When we face the rehabilitation of a patient after a cerebrovascular accident, who also has a hemiparesis in his body, we will find his descriptions of the body and the movement every day.

In the article: “The language as a tool of neuro cognitive rehabilitation”, we have defined the need of carefully focusing in the descriptions of his body and movement given by our patient, since they will allow us direct access to the elements which we want to recover, that is to say, what has been lived, the conscious experience, and its way of organizing against its pathology.


The language then becomes a mean of therapeutical interpretation at the same time. In the article, dedicated to the “Metaphor”, we analyze the keys to the reading and the sound of the patient’s words, in fact, we saw how “to feel a pull” was an explanation given by most of the patients who suffered a stroke, and it could be exhaustedly investigated until obtaining a description from the patient, that revealed his most intimately experiences in respect to the “pull” or “push”.


What follows is an extraction of the dialogue used in the previous article about the metaphor, if you are reading this article before you have read the previous two, i.e. the language as a tool and the other about the metaphor; I suggest you read this as the third, since they come in sequence.


T: “What happened?”

P: “I feel a pull”

T: “What do you mean by a pull?”

P: “Something that is pulling”

T: “And that pulling, feels like what“

P: “It is like an elastic band that when I try to make a movement, it pulls me”


In this brief dialogue, a first therapeutic act has been made, since the therapist with his questions, Clean, have reflected the same words as the patient´s and it also has allowed him to go deeper and clear up certain aspects of the patient’s experience with the body and the movement, that were previously hidden or implied, thus making them real and clear.


Inviting the patient to explain his experience through the metaphor resource, the therapist has allowed the patient to make his perception clear, through his experience explanation.


Spontaneously, the patient used a metaphor taken from the physical world, “the elastic band” which has common elements for him as “pull” does.


Obviously, the patient refers to the feeling, due to the increase in the muscle tone, often present in the hemiplegic patient due to the spasticity.

Summarizing, the spasticity, is the automatic answer of our organism to the alteration of the cognitive processes that allow us to intentionally execute the movement, even by an aggressive, altered and not so reliable manner but resulting in the information that we can build with our body.


Because of this, it is a first therapeutic act, to ask the patient “What do you mean by a pull?” “And that pulling, feels like what? “, since it places the patient in a condition of knowing his body better, and it is not by random the fact that in many cases and in this preliminary stage, the patients and the therapists have begun to perceive a reduction of “the pull” because they are supporting the necessity of the central nervous system to better organize the information set up by our body.


Without a doubt, we have invited the patient to pay more attention to his body, just as we do when we set up a position recognizing exercise in the space, and how we experiment little by little, a progressive adaption of the muscle tone. What often happens is, that outside of the therapy time, the patients cannot not always efficiently keep the changes made with the exercise, thus another role of the therapist is to make the patient autonomous, so he can continue his therapy even when he is alone with his body, refining his ability to comprehend his body and its tools to handle and control it.


Let us think in the patient who we see for the first time, and in our first interview to his internal him, we evidently see his arm hardened by the hypertonia, and then we ask:


T: “What can you tell me about you arm?”

P: “Nothing in particular, it just simply does not want to move”

T: “Is there anything else aside from the fact that it does not want to move?”

P: “No. it just does not move”


At this point, I decide to help him concentrate in one of the reasons why the movement is not possible at this moment.



T: “Aside from the fact that it does not want to move, I am seeing that it is in a different position than the other“(at this moment the arm was close to the body, with the elbow bent, the wrist flexed, and the hand closed, a rather diffused position in case of spasticity)

P: “It sometimes rises” (at the same time, he tries to stretch the elbow with his other hand, but the arm always comes back to its bent position). A patient like this one who is not even able to identify some obvious problems in his body, like the presence of a severe hypertonia, how can he then control this phenomenon if he still does not have any knowledge?


Our role as a therapist is not to externally intervene in the muscle, but rather internally in the abilities of our patient to properly organize his own body. Let us think in the great therapeutic opportunities that are open due to the possibility of exploring the “interior world” of the patient, let us think in the possibility of changing the experience of the body of our patient, using our language beyond the exercise as we are used to know it.


This is precisely the purpose of this article; describe the possibility of molding our patient’s metaphors, modifying his corporal experiences and his visible and hidden behavior.


Process that in linguistics and in psychology is defined as symbolic modeling.


[… the purpose of the modeling is to identify “something” and how does this “something” function, without affecting what modeled is. The modeler begins with an open mind, a blank sheet, and with the aim of discovering how a system works, without trying to change it…]


  1. Lawwley and Penny Tompkins in “Minds and Metaphors”


This is a very significant part of a book where the Clean Language topic is discussed, a sort of psychological analysis created by the New Zealander Psychologist Davide Groove.


But what we often do in rehabilitation is to even venture to ease the metaphoric outlook change of the patient, helping him to get rid of cables, threads, strings and elastics, thus setting up a relation between his body and the movement, getting away from the mechanical outlook and getting closer to the neurophenomenology.


In the symbolic modeling activity we should understand the patient’s metaphors as the matrix, the raw material, the” marble” block where his creation will be born.

Our role is to ease the understanding and the use of his metaphors and symbols in order to discover and develop his own self.


[… the essence of a metaphor is the comprehension and the experience of a certain thing in terms of another…] George Lakoff et Mark Johnson “Metaphors we live by”


To do so, we need to better know the metaphor as a cognitive process and consider that not all metaphors are the same and are organized by levels.


To explain the levels of experience that certain metaphors mature, I will use a wonderful article, due to the fact that, it is the first one used by Prof. Carlo Perfetti when at the beginning of the year 2000, sensed the fundamental importance of the metaphor for the neuro cognitive rehabilitation of the hemiplegic patient.


“My girl has her eyes like the sea”


Obviously, we could understand the metaphor at different levels, one sensorial, one conceptual, and one symbolic.


SENSORIAL:  We can understand the eyes like the sea metaphor, from a sensorial point of view, that is to say, our perception of the world through our senses, and then my girl´s eyes can be BLUE like the sea.


CONCEPTUAL: At an abstract and superior level, this metaphor could be read another way, my girl´s eyes are DEEP as the sea, and the concept of deep begins to assume more intimate and personal characteristics, than the sensorial idea of the blue.


SYMBOLIC: At a yet higher level, the mentioned metaphor can be understood from a symbolic point of view, and more closely related to the personal experience of each one of us, associating the emotion of getting LOST in the girl´s look to getting lost in the infinite sea. This difference of experience in multiple domains is essential in guiding us during the treatment of our patient; and to help us shape up his body to his movement and to himself.


Going back to our patient, we have the duty of helping him set up a more functional experience for the recovery of the movement in his body; we cannot allow our patient to keep living thinking that his body has elastic bands inside, because his behavior towards the movement will be closely related. Can you just imagine it in us, how would we move an arm with an elastic band in it?


We are certainly going to use our other hand to stretch it and try to achieve the elastic resistance and in order to move it, apply more force intentionally; activity that we know can only generate more tension and increase the rigidity.


[… in all aspects of the existence… we define our reality in terms of metaphors so we continue to behave based on metaphors…] G. Lakoff.


After this premise over the value of the metaphor of the experience, we concretely pass on to help the patient to guide himself in his metaphoric outlook.




As our first analysis, we asked him to solve the problem, the therapist wanting to help the patient identify certain aspects in his arm, and make him conscious of some details of the pathology; he softly stretched out the patient’s elbow telling him:


T: “What happened?”

P: “I feel a pull”

T: “What do you mean by a pull?”

P: “Something that is pulling”






Once you have placed  his attention over an existing problem, “Something that is pulling”, the therapist wants to help the patient to set up a more precise image of the event, making questions, aimed at the phenomenon, still not defined “I feel a pull” in a specific place of his body, and in a specific time of the movement.


T: “Where do you feel that something that pulls?”

P: “Precisely here” (the patient touches with his hand the area of the arm that goes from the elbow up to the shoulder.

T: “And it is when precisely here (the therapist touches the same area that the patient touched) “Do you feel something that pulls?” (the therapist helps him do the same movement of stretching the arm that came before he said, “I feel a pull”)

P: (in a third movement of stretching the arm) “Now, just now it begins to pull”


Moreover, as we see the simple “feel a pull” here it begins to enrich with new knowledge that in a superficial analysis and without the help of an external facilitator, the patient probably would not have identified alone, with the only difference that he is not doing it because of a necessity of explaining a second person, what is happening in his body.


While the patient is telling the therapist about what he feels; he is at the same time explaining himself. The therapist is in the position of not having to understand the explanation of the patient unless only with the condition of getting amazed, go deeper in the details and ask the patient what he has lived, as if he had to set up a model of his internal model.


It is due to this reason that up to now, the therapist’s questions have never contaminated the patient´s experience with his, he asked questions that David Grove calls “Clean” meaning clean facts which reflect the patient’s words with simple well prepared prefixes like “And what do you mean by…” “and where do you feel…” “and when…” where the constant presence of “and” is crucial in order to give the patient the sense that the question should be a continuation.


The only purpose of these questions is to allow the patient to explore his inner self, trying to achieve an abstract sensation of something real and place it in the time and space like all physical phenomena in nature.




Here we have a very creative passage, where we place the patient in a condition of making real all those effects that he is feeling in his body: we ask him to materialize them.


[…the metaphors used to describe thoughts, feelings, relations, complicated behaviors, and abstract concepts, mainly derive from experiences in the physical world, that is to say, a world where things with certain characteristics are in certain places and change with time because of internal and external happenings…] J. Lawwley and Penny Tompkins in “Minds and Metaphors”


T: “And that pulling, feels like what“



We have mentioned several times in the article, the metaphoric passage, that is to say, the ensemble of all the elemental components of the patient’s perception (symbols), the relations, the relation patterns, and the emerging characteristics of each relation.


In this case, the elastic is a symbol, the elemental unit of a metaphoric outlook, the basic level over which the relations and the meaning with other symbols are intercepted, weaving a more complex connection that is precisely a metaphoric outlook.


To better understand the relations and the emerging properties, let us think of “salty” which is not a property of sodium or chlorine, both poisonous if ingested individually, but the relation between them determines the salt which is the emerging property.


At this point we help even more our patient asking him to clear as much as possible the symbol “elastic”


T: “And what kind of elastic is this elastic? “

P: “Those green ones that we use in the office for the files”


In order to create a complete harmony with the patient, the therapist will not only reflects the exact patient’s words, but rather he will widen his knowledge with clean questions, he will also try to use his own facial mimes, tone of voice and prosody, since even these non verbal forms make the elastic symbol in the patient’s experience.




After having helped the patient to materialize this “pull” aspect, which is part of his corporal experience in a definite context, it is the time to help him influence this phenomenon producing changes.


T: “Yes, now I can imagine, you were very clear“


T: “And what would you like to happen now”


P: “I would like to feel It like this” (the patient shows the movement of the other arm, the one not involved in the plegia)


T: “I understand it looks like there are many differences between the two movements, do you agree if we go by levels? “

“If we are good and work well together in a month’s time how would you tell me this movement”


P: “I will tell you that instead of having a green office elastic band l will have that yellow one, finer and littler


T: “And you will have that yellow one, finer and littler”


T: “And you could imagine what sensation you will feel when you have that yellow finer and littler?”


At this point the patient closes his eyes and gets prepared to feel in his head the sensation that he would have had with the yellow finer and littler, and nods with his head to communicate with the therapist that produced that image.


To better understand this passage, where I ask the patient “to imagine” the sensation of the new symbol, which he himself defined as a yellow elastic  finer and littler, I suggest to read this article about the motor image and to understand my decision of not accepting at this moment the idea of using the healthy joint as a model, same as I would have not accepted if the patient would have said that he wanted to “cut the elastic”, I also suggest to read this article that treats the “intermediate worlds”


The therapist now proceeds making the same stretching the elbow movement made at the opening session and answering the same questions as at the beginning.


T: “What happened?”

P: “How strange, has it gone better?”

T: “It is strange, it has gone better, what do you mean by better?”

P: “It has pulled less”

T: “And it has pulled less like if you had that yellow, finer and littler”

P: “YES!”


At this point all patients tend to look at us a bit careful, incredulous about what happened, “it is strange…”, but also a bit excited about the possibility of being able to actively take part in the changes of some of the phenomena of the body specially the ones related to the hypertonia.


Here a lot of opportunities open up for the therapist, in fact he could explore the metaphoric outlook of the patient, and even help him more by putting together his perception or deciding to establish the change with a last step, that will allow the patient to acquire a more pleasant tool during the exercise or during his daily life, a token entirely his to spend it in autonomy: the label.


  1. LABEL


To label a change in the metaphoric outlook means to find a key, so the patient can remember and reuse in a more expeditious way, the process that took him to the change and without a doubt take the patient´s attention from a sensorial and conceptual control to a symbolic control, “remember the eyes of my girl?”



T: “And if I had to give a name to this sensation that you tried?”


P: “I would say it was WOW!”


T: “It was WOW!”


Now the therapist has helped the patient find a tool to control his body, stretch his arm alone only with his other hand, and use this experience remembering it with the label “WOW”, which was created by the patient, so in order to be able to reuse it within a cognitive exercise and also within a comparison of actions experience CTA, or simply in any situation that we want to take the patient’s attention to the control over that phenomenon.


The topic of the language of the metaphor or of the modeling is particularly ample and challenging, so we have to postpone new ideas in other articles where we will see how to apply the Clean Language, even in a patient with aphasia, where we do not have the ability of communicating with words and how to handle reticent cases or with difficulties to express a sensation with words, let us remember that we look for a therapist, we still expect that he will propose passive mobilizations or stretching ones and we are not always ready to open the doors of our interior world.


In this video there is a brief extract of a symbolic modeling with an aphasic patient. I consider this video a very important document since it attests that even an aphasic patient can communicate a lot about his condition to the therapist.