Adages, Aphorisms, and Proverbs in Psychiatry and Psychotherapy: Tools for Assessment and Treatment

Over decades supervising general psychiatric management and psychotherapy, we have observed thousands of clinical assessments, management visits, and psychotherapy sessions, during which we have heard numerous adages used by clinicians and patients for a variety of communicative purposes. The following lists represent a small portion of the available examples.

Standout examples from therapists include, “Practice makes perfect,” “Actions speak louder than words,” “Better safe than sorry,” “Appearances can be deceptive,” “The grass is always greener on the other side,” and “If it’s not one thing, it’s your mother” (a weak attempt at humor).

Standout examples from patients include, “All good things come to an end,” “Beggars can’t be choosers,” “It’s no use crying over spilled milk,” “The apple doesn’t fall far from the tree,” “Who ever said life was easy?” and “Never put off today what you can do tomorrow” (a cynical attempt at humor, reversing the usual order).

Both patients and therapists have notably used the aforementioned phrase, “It is what it is,” as well as “It’s not over till it’s over,” “Forgive and forget,” “Great minds think alike,” “No news is good news,” and “[Expletive] happens.”

The circumstances in which these adages emerged varied considerably. These sayings often served as summary statements at the conclusion of conversations, concisely encapsulating points that the patient or therapist wanted to emphasize. Whereas therapists’ adages often had upbeat or positive connotations, patients’ use of adages was more varied, particularly earlier in therapy, when demoralization often generated cynicism or pessimism.

The effect of clinicians’ adages depended heavily on their understanding of their patient’s situation and their timing in delivering the adage. Well-placed and well-timed adages sometimes provided emotionally meaningful interpretations and insights—highly impactful “infective messages” (33) that deeply resonated with patients. These well-timed adages sometimes became nodal points in psychotherapy that were recalled after treatment without distortion. In these cases, the well-timed adage conveyed some deep truth about a patient’s character, uniqueness, or circumstances that occasionally summarized entire treatments. However, ill-chosen or ill-timed adages often missed their mark and fell flat. At best, they had a neutral impact; at worst, they diminished the patient’s view of the therapist’s sensitivities or abilities. In some instances, to show impertinence or to fend off what they perceived as incorrect interpretations, patients parried their therapists’ adages with adages of their own that sometimes contradicted the therapist’s perspective. At times, misapplied adages can have long-term adverse effects, as recently noted in an essay in the Journal of the American Medical Association describing what turned out to be a detrimental therapeutic recommendation via the phrase, “fake it till you make it” (34). An example of a misapplied adage can be seen in the following vignette.

Assigned his first psychotherapy case, Dr. B was anxious about doing a good job. His patient, Ms. D, a woman in her mid-20s, sought treatment because she experienced numerous unsuccessful and disappointing relationships with men, which left her with strong doubts about her attractiveness and worth. Initial evaluation revealed a verbal, attractive woman who was depressed but not suicidal. She was a college graduate working successfully in her area of interest. During the second diagnostic session, Ms. D elaborated on her self-defeating experiences with men. Although he took note of the long-standing pattern of her dating relationships, Dr. B was completely unaware of and unfamiliar with the underlying issues that were being reenacted. As the session neared its end, hoping to be supportive, he shared with the patient an adage that his grandmother once told him: “Honey, men are like sausage: you never know what’s inside of them.”

Ms. D was stunned by this comment. After some silence, Dr. B implored her to tell him what she was feeling and thinking. Her caustic response was, “Are you telling me that I’ve been searching for good hot dogs?” A novice, Dr. B was unable to repair this therapeutic rupture resulting from his empathic failure. The session ended, and despite Dr. B’s repeated phone calls, Ms. D never returned to treatment.

Although his grandmother’s adage may have contained some truth, it failed to capture the depth of Ms. D’s struggle. Without an established close relationship with Dr. B, Ms. D seemed to experience his premature remark as a narcissistic assault, feeling criticized for her lack of insight. Although Ms. D may not have been able to verbalize her impression, this attempt to ask a man for help ended like all of her previous unsuccessful attempts to form relationships with men.

In addition to mental status assessments, adages can be used in several clinically relevant ways. For example, patients can be asked to identify the adages with which they are most familiar, especially those that they see as important guideposts, reminders, or, at times, annoyances that might induce shame or guilt. With reflection, many patients can retrieve adages implanted in their consciousness and consciences early in their lives by important figures—parents, other relatives, teachers, other authority figures, and peers. These adages might even constitute significant cognitive schemas, the internal “voices” that drive behavior. Asking patients to reflect on adages that easily come to mind may be similar to assessing patients for basic schemas, including those sometimes targeted in cognitive-behavioral therapy (CBT). Individuals’ use of adages may reflect the relative optimism or pessimism of their mental states, including by expressing conditions such as depression (35). Constructive adages may serve adaptive purposes, keeping patients organized and goal directed and helping them cope effectively. Alternatively, self-defeating, contradictory, or internalized ego-dystonic adages might generate conflict and need to be targeted in psychodynamic therapies and CBTs. For example, patients might harbor cynical variations of common adages that reinforce negative expectations and self-defeating behaviors, such as responding to, “Hope for the best, but plan for the worst” with the more cynical, “Hope for the best, but expect the worst.”

Adages may also hold significant personal meanings. They may be interpreted idiosyncratically in association with their sources or the contexts in which patients first heard them. Boesky (19) suggests that an individual’s use of a particular adage might serve as content akin to a dream—to be examined for its symbolic value and affect-laden associations.

Finally, stock series of adages can be used as projective tests. Patients can be asked not only to interpret them but also to reflect on what these sayings evoke in terms of emotions and potential meanings for their lives (20). Studies that asked participants to indicate how well each of a series of 200 proverbs expressed their behaviors and beliefs confirmed that proverbial wisdom promotes behavior and beliefs that align with important dimensions of individual personality. Individuals’ responses were largely consistent with their “big five” personality dimensions on the Neuroticism, Extraversion, Openness Personality Inventory (21, 22).

Adages have been used throughout history to promote character building and psychological improvement. Consider these adages about adages, which we might call “meta-adages”: “A quotation at the right moment is like bread to the famished,” from the Talmud (36), and “A short saying often contains much wisdom,” attributed to Sophocles. The adages may come in the form of well-trodden, solemn and somber declarations or compelling, pointed punchlines of insightful jokes or wisecracks (37).

The use of adages in routine psychotherapy has been championed by venerable psychotherapists at least as far back as Alfred Adler, a member of Freud’s original circle (23). Adages may educate, suggest, or persuade (38). Their use has been explicitly described in programs advocating the active, directive, and educational treatment of depression (39). However, similar to the use of humor in treatment relationships, therapists must appreciate that what may seem appropriate to them might not be heard as appropriate by patients. The therapeutic use of an adage is observable in the following vignette.

Mr. R was a new patient who was overwhelmed by devastating losses and multiple simultaneous heartbreaking misfortunes. After careful assessment, and after judging that Mr. R would appreciate an understanding statement and not feel put off by it, his new therapist, Dr. L, empathetically offered the old Yiddish saying, “Oy, so many horrible things happening to a person in such a brief time.” Hearing this, Mr. R broke down, began to cry, acknowledged that Dr. L understood his dilemma, and affirmed that the two of them, no matter how hopeless Mr. R felt, would work together to get his life back on track.

Dr. L used this example to teach residents the importance of the therapist both being able to convey, at the end of the diagnostic sessions, that they concretely understand the patient’s degree of distress and emphasizing hope as the patient initiates treatment.

Several models of psychotherapy propose the regular introduction of adages into discourse. For example, the objective of effectiveness (describe, express, assert, reinforce, [be] mindful, appear confident, negotiate [DEAR MAN]) in dialectical behavior therapy (DBT) is heralded by the phrase, “Be effective in maintaining your rights and wishes,” whereas the objective of self-respect (fair, apologies, sticking to your values, truthful [FAST]) is introduced with the phrase, “Act in such a way that you can maintain self-respect.” To manage setbacks, patients are counseled with, “If life gives you lemons, make lemonade” and “You may not have caused all of your own problems, but you have to solve them anyway” (40, 41). Quotations by Marsha Linehan often cited in DBT include, “Acceptance is the only way out of hell,” “You can feel like a mental patient, but that doesn’t mean you have to act like one,” and “Bear pain skillfully.”

In practice, DBT and other therapies explicitly value culturally appropriate adages (42, 43). For example, Spanish-language dichos (proverbs and sayings) may be regularly introduced in various therapies (24).

CBT and its close relative rational emotive behavior therapy help patients identify cognitive distortions by condensing them into adages that are easy for patients to identify with, such as the dysfunctional, “I feel it, therefore it must be true” and “If I don’t do something perfectly, I’m a complete failure.” Examples of adages classically used to counter such negative thoughts include, “Thoughts are not facts” and “You mainly feel the way you think” (44).

Adages about mindfulness have been integrated into numerous psychotherapeutic practices, including DBT and acceptance and commitment therapy (ACT), and are exemplified by those compiled in Jon Kabat-Zinn’s mindfulness-based stress reduction program (45). They include such well-known sayings as, “Wherever you go, there you are,” “Mindfulness means being awake, it means knowing what you’re doing,” and “The present moment is the only time over which we have dominion.”

To help patients write personal mission statements as they define and clarify their personal values, practitioners of ACT may ask them to collect and write down famous quotations they find moving and inspiring (46).

Finally, several self-help movements, such as Alcoholics Anonymous and other mutual aid programs, introduce slogans—aphorisms and proverbs—into their strategies to increase group cohesion and adherence to their behavior codes. Examples include, “No free lunch,” “It’s better to give than to receive,” “When the going gets tough, the tough get going,” “What goes around, comes around, if you stick around,” and “No pain, no gain” (25).

Similar collections of adages have appeared in psychiatry, psychotherapy, and psychoanalysis literature, intended to document oral traditions and to convey the “wisdom of the tribe.” Collections have addressed both general psychiatry practice overall (47, 48) and specific issues such as love and marriage (26), geriatrics and aging (27), and suicide (28).

Not all adages stand the test of time; in psychiatry and psychotherapy, science, evidence, and theoretical models rapidly evolve, and prior formulations may be discarded in favor of others that are better supported by contemporary information. For example, Semrad: The Heart of a Therapist, one of the most cherished collections of clinical wisdom, was derived from the teachings of Elvin Semrad, for decades an esteemed clinical supervisor at the Massachusetts Mental Health Center in the Harvard system (49). In retrospect, some former students now see many of his psychoanalytically based precepts as dated or misguided (50). For example, “Anything below genital level is body-to-body reaction. This is why men have such trouble becoming therapists. They can’t accept their pregenital states, that they’re just human beings with body feelings” (49). More than a few of the aphorisms attributed to another wise and practical psychoanalytic educator, Maxwell Gitelson, are similarly dated and out of step with current clinical thinking. For example, “Altruistic surrender by living through her husband is a woman’s way for compensating for her lack of a penis” (29). Several other tenets in these collections would no longer find favor among contemporary practitioners.

In some ways, clinicians self-disclose their beliefs and values through the ways they use adages. The use of self-disclosing adages can be helpful, when appropriately timed and dosed, by modeling openness, warmth, and the value of the therapeutic alliance for the patient. Similar to an effective interpretation, self-disclosing adages can reveal insights that have been outside the patient’s awareness, as demonstrated by the following vignette.

Ms. P, an English professor who struggled with enduring hatred toward her ambivalently held mother, was being treated by Dr. J via weekly psychotherapy. Ms. P had recently completed a quasi-autobiographical novel in which she diligently worked through her lifelong resentments and in which she ultimately found peace in accepting her mother’s negative attributes. On hearing that the novel was completed and was to be published, borrowing one of his own mother’s favorite sayings, Dr. J effusively exclaimed, “Good things come to good people who work hard!” Momentarily taken aback, Ms. P then responded warmly to Dr. J’s spontaneity and genuine happiness for her accomplishment. From that point on in the therapy, Ms. P’s holiday cards to Dr. J (and, eventually, the cards she continued to send for years after terminating therapy) were addressed to “Dr. Hard Work.”

Dr. J’s authentic reactions, including his use of this adage, further deepened the therapeutic alliance during the “working through” phase of treatment.