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Metaphors and problematic understanding in chronic care communication
Abstract
Metaphors can be used as crucial tools for reaching shared understanding, especially where an epistemic imbalance of knowledge is at stake. However, metaphors can also represent a risk in intercultural or cross-cultural interactions, namely in situations characterised by little or deficient common ground between interlocutors. In such cases, the use of metaphors can lead to misunderstandings and cause communicative breakdowns. The conditions defining when metaphors promote, and hinder understanding have not been analyzed in detail, especially in intracultural contexts. This study proposes an analysis of metaphors identified within an Italian corpus of diabetes care interviews. Through a coding scheme capturing the types and the probative weights of the linguistic evidence that can be used to detect misunderstandings, the communicative effectiveness of metaphors is indirectly assessed. The quantitative and qualitative analyses show a positive correlation between metaphor use and problematic understanding. A more detailed scrutiny of the interlocutors’ roles and topics of the metaphors points out that most of the problematic metaphors are used by patients, while most of the problematic ones used by providers concern non-clinical matters. These results can be explained as resulting from incorrect presumptions of common ground between the interlocutors.
... Evoke multiple meanings beyond the literal interpretation [67] Draw clear parallels between two elements, leaving less room for ambiguity [68] Common aspects Cognitive tools for understanding and enhancing design problems and involve personal interpretations [59,69] ...
... Diverse and multifaceted, where effective communication and creative thinking are paramount, and spanning across various fields and disciplines [51,53,69]. In literary fiction Evoke emotions and enhance the richness of descriptions [73] Create vivid imagery and provide deeper insights into characters, settings, and themes [74,75]. ...
... In art and design, metaphors and analogies contribute to creations imbued with deeper meaning, symbolism, and emotional resonance, thereby enriching the aesthetic experience [51,78]. Additionally, they find diverse and multifaceted applications across various fields and disciplines, emphasizing effective communication and creative thinking as paramount [51,69]. In literary contexts, both devices evoke emotions and enhance descriptions [73], further emphasizing their shared role in stimulating imagination and conveying nuanced ideas. ...
This review article explores how metaphors and analogies used throughout urban history can simulate mental imagery to inspire innovation. The study addresses three critical questions using qualitative literature review methods like text data mining and content analysis. The results yielded from the first question showed a link between mental imagery and architectural discourse. The second question yielded the crucial role of metaphor and analogy as literary devices that can enhance mental imagery. The answer to the third question yielded five procedures of how literary devices foster innovation. The discussion found a complex interplay between recalling mental imagery and imagination and using metaphors and analogies. While recognizing their effectiveness in inspiring innovative ideas, the review cautions against oversimplification and cultural biases. The review of literature offers a nuanced understanding of their theoretical and practical foundations, shedding light on their role in shaping architectural mental imagery within urban history narratives.
... This paper studies the metaphors of pain, the body, illness and medicine that health professionals and chronic pain patients construct in consultations in a Belgian pain clinic. Research has extensively evidenced the importance of metaphors in general, and in health care specifically (Casarett et al., 2010;Macagno and Rossi, 2019;Munday et al., 2021;Semino et al., 2017a,b). Metaphors structure our reasoning and understanding, including experiences such as illness. ...
... In health care settings, metaphors are a potential source of confusion and shared understanding, and of empowerment and stigma (Casarett et al., 2010;Macagno and Rossi, 2019;Olsman et al., 2014;Semino et al., 2017). For instance, in the case of war metaphors, patients are often framed as winners or losers, and thus as having an important role in getting better, while in reality they often may not have a lot of impact on their illness and treatment. ...
... In any case, the literature shows that metaphors come with particular perspectives on pain, illness, and medicine, which are socially constructed through language. These perspectives have also been shown to influence illness and pain experiences (Macagno and Rossi, 2019). For instance, Munday et al. (2021) found a connection between the type of metaphor and patients' diagnoses, as well as to how much their pain interfered with daily life. ...
Introduction:
This paper examines pain, illness and medicine metaphors as used in consultations between chronic pain patients and anaesthesiologists, physiotherapists and psychologists in a Belgian pain clinic. As metaphors frame and highlight aspects of understanding and experiences of life events, including illness, they can provide insight in how health professionals and patients construct illness, pain and medicine in interaction.
Materials and method:
16 intake consultations (collected in Belgium in April-May 2019) between 6 patients and 4 health professionals were qualitatively coded twice ATLAS. TI by a team of 3 coders, using an adjusted form of the Metaphor Identification Procedure. Each metaphor was labelled for source domain, target domain and speaker.
Results:
A number of metaphors that have been previously documented in past research were frequent in our data too, such as journey and machine metaphors, although sometimes also used differently, like war metaphors. Our data set also contained many few-used and sometimes more novel metaphors, such as ILLNESS IS A YO-YO. Many metaphors highlight particular aspects of living with and talking about chronic pain, such as its duration and persistent presence, a lack of agency and feelings of powerlessness, and a dualistic perspective on body and mind.
Discussion and conclusion:
The metaphors used by health professionals and patients give insight in the lived experience of having and treating chronic pain. In this way, they can contribute to our understanding of patients' experiences and challenges, how they recur in clinical communication, and how they are related to wider discourses on health, illness and pain.
... Videre henger tilgang til metaforer også sammen med den ansattes tilknytning til arbeidsplassen. Forming og forståelse av språkbilder er betinget av kulturelle dynamikker og forutsetter en felles plattform for å gi mening, noe som kan føre til at normene som ligger til grunn for bildene av omsorgsarbeidet, forblir stille (Lakoff & Johnson, 1980;Macagno & Rossi, 2019). Vi ønsker med denne artikkelen også å bidra til diskusjoner om hvordan inkludering og opplaering av ansatte med innvandrerbakgrunn bedre kan tilrettelegges i sykehjem spesielt, og ved andre arbeidsplasser generelt. ...
... Bilder, eller metaforer, finnes både i dagligtale og i spesifikke diskurser i ulike samfunnsfelt, som i helsefeltet. Det å ramme inn et tema er metaforens sentrale funksjon (Lakoff & Johnson, 1980, s. 3;Macagno & Rossi, 2019;Semino et al., 2018). Metaforer er ikke bare en karakteristikk av språket eller noe som blir brukt i tekstlig formidling; de er også virksomme i meningsdannelse og handling. ...
... I det ovenfornevnte ser vi hvordan bildet «å jobbe med henda på ryggen» former omsorgsarbeidet, men også hvordan det utfordres gjennom ulike forståelser av «å jobbe» og av «omsorg» samt av at normen som ligger til grunn for metaforen ikke blir eksplisitt kommunisert. Bruk av metaforer for kommunikasjon i helseinstitusjoner er vanlig, og språkbilder kan vaere effektive kommunikative redskaper, men også kilder til misforståelser og manglende forståelser (Macagno & Rossi, 2019;Semino et al., 2016). Det er kjent at i et flerkulturelt arbeidsfellesskap blir etablerte ideer om hvordan ting skal gjøres, utfordret, og arbeidsoppgaver og fremgangsmåter må laeres (Mendes, 2013;Rogstad, 2012;Leseth & Solbraekke, 2011). ...
... The problems that arise in real-life interactions have been explained with reference to theoretical constructs such as 'asymmetry', 'power relations', 'medical world vs. life world', 'voices', etc. (Beisecker 1990;Bigi 2012;Heritage and Greatbatch 1991;Irwin and Richardson 2006;Rossi 2016;Thesen 2005;Todd 1989) and have been explained in terms of communicative breakdowns and strategies used to repair them (Levinson et al. 2000;McCabe and Healey 2018;Macagno and Rossi 2019;Schegloff 1987). As we stress in greater detail in Sect. ...
... However, the same type of linguistic evidence appears to be less interesting in monolingual consultations, especially when detected in doctors' turns. It has already been noticed that the strength of turns characterised by a lack of uptake is only a weak evidence of problematic understanding (Macagno 2018;Macagno and Rossi 2019;Rossi and Macagno submitted). Case 2 provides an example from a corpus of monolingual consultations conducted in the context of diabetes care and collected in Italy (Bigi 2014). ...
... This interpretation is in some way challenged by the patient who makes explicit he is worried because he swells due to cortisone consumption (lines 2 and 4). At line 5, Macagno and Rossi (2019) detected a lack of uptake when the nurse interrupts the dialogue by introducing two new topics of conversation. Clearly the nurse does not provide any information in reply to the patient's worries related to the consumption of cortisone. ...
In this contribution, we adopt a theoretical framework that allows to consider mono- and multilingual medical settings on a continuum, thus offering analysts of communication homogeneous tools for the analysis of misunderstandings and communicative breakdowns in these contexts. After considering the main issues regarding misunderstandings in mono- and multilingual settings, we propose to consider doctor-patient interactions by using the concept of activity type. Combining this perspective with the socio-cognitive approach (SCA), we show how our description of the clinical interactions allows to produce hypotheses that can be tested empirically. We describe dialogical processes that may allow the parties to build a common ground starting from the salient aspects of two perspectives that are often different and misaligned, yet may still be reconciled.
... The findings from this study provide support for the use of metaphors as a communication tool useful in facilitating healthcare communication, especially for youth with anxiety, and reducing knowledge translation barriers. Communication in healthcare is a characterized by cross-cultural interactions (e.g., age, social class, professional background) [31] and an epistemic imbalance between the patient and the healthcare provider [99]. Culture denotes the cognitive schemata a group of people use to make sense of new information [100]. ...
... Every mental illness experience, especially anxiety [13,89] and depression [12,101,102], is unique to the individual and embedded in their context. For this reason, a clinician's use of metaphor should be tailored to the patient's context and individual characteristics (e.g., cultural values, background, illness type and stage) [17,31,36]. By attending and responding to a patient's chosen metaphors, a clinician stands to gain a deeper understanding of the many languages of mental illness and, in particular, their patient's language. ...
Living with anxiety can be a complex, biopsychosocial experience that is unique to each person and embedded in their contexts and lived worlds. Scales and questionnaires are necessary to quantify anxiety, yet these approaches are not always able to reflect the lived experience of psychological distress experienced by youth. Guided by hermeneutic phenomenology, our research aimed to amplify the voices of youth living with anxiety. Fifty-eight youth living with anxiety took part in in-depth, open-ended interviews and participatory arts-based methods (photovoice and ecomaps). Analysis was informed by van Manen’s method of data analysis with attention to lived space, lived body, lived time, and lived relationships, as well as the meanings of living with anxiety. Youth relied on the following metaphors to describe their experiences: A shrinking world; The heavy, heavy backpack; Play, pause, rewind, forward; and A fine balance. Overall, youth described their anxiety as a monster, contributing to feelings of fear, loss, and pain, but also hope. The findings from this study can contribute to the reduction of barriers in knowledge translation by encouraging the use of narrative and visual metaphors as a communicative tool to convey youth’s lived experience of anxiety to researchers, clinicians, and the public.
... Overall, the most prevalent specific constructs that other systems assess are decision making (n = 19), behavior change counseling (n = 13), and patientcentered communication (n = 8). The 24 remaining systems focus on specific interaction elements, for example metaphor use [29], advance care planning [30], relational style [31], triadic interactions [32], and interaction style with electronic health records during consultations [33]. Various systems included some non-verbal aspects as part of a broader range of behaviors, and four focused exclusively on non-verbal communication, such as touch or eye contact [34][35][36][37]. ...
... In addition, most of the participants were Caucasian, and the diversity of people from various cultural and racialized backgrounds, socioeconomic status, age at diagnosis, at later stages in the dementia journey, and other factors were limited in our research. The use of metaphors may not be a common reference point and may not apply across different groups and cultures (Macagno & Rossi, 2019). As such, future research should explore whether the dementia journey metaphor as methodology is one that resonates and works with diverse people living with dementia, including people living with dementia from different cultures, at later stages in the dementia journey, and who experience social categories that intersect to cause marginalisation and oppression. ...
Metaphors to describe and understand dementia have been used in Western culture for many years. However, the ways in which people living with dementia and care partners use metaphors and symbols to illustrate and give meaning to their own experiences has been less understood. In this paper we explore the use of metaphor as methodology-- a way to support people living with dementia and their care partners in reflecting on and sharing their experiences of dementia. More specifically, drawing on our experiences using metaphor and symbols to map out the dementia journey from the perspectives of people living with dementia, care partners, and health and social care providers in Ontario, Canada, we describe our process of employing metaphor as methodology. We reflect on the use of metaphor as methodology through framing the dementia experience, exploring complexity, and representing multidimensionality. The use of metaphors has the potential to open space for new understandings of dementia.
... Overall, the most prevalent specific constructs that other systems assess are decision making (n = 19), behavior change counseling (n = 13), and patientcentered communication (n = 8). The 24 remaining systems focus on specific interaction elements, for example metaphor use [29], advance care planning [30], relational style [31], triadic interactions [32], and interaction style with electronic health records during consultations [33]. Various systems included some non-verbal aspects as part of a broader range of behaviors, and four focused exclusively on non-verbal communication, such as touch or eye contact [34][35][36][37]. ...
Background
Patients with cancer increasingly use the internet to seek health information. However, thus far, research treats web-based health information seeking (WHIS) behavior in a rather dichotomous manner (ie, approaching or avoiding) and fails to capture the dynamic nature and evolving motivations that patients experience when engaging in WHIS throughout their disease trajectory. Insights can be used to support effective patient-provider communication about WHIS and can lead to better designed web-based health platforms.
Objective
This study explored patterns of motivations and emotions behind the web-based information seeking of patients with cancer at various stages of their disease trajectory, as well as the cognitive and emotional responses evoked by WHIS via a scenario-based, think-aloud approach.
Methods
In total, 15 analog patients were recruited, representing patients with cancer, survivors, and informal caregivers. Imagining themselves in 3 scenarios—prediagnosis phase (5/15, 33%), treatment phase (5/15, 33%), and survivor phase (5/15, 33%)—patients were asked to search for web-based health information while being prompted to verbalize their thoughts. In total, 2 researchers independently coded the sessions, categorizing the codes into broader themes to comprehend analog patients’ experiences during WHIS.
Results
Overarching motives for WHIS included reducing uncertainty, seeking reassurance, and gaining empowerment. At the beginning of the disease trajectory, patients mainly showed cognitive needs, whereas this shifted more toward affective needs in the subsequent disease stages. Analog patients’ WHIS approaches varied from exploratory to focused or a combination of both. They adapted their search strategy when faced with challenging cognitive or emotional content. WHIS triggered diverse emotions, fluctuating throughout the search. Complex, confrontational, and unexpected information mainly induced negative emotions.
Conclusions
This study provides valuable insights into the motivations of patients with cancer underlying WHIS and the emotions experienced at various stages of the disease trajectory. Understanding patients’ search patterns is pivotal in optimizing web-based health platforms to cater to specific needs. In addition, these findings can guide clinicians in accommodating patients’ specific needs and directing patients toward reliable sources of web-based health information.
... The knowledge gap (varying from patient to patient) combines with other types of gaps, including unmatching background knowledge (such as values, expectations, facts, or theories) and different degrees of language proficiency or use of different languages or dialects (Macagno and Rossi 2019). Moreover, the most challenging aspect of asymmetry in medical interactions is not so much the quantitative knowledge disparity between the parties, but rather the qualitative knowledge disparity. ...
This volume addresses the issue of pragmatic meaning and interpretation in communication contexts regarding health and does so by combining a series of diverse and complementary approaches, which together highlight the relevance of successfully shared understanding to achieve more accessible, inclusive, and sustainable healthcare systems. The volume is divided into five thematic sections: 1) Analytical approaches to health communication, 2) Intercultural and mediated communication, 3) Negotiation and meaning construction, 4) Expertise and common ground, 5) Uncertainty and evasive answers, bringing together a group of top scholars on the much-debated issue of shared understanding both at the micro-level of dialogues between professionals and patients, and the macro-level of institutional communication. In the variety of its contributions, it represents an ambitious attempt at setting pragmatics at the core of healthcare communication research and practice, by combining conceptual reflections on core topics in the field of pragmatics (among which are speech acts, common ground, ambiguity, implicitness), with discourse and linguistic analysis of real-world examples exploring various problems in health communication.
... Th e results of corpus studies on metaphors' communicative eff ects in other medical fi elds are mixed, also questioning the role of metaphors as useful reasoning devices in health communication. Previous studies looked at metaphor as a source of ambiguity and misunderstandings, highlighting missed alignments between experts' and patients' understanding of metaphors in consultations (Skelton, Wearn and Hobbs 2002;Macagno and Rossi 2019). Th erefore, the question of the superiority of metaphor over literal language in health communication remains open. ...
This open access collection brings together a team of leading scholars and rising stars to consider what experimental philosophy of medicine is and can be.
While experimental philosophy of science is an established field, attempts to tackle issues in philosophy of medicine from an experimental angle are still surprisingly scarce. A team of interdisciplinary scholars demonstrate how we can make progress by integrating a variety of methods from experimental philosophy, including experiments, sociological surveys, simulations, as well as history and philosophy of science, in order to yield meaningful results about the core questions in medicine. They focus on concepts central to philosophy of medicine and medical practice, such as death, pain, disease and disorder, advance directives, medical explanation, disability and informed consent.
Presenting empirical findings and providing a crucial foundation for future work in this dynamic field, this collection explores new ways for philosophers to cooperate with scientists and reveals the value of these collaborations for both philosophy and medicine.
The eBook editions of this book are available open access under a CC BY-NC-ND 4.0 licence on bloomsburycollections.com. Open access was funded by the European Research Council Starting Grant.
This volume presents a sample of exciting new ‘naturalistic’ work on quasi-perennial topics in the philosophy of medicine, such as the demarcation of disease, life, death, pain and disability. Some chapters engage surveys and vignettes, others use corpus analysis or simulations, while others offer interesting reflections on how such experimental philosophy touches upon other new developments in philosophy (of medicine), such as conceptual engineering. A couple of contributions mainly focus on the limitations of experimental philosophy of medicine, and point out potential problems with its assumptions or goals.
... Metaphors have been considered powerful devices in such areas as medicine and healthcare communication, with scholars investigating their role as cognitive tools to acquire knowledge, share illness experiences, and promote healthy behaviors (Gibbs and Franks, 2002;Nie et al., 2016;Semino, 2018;Macagno and Rossi, 2019;Hauser and Schwarz, 2020). This topic has also found resonance in the public and cultural debate, especially regarding the issue of the "war on cancer" (Sample, 2019). ...
This study aimed to explore how metaphors were used to interpret the pandemic and to address its challenges in primary and secondary schools in Reggio Emilia, Italy. A questionnaire was administered to educators and teachers to understand how languages, images, and metaphors were used by themselves and their students to talk about the pandemic and their experiences of living with it. The goal of the questionnaire was to guide critical reflection and encourage more informed language choices. While the existing literature points out the alleged overuse of war metaphors and military frames in public discourse, our findings show that war metaphors are relatively frequent, with other metaphorical frames widely used by teachers and educators to foster resilient attitudes in students. Moreover, in their professional contexts, teachers and educators mostly use metaphorical frames involving resilient attitudes. Our interpretation of the results supports the hypothesis that the purposeful use and deliberate production of metaphors support the choice of metaphors with positive, constructive implications. Finally, some implications of these findings on the theory of metaphor and the methodology of the research are discussed.
... Actually, metaphor is central to analogical reasoning; it is an intrinsic part of human creativity and has a significant role in linguistic creativity and change (Lai & Shen, 2014). On the other hand, metaphor is conceptual mappings that in many cases pre-exist communication, structuring our thinking, reasoning, and understanding (Macagno & Rossi, 2019). Metaphor is at the nexus of mind and language. ...
This study is focused on analyzing the publication trends on metaphor in the last five decades with the assistance of bibliometric analysis. The data used were 620 studies classified into several types of publication: 440 articles, 74 reviews, 39 book chapters, 33 books, 24 conference papers, two short surveys, three notes, two editorials, two conference reviews, and one press article. The data analysis used VOSviewer 1.6.5 and Tableau to form the data visualization. The results of this study show that the highest number of publications in 2018 was 66, while the keywords co-occurrence aspect in the metaphor study was dominated by human, metaphor, young adult, humans, figurative language and so on. Furthermore, the highest source trend analysis was ‘Neuropsychologia’ with 397 citations and Mashal’s author-based citation analysis with 292 citations. In contrast, the countries-based citation analysis was dominated by two countries: the United States at 2358 and United Kingdom at 1113. Then, the highest organizational trend was University College London, United Kingdom, with four documents and 77 citations.
... No study on the effects of metaphors for vaccination on reasoning in uncertain scenarios has been conducted, even though it should be required in vaccine communication, especially during pandemic times. Previous literature in corpus studies provided mixed results and questioned the use of metaphors in health communication (Skelton et al., 2002;Macagno and Rossi, 2019), showing that it might be a source of ambiguity and failures in understanding. Thus, the role and usefulness of metaphor in reasoning about vaccination remain an open problem. ...
Introduction
The paper investigates the impact of the use of metaphors in reasoning tasks concerning vaccination, especially for defeasible reasoning cases. We assumed that both metaphor and defeasible reasoning can be relevant to let people understand vaccination as an important collective health phenomenon, by anticipating possible defeating conditions.
Methods
We hypothesized that extended metaphor could improve both the argumentative and the communicative effects of the message. We designed an empirical study to test our main hypotheses: participants (N = 196, 78% females; Meanage = 27.97 years, SDage = 10.40) were presented with a text about vaccination, described in either literal or metaphorical terms, based on uncertain vs. safe reasoning scenarios.
Results
The results of the study confirmed that defeasible reasoning is relevant for the communicative impact of a text and that an extended metaphor enhances the overall communicative effects of the message, in terms of understandability, persuasion, perceived safety, and feeling of control over the health situation, collective trust in expertise and uptake of experts' advice. However, the results show that this effect is significantly nuanced by the type of defeasible reasoning, especially in the case of participants' trust in expertise and commitment to experts' advice.
Conclusion
Both communicative and defeasible reasoning competences are needed to enhance trust in immunization, with possible different outcomes at an individual and collective level.
... Using a metaphorical style of counseling by a counselor 6 G. M. Hildenbrand resulted in greater likelihood for participants to express emotions and experience affective engagement compared to using a literal counseling style (Tay, 2020). However, metaphorical language can be misleading (Talley, 2016), or cause confusion or misunderstanding (Hui, Zhukovsky, & Bruera, 2018;Macagno & Rossi, 2019). While clinicians could consider using analogies because of their potential to have a positive impact, they must also try to avoid problematic analogies. ...
Healthcare providers must explain medical information to patients in a way that patients can understand. Provider use of analogies is one strategy that may help patients better understand medical information. The present study, guided by a memorable message framework, investigated whether participants remembered any analogies used by their healthcare providers, and included a content analysis of the function the analogies served, the types of analogies participants remembered, and the body systems associated with the health issues that were described. Almost one-quarter of participants recalled an analogy used by a provider. The most frequently recalled analogies functioned to describe health conditions or phenomena, followed by elements of the body, and treatments or something external to the body. Analogies were most frequently used to describe health issues associated with the cardiovascular system, musculoskeletal system, digestive system, dental, eye, or skin issues, or the nervous system. The analogies were categorized as mechanical, a feeling or experience, random object, structure, food, nature, war/battle, or medical/body. Provider analogies may be a type of memorable message for some patients. Providers could consider using suitable analogies to explain health issues when communicating with patients, and be trained in effective use of analogies.
... Therefore, considering key distinctions made in pragmatics and linguistics (Bazzanella and Damiano, 1999a,b;Weigand, 1999;Yus, 1999;Verdonik, 2010), it included different types of problematic understandings, grouped into three main categories based on their strength of linguistic evidence. Following the procedures described in previous studies (Macagno and Rossi, 2019;Rossi and Macagno, 2020), two researchers (MGR and JM) independently worked on the transcripts of the consultations and detected the seven different types of problematic understandings considered by the coding scheme. The two researchers met several times along the process to discuss doubts, and a third researcher (EV) was involved in case of disagreement. ...
Background
Misunderstandings in medical interactions can compromise the quality of communication and affect self-management, especially in complex interactions like those in the assisted reproductive technology (ART) field. This study aimed to detect and describe misunderstandings in ART triadic visits. We compared first and follow-up visits for frequency, type, speakers, and topics leading to misunderstandings.
Methods
We purposively sampled 20 triadic interactions from a corpus of 85 visits. We used a previously developed coding scheme to detect different types of misunderstandings (i.e., with strong, acceptable, and weak evidence). We analyzed also the different topics leading to strong misunderstandings (direct expressions of lack of understanding, pragmatic alternative understandings, semantic alternative understandings) to provide insights about the contents of the consultation that may need particular attention and care.
Findings
We detected an overall number of 1078 misunderstandings in the 20 selected visits. First visits contained almost two-third of the misunderstandings (n = 680, 63%). First visits were particularly rich in misunderstandings with acceptable evidence (e.g., clarifications and checks for understanding), compared to follow-up visits. In first visits, doctors’ turns more frequently than couples’ turns contained misunderstandings, while in follow-up visits it was the other way around. Looking at the couple, the majority of the misunderstandings were expressed by the woman (n = 241, 22%) rather than by the man (n = 194, 18%). However, when weighting for their number of turns, 9% of the men’s turns included an expression of misunderstanding, compared to the 7% of the women’s turns. Finally, more than half of the misunderstandings with strong evidence were about history-taking and treatment-related topics, and while the history-taking ones were particularly frequent in first visits the treatment-related ones were more present in follow-up visits.
Discussion
Findings indicate that first visits may deserve particular attention to avoid misunderstandings, as they are the moment where a shared understanding can be harder to reach. In particular, misunderstandings happening in first visits seem mostly related to physicians having to reconstruct the clinical history of patients, while those in the follow-up visits seem to reflect residual and unsolved doubts from the couple, especially concerning treatments.
... However, some studies looked at metaphor as a source of possible misunderstanding, highlighting a certain degree of mismatch between the understanding of metaphors by doctors and by patients in consultations (Skelton et al. 2002;Macagno and Rossi 2019). Moreover, patients themselves often employ metaphors to describe their own symptoms, as for instance in "a dark cloud hangs over me," "the nausea comes in waves," "it feels as if there is an elephant sitting on my chest," (Hanne 2015, p. 36), and doctors need to interpret these metaphors for the aims of diagnosis. ...
The paper investigates the epistemological and communicative competences the experts need to use and communicate evidence in the reasoning process leading to diagnosis. The diagnosis and diagnosis communication are presented as intertwined processes that should be jointly addressed in medical consultations, to empower patients’ compliance in illness management. The paper presents defeasible reasoning as specific to the diagnostic praxis, showing how this type of reasoning threatens effective diagnosis communication and entails that we should understand diagnostic evidence as defeasible as well. It argues that metaphors might be effective communicative devices to let the patients understand the relevant defeasors in the diagnostic reasoning process, helping to improve effective diagnosis communication, and also encouraging a change in patients’ beliefs and attitudes on their own experience of illness and illness’ management.
... Case 2), which is manifested by a meta-dialogical sequence in which a problematic interpretation is declared. This type of evidence can be caused by the impossibility of decoding part of the sentence (Macagno, 2018;Macagno & Rossi, 2019), or by a conflict between the hearer's interpretation and other stronger background assumptions. The second type of direct meta-dialogical evidence of misunderstanding consists in the correction of an alternative interpretation, which reveals a mismatch of interpretation at the level of the semantic representation (e.g. ...
This article proposes a coding scheme for identifying and assessing linguistic evidence of problematic understanding in health-care provider communication with patients affected by type 2 diabetes mellitus. Drawing on the existing literature in pragmatics and linguistics, the scheme is grounded on the distinctions between the different types of linguistic evidence of the occurrence of a misunderstanding or a problematic understanding, divided into three levels (stronger, acceptable and weak) based on their probative force. The application of the scheme is illustrated through a pilot study, conducted on an Italian corpus of 46 transcripts of videotaped consultations between six health-care providers and 13 patients affected by diabetes mellitus type 2. The most frequent types of linguistic evidence of problematic understanding were the categories of "acceptable" (amounting to 58% of the total) and the "strong" evidence (35%). Patients' problematic understanding was detected to occur significantly more frequently than health-care providers. Providers were also found to be significantly more aware of possible misunderstandings, tending to verify more frequently the correctness of their own interpretations. This pilot study represents a first step in the process of developing a productive evidence-based tool for detecting problematic understanding, which can be used for implementing linguistic strategies for helping prevent the risk of misunderstandings in health-care communication. Our findings show that misunderstandings are widespread between patients and that some linguistic strategies may be more effective than others in preventing the risk of misunderstandings, suggesting possible directions of research for improving health-care providers' communicative skills.
... Moreover, it does not differentiate nor fully address the complex relationship between recall and understanding, even if it includes rules to credit recall when the information is heavily paraphrased, attempting to catch patient 'gist' understanding as well as more precise recollections. There is a recently published coding scheme that would be better equipped to detect mismatch between the intended meaning of the health care provider and the understanding of the patient [36]. ...
Background:
Information exchange between physician and patient is crucial to achieve patient involvement, shared decision making and treatment adherence. No reliable method exists for measuring how much information physicians provide in a complex, unscripted medical conversation, nor how much of this information patients recall. This study aims to fill this gap by developing a measurement system designed to compare complex orally provided information to patient recall.
Methods:
The development of the complex information transfer measurement system required nine methodological steps. Core activities were data collection, definition of information units and the first draft of a codebook, refinement through independent coding and consensus, and reliability testing. Videotapes of physician-patient consultations based on a standardized scenario and post-consultation interviews with patients constituted the data. The codebook was developed from verbatim transcriptions of the videotapes. Inter-rater reliability was calculated using a random selection of 10% of the statements in the transcriptions.
Results:
Thirtyfour transcriptions of visits and interviews were collected. We developed a set of rules for defining a single unit of information, defined detailed criteria for exclusion and inclusion of relevant units of information, and outlined systematic counting procedures. In the refinement phase, we established a system for comparing the information provided by the physician with what the patient recalled. While linguistic and conceptual issues arose during the process, coders still achieved good inter-rater reliability, with intra-class correlation for patient recall: 0.723, and for doctors: 0.761. A full codebook is available as an appendix.
Conclusions:
A measurement system specifically aimed at quantifying complex unscripted information exchange may be a useful addition to the tools for evaluating the results of health communication training and randomized controlled trials.
Physical Restraint (PR) is a coercive procedure used in emergency psychiatric care to ensure safety in life-threatening situations. Because of its traumatic nature, studies emphasize the importance of considering the patient’s subjective experience. We pursued this aim by overcoming classic qualitative approaches and innovatively applying a multilayered semiautomated language analysis to a corpus of narratives about PR collected from 99 individuals across seven mental health services in Italy. Compared to a reference corpus, PR narratives were characterized by reduced fluency and lexical density, yet a greater use of emotional and cognitive terms, verbs, and first-person singular pronouns. Sadness was the most represented emotion, followed by anger and fear. One-third of the PR narratives contained at least one metaphor, with Animals and War/Prison as the most distinctive source domains. The quality and length of the PR experience impacted both the structure and the sentiment of the narratives. Findings confirm the distressful nature of PR but also point to the use of various linguistic mechanisms which might serve as an early adaptive response toward healing from the traumatic experience. Overall, the study highlights the importance of Natural Language Processing as an unobtrusive window into subjective experience, offering insights for therapeutic choices.
Supplementary Information
The online version contains supplementary material available at 10.1038/s41598-024-83999-9.
In this chapter, we aim to provide a transdisciplinary account of the phenomenon of “metaphor” by looking at selected topics in order to gain a basic understanding of its complex nature. In particular, in the first section we will highlight the different manifestations of metaphor and explain the different qualities and characteristics associated with each manifestation. We will then turn to the multiple functions of metaphor, highlighting its importance in different discursive contexts and explaining the cognitive and persuasive potency of this captivating and elusive phenomenon.
Medical communication is characterized by an essential cultural difference, as the nature of healthcare provider–patient interactions consists of an epistemic imbalance between the expert and the layperson. This specialized knowledge gap combines with other types of cultural differences, defined by mismatched background knowledge (including values, expectations, facts, or theories) and the proficiency in the use of distinct languages or dialects. Such cultural differences define a type of communication that is essentially and primarily intercultural.
Drawing on examples from different types of medical communication, we provide an overview of these studies in linguistics, pragmatics, and health communication to describe differences and commonalities between pragmatic strategies used in interactions of different types and levels of “interculturality.”
We propose a more consistent integration of pragmatics in healthcare communication by looking at how shared understanding is obtained in language-discordant contexts through the mediation of interpreters. Based on this analysis, we design a new communicative role for healthcare providers highlighting future perspectives for clinical training and practice. In this sense, the role played by an intercultural pragmatic approach in healthcare communication leads to redefining pragmatic strategies as part of a communicative toolbox, and not only as a discipline explaining how context affects meaning.
This paper proposes a method for analyzing the dialogical functions of metaphors in communicative interactions, and more specifically in the context of medical interviews. The dialogical goals proposed and pursued by the interlocutors are coded using a coding scheme that captures seven mutually exclusive categories of dialogical moves. The functions of the moves, including metaphors, can be identified and correlated with other variables relevant to the type of communication under analysis. The coding scheme is used to analyze a corpus of 39 interactions between healthcare providers and patients affected by Type 2 diabetes. The exploratory quantitative analysis, for the purpose of determining the different distributions of metaphor uses between patients and providers, is combined with qualitative analysis in which the thematic areas of the metaphors are considered. The findings show how patients and providers use metaphors for pursuing different dialogical goals and meeting distinct communicative needs.
L’objectif principal de cet article est de montrer comment les métaphores peuvent être utilisées comme outils pédagogiques dans des contextes médicaux. Partant d’une réflexion sur les métaphores en tant que stratégies persuasives caractérisées par des arguments implicites ou condensés, cet article examine les conditions sous lesquelles les métaphores lors des consultations médicales favorisent la construction d’un terrain d’entente et permettent ainsi une meilleure compréhension par les patients et une participation accrue de ces derniers dans la prise de décisions. En utilisant des principes issus de l’approche pragmatique interculturelle développée par Kecskes (2014), des extraits d’interactions patient-prestataire sont discutés pour déterminer si les métaphores sont appropriées ou non.
The article is devoted to the study of metaphorization in the field of abstract categories in linguistic consciousness on the example of the cultural meaning “vanity”. The aim of the article is to establish the role and functions of metaphorical transfer in the visualization of abstract cultural meanings. The work used the methods of semantic, component, definitional and conceptual analysis, with the help of which the means and functions of semantic transfer in the metaphorization of vanity were investigated. The material for the research was the collected corpus of aphoristic sentences about vanity and the contexts of the metaphorical representation of vanity in the National Corpus of the Russian language. It is established that the metaphor in the language performs two main functions: cognitive, which gives the intellect the ability to comprehend something rationally incomprehensible, and expressive-evaluative, which allows the subject of speech to emotionally highlight any aspects and characteristics of the object. In the visualization of vanity, all the main types of metaphorical transfer on the auxiliary subject are used. Of the totality of semantic features of any category, in most cases, only a few are metaphorically distinguished, and these are connotative, evaluative features that are not associated with its definitional core. The attribute of negative evaluativeness in the semantics of vanity is metaphorized through the assimilation of this personal property to various kinds of unpleasant, harmful and dangerous creatures, plants, phenomena and objects. Like all “sinful passions” that subjugate a person and take possession of his will, vanity in speech is easily demonized – it is likened to “evil spirits”, mainly a demon. A specific feature of “reflexive feelings” – directed at oneself – conveys the likeness of vanity to a certain expanding substance, blowing a person from inside. In isolated cases, the likening of vanity to a crooked mirror and cotton wool metaphorizes such an essential semantic features of it as the imaginary, emptiness and futility of flaunting virtues. Thus, the study indicates that when metaphorizing abstract categories, which include vanity, not definitional semantic features of this category are visualized, but mainly semantic features relevant to assessment and emotional attitude of the subject of speech.
Together with the volume “Inquiries in philosophical pragmatics: Linguistic and theoretical issues,” this book provides a journey through the more recent developments of pragmatics, considering both its philosophical and linguistic nature. This first volume is devoted to the theoretical models developed from a philosophical perspective, including both the newest advances of the classical theories and approaches, and pioneering and interdisciplinary ideas proposed to face the challenges of the fields and areas of practice and analysis. The topics investigated, which include implicatures, reference, presupposition, speech acts, metaphor, relevance, and common ground, represent the core of the state of the art in philosophical pragmatics. Research on these matters have been continuously changing the way that we can look at them. This book serves as a collection of works from the most eminent authors who represent the theoretical developments of the approaches that defined this field, together with the new philosophical insights coming from more applied disciplines such as argumentation, discourse analysis, or linguistics. The combination of these two perspectives provides a unique outline of the current research in pragmatics.
In the literature, the pragmatic dimension of metaphors has been clearly acknowledged. Metaphors are regarded as having different possible uses, especially pursuing persuasion. However, an analysis of the specific conversational purposes that they can be aimed at achieving in a dialogue and their adequacy thereto is still missing. In this chapter, we will address this issue focusing on the classical distinction between the explanatory and persuasive uses of metaphors, which is, however, complex to draw at an analytical level and often blurred and controversial also from a theoretical point of view. Building on the analysis of explanation in different theories and fields of study, we show how it can be conceived as characterized by a cognitive and a pragmatic dimension, where the transference of understanding is used pragmatically for different dialogical goals - such as informing, making a joint decision, and most importantly persuading. In this sense, the cognitive effects of understanding are not incompatible with a persuasive dialogical purpose. This theoretical proposal will be applied to examples drawn from the medical context, to show how a pragmatic approach to explanation can account for the complexity of the cases that can be found in actual dialogical contexts.
The paper investigates the impact of the use of metaphors in reasoning tasks concerning vaccination, especially for defeasible reasoning cases. We assumed that both metaphor and defeasible reasoning can be relevant to let people understand vaccination as an important collective health phenomenon, by anticipating possible defeating conditions. We hypothesized that extended metaphor could improve both the argumentative and the communicative effects of the message. We designed an empirical study to test our main hypotheses: participants were presented with a text about vaccination, described in either literal or metaphorical terms, based on uncertain vs. safe reasoning scenarios. The results of the study confirmed that defeasible reasoning is relevant for the communicative impact of a text and that an extended metaphor enhances the overall communicative effects of the message, in terms of understandability, persuasion, perceived safety and feeling of control over the health situation, collective trust in expertise and uptake of experts’ advice. However, the results show that this effect is significantly nuanced by the type of defeasible reasoning, especially in the case of participant’s trust in expertise and commitment to experts’ advice.
Metaphors are considered as instruments crucial for persuasion. However, while many studies and works have focused on their emotive, communicative, and persuasive effects, the argumentative dimension that represents the core of their “persuasiveness” is almost neglected. This paper addresses the problem of explaining how metaphors can communicate arguments, and how it is possible to reconstruct and justify them. To this purpose, a distinction is drawn between the arguments that are communicated metaphorically and interpreted based on relevance considerations, and the ones that are triggered implicitly by the use of a metaphorical expression. In both cases, metaphorical arguments are reconstructed through different patterns of argument, called argumentation schemes (Walton, Reed and Macagno 2008). However, while the purpose of a metaphorical sequence of discourse (called metaphorical move) can guide and justify the reconstruction of the argument that can sufficiently support the intended conclusion in a persuasive move, a more complex analysis is needed for analyzing the additional inferences that a metaphorical move can trigger. These inferences are claimed to represent part of the connotation of the metaphorical expression and can be captured through its most frequent collocations, determinable using some tools of the corpus linguistics.
With this study we aimed to explore the role of social media in the healthcare
context by analysing how Facebook can represent a tool to foster patient education
and engagement within the context of chronic care. More specifically,
we have explored how Facebook is used by patients with diabetes (and by their
relatives) to share information and/or discuss issues relevant for managing
their disease. This is a preliminary explorative study, with a quantitative phase
where a survey was administered to 119 patients with diabetes and Facebook
users, and qualitative phase where a sample of interactions among members of
a Facebook group for patients with diabetes and their relatives was inductively
analysed. The qualitative analysis showed how participating in the Facebook
group has the main function of sharing information on how to manage diabetes,
followed by having the function of emotionally support patients. The results
from the survey confirmed these findings and revealed how patients using Facebook
groups for diabetes are usually more engaged in their care, with good
health literacy levels, and low informational needs. Based on these findings,
we highlight the potential relevance of these online groups and communities to
promote peer support; they can indeed represent important tools to improve the
abilities of patients to self-manage their disease and their motivation in playing
an active role in the care process.
This article proposes a coding scheme for identifying and assessing linguistic evidence of problematic understanding in health-care provider communication with patients affected by type 2 diabetes mellitus. Drawing on the existing literature in pragmatics and linguistics, the scheme is grounded on the distinctions between the different types of linguistic evidence of the occurrence of a misunderstanding or a problematic understanding, divided into three levels (stronger, acceptable and weak) based on their probative force. The application of the scheme is illustrated through a pilot study, conducted on an Italian corpus of 46 transcripts of videotaped consultations between six health-care providers and 13 patients affected by diabetes mellitus type 2. The most frequent types of linguistic evidence of problematic understanding were the categories of "acceptable" (amounting to 58% of the total) and the "strong" evidence (35%). Patients' problematic understanding was detected to occur significantly more frequently than health-care providers. Providers were also found to be significantly more aware of possible misunderstandings, tending to verify more frequently the correctness of their own interpretations. This pilot study represents a first step in the process of developing a productive evidence-based tool for detecting problematic understanding, which can be used for implementing linguistic strategies for helping prevent the risk of misunderstandings in health-care communication. Our findings show that misunderstandings are widespread between patients and that some linguistic strategies may be more effective than others in preventing the risk of misunderstandings, suggesting possible directions of research for improving health-care providers' communicative skills.
The detection and analysis of misunderstandings are crucial aspects of discourse analysis, and presuppose a twofold investigation of their structure. First, misunderstandings need to be identified and, more importantly, justified. For this reason, a classification of the types and force of evidence of a misunderstanding is needed. Second, misunderstandings reveal differences in the inter-locutors' interpretations of an utterance, which can be examined by considering the presumptions that they use in their interpretation. This paper proposes a functional approach to misunderstandings grounded on presumptive reasoning and types of presumptions, in which incompatible interpretations or interpre-tative failures are examined as defaults of the underlying interpretative reasoning , caused by overlooked evidence or conflicting presumptions. Moreover, it advances a classification of the types and the probative weights of the evidence that can be used to detect misunderstandings. The proposed methodology and its implications are illustrated through the analysis of doctor-patient communication in diabetes care.
This paper argues that current pragmatic theories fail to describe common ground in its complexity because they usually retain a communication-as-trans-fer-between-minds view of language, and disregard the fact that disagreement and egocentrism of speaker-hearers are as fundamental parts of communication as agreement and cooperation. On the other hand, current cognitive research has overestimated the egocentric behavior of the dyads and argued for the dynamic emergent property of common ground while devaluing the overall significance of cooperation in the process of verbal communication. The paper attempts to eliminate this conflict and proposes to combine the two views into an integrated concept of common ground, in which both core common ground (assumed shared knowledge, a priori mental representation) and emergent common ground (emergent participant resource, a post facto emergence through use) converge to construct a dialectical socio-cultural background for communication. Both cognitive and pragmatic considerations are central to this issue. While attention (through salience, which is the cause for interlocutors' egocentrism) explains why emergent property unfolds, intention (through relevance, which is expressed in cooperation) explains why presumed shared knowledge is needed. Based on this, common ground is perceived as an effort to converge the mental representation of shared knowledge present as memory that we can activate, shared knowledge that we can seek, and rapport, as well as knowledge that we can create in the communicative process. The socio-cognitive approach emphasizes that common ground is a dynamic construct that is mutually constructed by interlocutors throughout the communicative process. The core and emergent components join in the construction of common ground in all stages, although they may contribute to the construction process in different ways, to different extents, and in different phases of the communicative process.
This paper advances an approach to presupposition rooted in the concept of commitment, a dialectical notion weaker than truth and belief. It investigates ancient medieval dialectical theories and develops the insights thereof for analyzing how presuppositions are evaluated and why a proposition is presupposed. In particular, at a pragmatic level, presuppositions are reconstructed as the conclusions of implicit arguments from presumptive reasoning, grounded on presumptions of different type and nature. A false (or rather unaccepted) presupposition can be thus represented as the outcome of a conflict of presumptions – the ones used by the speaker and the ones commonly accepted or backed by evidence. From an interpretative perspective, this defaulted presumptive reasoning can be explained by comparing the available presumptions and repaired by replacing the weaker and unacceptable ones.
This paper advances an approach to relevance grounded on patterns of material inference called argumentation schemes, which can account for the reconstruction and the evaluation of relevance relations. In order to account for relevance in different types of dialogical contexts, pursuing also non-cognitive goals, and measuring the scalar strength of relevance, communicative acts are conceived as dialogue moves, whose coherence with the previous ones or the context is represented as the conclusion of steps of material inferences. Such inferences are described using argumentation schemes and are evaluated by considering 1) their defeasibility, and 2) the acceptability of the implicit premises on which they are based. The assessment of both the relevance of an utterance and the strength thereof depends on the evaluation of three interrelated factors: 1) number of inferential steps required; 2) the types of argumentation schemes involved; and 3) the implicit premises required.
Background
Metaphors in communication can serve to convey individuals’ backgrounds, contexts, experiences, and worldviews. Metaphors used in a health care setting can help achieve consensual communication in professional–patient relationships. Patients use metaphors to describe symptoms, or how disease affects them. Health professionals draw on shared understanding of such metaphors to better comprehend and meet patient needs, and to communicate information that patients can more easily integrate into their lives.This study incorporated a theoretical framework based on four worldviews, each with an underlying foundational metaphor (root metaphor). The use of these root metaphors (formism, mechanism, contextualism, and organicism) can have an explanatory function and serve to impart new meanings, as each type of metaphor can lead to a particular interpretation. The study aimed to extract and discuss the root metaphors, with a view to analyzing the communication between health professionals and patients. Methods
In a case study in Spain over a six-month period, we analyzed the content of recorded, transcribed interviews conducted by one nurse with 32 patients who had chronic illnesses. We inductively extracted five categories that emerged from the interviews: blood sugar, cholesterol, exercise, blood pressure, and diet. We then examined these categories from the standpoint of each of the four root metaphors using two approaches: A series (deductive) and an emergent (inductive) approach. ResultsThe results show that the nurse tended to primarily use two worldviews: mechanism and formism. In contrast, patients tended to favor mechanism when discussing cholesterol, blood pressure, and blood sugar levels, whereas contextualism was predominant when the category was diet or exercise. Conclusions
This study adds to the existing literature on health professionals and patients’ communication. It shows how the use of Pepper’s root metaphors help to analyze the communication between the nurse and patients. Furthermore, it shows they are both using different root metaphors when they are talking about illness and treatments especially regarding blood sugar, cholesterol, exercise, blood pressure, and diet. Further qualitative and quantitative studies are needed to solidly these findings.
The paper focuses on the kind of expertise required by doctors in health
communication and argues that such an expertise is twofold: both epistemological
and communicative competences are necessary to achieve compliance with
the patient. Firstly, we introduce the specific epistemic competences that deal
with diagnosis and its problems. Secondly, we focus on the communicative competences
and argue that an inappropriate strategy in communicating the reasons
of diagnosis and therapy can make patient compliance unworkable. Finally, we
focus on the case of diabetes metaphor and propose the deliberate use of metaphors
in health communication as an educational tool. On the one hand, metaphors
might help doctors in explaining the disease in simpler terms and framing
the experience of illness according to patient’s specific needs. On the other hand,
metaphors might encourage a change in patient’s beliefs on their own experience
of illness, and enable them to reach a shared decision making with doctors.
The purpose of this article is to investigate metaphors as argumentative devices in the context of communication in chronic care and, more specifically, in diabetes care. While scholars have compellingly insisted on the strong cognitive power of metaphors in communication and education (BLACK 1962, BURGERS, KONIJN and STEEN 2016, GIORA 2003, HESSE 1963, LOW 2008, ORTONY 1975, STEEN 2008, 2011), these insights have barely received attention in the field of health communication (CASARETT et al. 2010, DEMJEN, SEMINO & KOLLER 2016; DEMMEN et al. 2015, NAIK et al. 2011). This article introduces the main theoretical and practical problems with respect to the relationship between metaphors and argumentation, in both fields of health communication and philosophy of language. We will adopt a pragmatic-argumentative model of verbal communication with the final aim to propose a theoretical framework useful to evaluate metaphors in clinical contexts. The theoretical step discussed in this article constitutes the preliminary phase of a larger research program – Metaphors for diabetes – devoted to test the educational aptness of diabetes metaphors, in order to propose them as evidence-based instruments to health providers for patient education.
In this article, we examine the notion of 'framing' as a function of metaphor from three interrelated perspectives—cognitive, discourse-based, and practice-based—with the aim of providing an adaptable blueprint of good practice in framing analysis. We bring together cognitive and discourse-based approaches in an integrated multi-level framework, and demonstrate its value to both theory and practice by applying it to a corpus-based study of violence-related metaphors for cancer. Through the application of this framework, we show that there are merits in applying the notion of framing at different levels of generality in metaphor analysis (conceptual metaphors, metaphor scenarios, and linguistic metaphors), depending on one's research aims. We warn that researchers and practitioners need to remain aware of what conclusions can and cannot be drawn at each level, and we show the theoretical and practical advantages of taking all three levels into account when considering the use of metaphor for communicating about sensitive topics such as cancer. We emphasize the need for a 'rich' definition of framing, including aspects such as agency, evaluation, and emotion.
This paper discusses the metaphors used by sixteen palliative healthcare professionals from around the United Kingdom in semi-structured interviews to describe what they see as ‘good’ and ‘bad’ deaths. The interviews, conducted for the large-scale “Metaphor in End-of-Life Care” project, are set against the background of contemporary practices and discourses around end-of-life care, dying and quality of death. To date, the use of metaphor in descriptions of different types of deaths has not received much attention. Applying the Metaphor Identification Procedure (Pragglejaz Group, 2007) we find that the difference between good and bad deaths is partly expressed via different frequencies of contrasting metaphors, such as ‘peacefulness’ and ‘openness’ as opposed to ‘struggle’ and ‘pushing away’ professional help. We show how metaphors are used to: evaluate deaths and the dying; justify those evaluations; present a remarkably consistent view of different types of deaths; and promote a particular ‘framing’ of a good death, which is closely linked with the dominant sociocultural and professional contexts of our interviewees. We discuss the implications of these consistent evaluations and framings in broader end-of-life care contexts, and reflect on the significance of our findings for the role of metaphor in communication about sensitive experiences.
