me explain. When helping others to understand pain we inevitably use metaphors to help people make sense of confusing scientific jargon. For those of you who haven’t already done so, take a look at my work on metaphors HERE & .

Whilst metaphors can, and do, offer a useful and meaningful way of getting our technical pain education points across, they can also be misinterpreted by the recipient. It takes two to tango in any conversation, so with this in mind, the use of two way, dialogical metaphors should always be considered within practice when explaining pain.

Here’s a recent example from my practice of a dialogical metaphor that facilitated a meaningful change:

Me: “For lots of people, pain education forms an essential part of a successful, long-term plan to help you do the things that you want to do in the future. Think of it as the important foundation that has to go in ahead of the building process. All buildings need good foundations. Right?”

Dave: “Ok. I suppose. What you’re saying is..I need to learn a few things so that, later on down the line, my 10th floor isn’t all skew-whiff?”

Me: “Yeah. That’s it. Have you ever been to the leaning tower of Pisa?”

Dave: “No. Is it still standing?”

Me: “It was when I last saw it 3 years back! It’s poor 12th century foundations are a fine example of shoddy workmanship aren’t they?

Dave: “Hmmm. I suppose. But you could also argue that it’s still standing after all these years. So, even with rubbish foundations, it’s still doing alright.”

Me: “I see your point Dave. It also seems to have done alright for itself on the world tourism map. However, the only reason the tower is still standing (leaning) today, after all these years, is the ongoing structural support work and millions of Euros of funding to keep it upright.”

Dave: “Ahhh, you’re right. All that cash and structural propping up sounds a bit like all those years of treatments I’ve had!”

Me: “Oh. How’s that?”

Dave: “All those treatments have kept me going for all these years, but with better foundations and a bit of know how, I can rebuild things myself I suppose.”

Me: “That’s great Dave. Sounds like a plan. Where should we begin?”

For me, the moral of the story is to keep curious, keep playing with your approach to communication, keep things meaningful and engage in open & honest discussion.

On that day, both Dave & I managed to help each other out of the muddy swamp for just long enough to see where we needed to head.

Give me the curious muddy swamp any day! I might one day revisit Pisa and get to stand on top of it’s leaning tower, but the view from the top is always going to be slightly uneven.


The leaning tower of Pisa is still standing. It’s taken a recent £20 million restoration project to keep up upright for another 300 years. Read more here: