Metaphor, Cancer and the End of Life

A Corpus-Based Study

Elena Semino, Zsófia Demjén, Andrew Hardie, Sheila Payne, Paul Rayson

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781317245216
• Edition: 1
• Topic: Languages & Linguistics
• Subtopic: Communication Studies
• Index: Languages & Linguistics

This book presents the methodology, findings and implications of a large-scale corpus-based study of the metaphors used to talk about cancer and the end of life (including care at the end of life) in the UK. It focuses on metaphor as a central linguistic and cognitive tool that is frequently used to talk and think about sensitive and subjective experiences, such as illness, emotions, death, and dying, and that can both help and hinder communication and well-being, depending on how it is used. The book centers on a combination of qualitative analyses and innovative corpus linguistic methods. This methodological assemblage was applied to the systematic study of the metaphors used in a 1.5-million-word corpus. The corpus consists of interviews with, and online forum posts written by, members of three stakeholder groups, namely: patients diagnosed with advanced cancer; unpaid carers looking after a relative with a diagnosis of advanced cancer; and healthcare professionals. The book presents a range of qualitative and quantitative findings that have implications for: metaphor theory and analysis; corpus linguistic and computational approaches to metaphor; and training and practice in cancer care and hospice, palliative and end-of-life care.

1 Introduction

1.1 What This Book Is About

This book presents the methodology, findings and implications of a large-scale corpus-based study of the metaphors used to talk about cancer and the end of life (including care at the end of life) in the UK.¹

Our topic, rationale and approach are best introduced by means of an example. The extract in Example 1.1 is taken from a contribution to a UK-based online forum dedicated to cancer, from January 2008.² Contributors to this forum include people who have cancer and people who look after (or have looked after) someone with cancer, such as a partner, spouse or parent. The author of this particular forum post is a man whose wife recently died of cancer. For the purposes of our discussion, we will call him Peter. In the post, Peter responds to a woman who has asked for advice about the problems that her own illness is causing in her relationships with friends and family, and particularly her husband. As is often the case in peer-to-peer online communication about illness (Harvey and Koteyko 2013: 163–211), Peter provides advice and encouragement on the basis of his own personal experiences (NB: throughout this book, original spellings are retained in quotations from the online data).

Example 1.1

I don’t quite know where to start with any comment about your situation, but I have been where your hubby currently is and I have run the whole gambit of emotions. I have been at an all time low, wishing somehow it could be me, not my wife, going through the ordeal. Then I have been secretly glad that it wasn’t me that was ill, because I am the world’s worst patient and would have been more trouble to my wife than her illness ever was. We had days when the situation kicked our lives to pieces, and we had some days that gave us moments of extreme delight. Cancer is a journey, some people have similar experiences to others on that journey, but by and large the journey has many twists and turns that means no two people go the exact same route. I think it is like trying to drive a coach and horses uphill with no back wheels on the coach. You do need to stop occasionally and rest the horses, review the situation with your husband. Its his time to step up to the plate. […] My wife when she was diagnosed wanted me to divorce her. Can you imagine that. We had been happily married for 40 years but she tried for several months to make me leave her. When we eventually talked it through, I discovered it was because she loved me so and did not want me to endure her suffering. […] Naturally, being kind of stubborn, I refused to go, I worked on the basis that this was an enemy attacking my loved one and it had picked a fight with me as well. I wish I could say that we won all the battles, and that she is alive and well and cancer free. We did however win a significant number of the skirmishes to make me proud to have been worthy to be by my darling’s side. […] The other thing that is very true is the emotions you are both rollercoasting along with have all been experienced by so many on this site that you will be flooded with kindly warm support. I am a praying soul so shall be adding you to my list. Wishing you the very best with all you face kindest Regards

In this extract, Peter discusses the two main topics that we are concerned with in this book: the experience of being affected by cancer; and the experience of the end of life and care at the end of life. More specifically, Peter’s post addresses the consequences that caring for someone with incurable cancer can have for one’s emotions, perceptions of oneself and others, relationships and so on. Although these consequences are mostly negative, they can also be positive, as in the ‘moments of extreme delight’ mentioned by Peter.

In this book, we are particularly concerned with the metaphors that are used to talk about these topics and experiences. The post above is a good example of why metaphor is an important phenomenon to consider in relation to cancer and the end of life. Peter writes metaphorically about the experience of cancer as a ‘journey’ and as a ‘fight’, and about the contrast between positive and negative emotions in terms of the opposition between up and down (e.g. ‘I have been at an all time low’, ‘the emotions you are both rollercoasting along with’). These metaphors do not just make it possible to verbalise experiences that could not easily be expressed using literal language. They also reveal Peter’s own specific and sometimes conflicting perceptions, views, attitudes and challenges.

For example, several metaphors in Example 1.1 emphasise Peter’s sense of vulnerability, difficulty and lack of control while his wife was ill, such as ‘days when the situation kicked our life to pieces’ and the simile ‘like trying to drive a coach and horses uphill with no back wheels on the coach’.³ Other metaphors, in contrast, present him as determined, active and resilient, such as ‘I worked on the basis that this was an enemy attacking my loved one and it had picked a fight with me as well’. As we explain in more detail later, metaphors have a ‘framing’ function: different metaphors can both reflect and facilitate different ways of making sense of and evaluating a particular topic or experience (e.g. Lakoff and Johnson 1980; Ritchie 2013; Semino et al. 2016). The Fight⁴ metaphor makes cancer into an enemy to be confronted, while the Journey metaphor does not involve an opponent, but rather impediments to moving forward.

Military metaphors for cancer in particular have often been criticised (e.g. Sontag 1979; Miller 2010) because they tend to frame the relationship between the sick person and the illness as a battle, and the person him- or herself as ‘losing the battle’ if they do not get better. Later in this book, we show how this and other types of metaphors can indeed have harmful implications, for example by leading to negative self-perceptions, and/or by contributing to a sense of disempowerment. However, in Example 1.1 Peter’s own Military metaphor emphasises his pride at being with his wife throughout her illness, even though she ultimately died of it (cf. ‘to make me proud to have been worthy to be by my darling’s side’). This begins to suggest a point that we will provide evidence for throughout the book: the framing effects of metaphors are a context- and usage-dependent phenomenon. Different people may use the same broad kind of metaphor in different ways at different points in time. It is important to consider variation across groups, individuals and contexts, from the perspective of both research on metaphor and research and practice in healthcare. We will look particularly at the metaphorical language used by members of three different participant groups in healthcare: people diagnosed with advanced cancer, unpaid family carers looking after someone who has cancer, and healthcare professionals.

In order to study systematically the metaphors used by the members of these three groups to talk about cancer and the end of life, we adopted the methods of corpus linguistics (see McEnery and Hardie 2011)—a branch of linguistics that exploits computer-aided methods to study a variety of linguistic phenomena in large digital collections of texts known as ‘corpora’ (singular, ‘corpus’). We built a 1.5-million-word corpus consisting of interviews with and online forum posts by people diagnosed with advanced cancer, family carers and healthcare professionals (see Chapter 3 for more detail). We then used a combination of qualitative analysis and corpus linguistic methods to identify and analyse the metaphors used in the corpus to talk about cancer and the end of life, including care at the end of life.⁵ In the course of the book, we present a range of qualitative and quantitative findings that have implications for different fields, including particularly: metaphor theory and analysis; corpus linguistic and computational approaches to metaphor; and training and practice in cancer, hospice, palliative and end-of-life care. This book has therefore been written to cater for audiences from these different fields.

In the next section, we provide a brief overview of the background to this book, i.e.: language, illness and healthcare (section 1.2.1), metaphor (section 1.2.2) and corpus linguistics (section 1.2.3). More detail on each of these areas is provided in Chapter 2. In section 1.3, we spell out the contribution of this book, particularly for metaphor studies, corpus linguistics and healthcare research and practice. In section 1.4 we provide a chapter-by-chapter overview of the book, and some suggestions for how readers from different disciplinary backgrounds might approach the different chapters.

1.2 Background to This Book

1.2.1 Language, Illness and Healthcare

Language is central to the practice and provision of healthcare, and mediates the ways that we experience illness. It can both facilitate and obstruct positive experiences and good quality care. When it works well, language improves information provision, diagnosis, support, self-management and self-esteem, resulting in the overall empowerment of both patients and healthcare professionals. However, language can also cause misunderstandings, misdiagnoses, frustration, anxiety and stigma, resulting in overall disempowerment. In particular, people with serious and potentially life-limiting illnesses such as cancer need to (be helped to) understand the nature of their condition and its likely consequences. Their interactions with healthcare professionals may involve a new diagnosis, a change in the illness trajectory or a transition from curative-oriented therapy to supportive and palliative care. These difficult interactions often have to happen in clinical environments that are noisy, busy and time-pressured, and hence not usually conducive to good communication. Professionals may also be reluctant to initiate conversations with patients because they lack skills, are uncertain about the patient’s prognosis or may not have an established relationship. They may be uncomfortable with the emotions that can be generated in addressing difficult topics and may withdraw particularly from interacting with terminally ill patients, offer inappropriately optimistic information or change the focus to ‘safer’ topics.

Communication in doctor-patient encounters has received considerable scholarly attention, particularly with regard to issues such as power imbalances and sources of misunderstanding (e.g. Ong et al. 1995; Harvey and Koteyko 2013: 7–38). There is also evidence that communication skills training programmes can improve clinicians’ ability to talk with patients with serious illness, and cancer in particular (Gysels et al. 2004; Moore et al. 2013). In addition, a growing body of work has started to show the important insights that can be gained from studying how illness and healthcare are talked about outside doctor-patient interactions, such as in first-person accounts by patients and in media reporting on serious and/or infectious diseases. This broader focus on different types of communication about illness can lead to a better understanding of the subjective experience of illness, including cancer (e.g. Appleton and Flynn 2014), and also shed light on socio-cultural views of illness that can influence self-perceptions, social relations, preventative behaviours and compliance with treatment (e.g. Hanne and Hawken 2007). These insights can in turn be used to facilitate sensitive and effective communication in institutional healthcare settings (e.g. Charon 2006; Carel 2013). For example, it has been shown that being exposed to patients’ narratives makes a positive contribution to the learning and communication skills of medical students (Easton 2016; Snow et al. 2016). Indeed, a 2016 World Health Organization report on ‘The Cultural Contexts of Health’ (Greenhalgh 2016: ii) significantly concludes that research on narratives of health and illness can ‘convey the individual experience of illness and well-being, thereby complementing (and sometimes challenging) epidemiological and public health evidence’.

In this context, attention to language in communication about illness is paramount. This does not just mean focusing on what people say, but also paying detailed and systematic attention to how they say what they say (e.g. Sarangi 2004; Hunt and Carter 2012). For example, we have suggested that how Peter uses metaphors in Example 1.1 gives us insights into aspects of his experiences that he does not state explicitly, such as an alternation between a sense of helplessness and feelings of defiance and pride. It is in fact well-known that metaphors are particularly important in the communication and experience of illness (see 1.2.2 and 2.5.1; see also Demjén and Semino 2017 for an overview). However, there is also awareness that metaphors can be, as Czechmeister (1994: 1227) puts it in relation to cancer, a ‘two-edged sword’. When they work well, they can help people express, understand and cope with the experience of illness. When they work badly, they can cause misunderstandings and negative emotions.

By exploring systematically the metaphors used by patients, family carers and healthcare professionals in the context of cancer and the end of life, we hope to increase healthcare professionals’ awareness of their own and others’ uses of language, so that they can adopt more sensitive and effective communication strategies with patients and their families.

1.2.2 Metaphor

Definition

Metaphor in verbal communication involves talking and, potentially, thinking about one thing in terms of another, where the two things are different, but some form of similarity can be perceived between them. For example, in the extract above, Peter talks about cancer in terms of an ‘enemy’ who had ‘attack[ed]’ his wife and therefore ‘pick[ed] a fight’ with him too. Illnesses such as cancer and physical attacks by an enemy are different kinds of experiences, but they can be perceived as similar: both are unwelcome; both have negative and potentially fatal consequences; both require some kind of action; and so on. We describe these similarities as ‘perceived’ because they are not objectively given or constrained in an absolute sense. Rather, they are at least in part created in the production and interpretation of the metaphor itself. In the terms we used in the previous section, they are part of the framing that a particular use of metaphor imposes on its topic. In addition, each choice of metaphor facilitates further inferences, evaluations, emotional reactions and so on. Peter’s Fight metaphor does not just evalu...