This chapter argues that the main difference between intracultural and intercultural communication is that the latter, to some extent, shifts the emphasis from the communal to the individual. What standard pragmatics assumes about how things work in communication depends on there being commonalities, conventions, standards, and norms between speakers and hearers. This, however, may not be exactly so in intercultural communication. Commonalities, conventions, common beliefs, norms, shared knowledge, and the like, all create a core common ground on which intention and cooperation-based pragmatics is built. (Of course, there are plenty of varieties within those commonalities.) However, when this core common ground appears to be limited, as is the case in intercultural communication, interlocutors cannot take it for granted; rather they need to co-construct it, at least temporarily. So what is happening here is a shift in emphasis from the communal to the individual. It is not that the individual becomes more important than the societal. Rather, since there is limited common ground, it should be created in the interactional context in which the interlocutors function as core common ground creators rather than just common ground seekers and activators as is the case in intracultural communication.
The common ground theory of presupposition has been dominant since the seventies (Stalnaker 1974, 1978, 2002). This theory has resulted from a view of communication as transfer between minds. In this view interlocutors presume that speakers speak cooperatively, they infer that they have intentions and beliefs that are necessary to make sense of their speech acts, and treat such entities as pre-existing psychological ones that are later somehow formulated in language. Common ground is considered as a distributed form of mental representation and adopted as a basis on which successful communication is warranted (Arnseth and Solheim 2002; Kecskes and Zhang 2009). However, the theory has not gone without objection and criticism (e.g. Abbott 2008; Beaver and Zeevat 2004; von Fintel 2001, 2006; Simons 2003) because it is based on “an oversimplified picture of conversation” (Abbott 2008), and as a consequence the relationship between common ground and presupposition has also been oversimplified. In this approach presupposition is often considered as a conventional or conversational constraint of common ground, or requirement on common ground that must be satisfied in order to make an appropriate utterance. The problem of accommodation is a critical issue that has been raised against this view, and caused great challenge to the theory by stimulating diverse alternatives. The goal of this paper is to redefine the relationship between common ground and presupposition within the confines of the socio-cognitive approach (SCA). SCA (Kecskes 2008; Kecskes and Zhang 2009; Kecskes 2010a, b) adopted in this paper offers an alternative view on communication, which claims that communication is not an ideal transfer of information, and cooperation and egocentrism (Barr and Keysar 2005; Colston 2005; Keysar
2007), are both present in the process of communication to a varying extent. The SCA emphasizes the dynamics of common ground creation and updating in the actual process of interaction, in which interlocutors are considered as “complete” individuals with different possible cognitive status being less or more cooperative at different stages of the communicative process. Presupposition is a proposal of common ground, and there is a vibrant interaction between the two. They enjoy a cross relation in terms of content and manners in which they are formed, and their dynamism is inherently related and explanatory to each other. This claim has important implications to the solution to presupposition accommodation. After the introduction Sect. 2 describes the socio-cognitive approach. Section 3 reviews the assumed common ground, and Sect. 4 introduces the speaker-assigned presupposition. Section 5 discusses the dynamism of presuppositions and common ground, and claims that their dynamic observations are coherent and explanatory to each other. Section 6 readdresses the accommodation problem with redefinition of the relations.
This study combines quantitative semi-automated corpus methods with manual qualitative analysis to investigate the use of Violence metaphors for cancer and end of life in a 1,500,000-word corpus of data from three stakeholder groups in healthcare: patients, family carers and healthcare professionals. Violence metaphors in general, especially military metaphors, are conventionally used to talk about illness, particularly cancer. However, they have also been criticized for their potentially negative implications. The use of innovative methodology enables us to undertake a more rigorous and systematic investigation of Violence metaphors than has previously been possible. Our findings show that patients, carers and professionals use a much wider set of Violence-related metaphors than noted in previous studies, and that metaphor use varies between interview and online forum genres and amongst different stakeholder groups. Our study has implications for the computer-assisted study of metaphor, metaphor theory and analysis more generally, and communication in healthcare settings.
Over the last two decades, questions of languages’ cultural specificity, diversity, and of linguistic universalism versus relativism, have increasingly been applied to the study of metaphor in analyses that take data from a wide range of languages into account. After reviewing existing research on cross-cultural metaphor variation, this paper focuses on the phenomenon of ‘false-friend metaphors,’ i.e., seemingly identical mappings which reveal hidden culture-specific differences when used in intercultural communication and in contrastive analysis. Examples of this phenomenon are drawn (1) from interpretations tasks concerning the metaphor THE STATE IS A (HUMAN) BODY, and (2) from cross-cultural research on the concept of SOCIAL FACE. In conclusion, a preliminary categorization of types of metaphor-induced intercultural misunderstanding is proposed.
One of the biggest challenges for doctors working in chronic care is the correct management of the argumentation phases during the encounters with their patients. During these phases doctors should provide patients with acceptable reasons for being adherent to treatment and for changing certain unhealthy
behaviors and lifestyles, something which is particularly difficult for elderly patients, for whom changing life long habits can be extremely hard. However, the medical literature on the subject of communication in the chronic care encounter shows lack of theoretical models and methodological approaches that can highlight which specific linguistic structures or elements in different communication styles favor or impede patient commitment, trust in the relationship and adherence to treatment. The contribution describes ongoing research on argumentative strategies in the encounter with diabetes patients. I describe one recently concluded research project on the argumentation phases of medical encounters in diabetes care, which highlighted critical areas in need of improvement. I also describe the design and aims of a new research project, aimed at testing the effectiveness and usability of certain argumentation schemes in the medical encounter.
The problem of establishing the best interpretation of a speech act is of fundamental importance in argumentation and communication in general. A party in a dialogue can interpret another’s or his own speech acts in the most convenient ways to achieve his dialogical goals. In defamation law this phenomenon becomes particularly important, as the dialogical effects of a communicative move may result in legal consequences. The purpose of this paper is to combine the instruments provided by argumentation theory with the advances in pragmatics in order to propose an argumentative approach to meaning reconstruction. This theoretical proposal will be applied to and tested against defamation cases at common law. Interpretation is represented as based on a hierarchy of interpretative presumptions. On this view, the development of the logical form of an utterance is regarded as the result of an abductive pattern of reasoning in which various types of presumptions are confronted and the weakest ones are excluded. Conflicts of interpretations and equivocation become essentially interwoven with the dialectical problem of fulfilling the burden of defeating a presumption. The interpreter has a burden of explaining why a given presumption is subject to default, assuming that the speaker is reasonable and acting based on a set of shared expectations.
To compare the frequencies with which patients with cancer and health professionals use Violence and Journey metaphors when writing online; and to investigate the use of these metaphors by patients with cancer, in view of critiques of war-related metaphors for cancer and the adoption of the notion of the 'cancer journey' in UK policy documents.
Computer-assisted quantitative and qualitative study of two data sets totalling 753 302 words.
A UK-based online forum for patients with cancer (500 134 words) and a UK-based website for health professionals (253 168 words).
56 patients with cancer writing online between 2007 and 2012; and 307 health professionals writing online between 2008 and 2013.
Patients with cancer use both Violence metaphors and Journey metaphors approximately 1.5 times per 1000 words to describe their illness experience. In similar online writing, health professionals use each type of metaphor significantly less frequently. Patients' Violence metaphors can express and reinforce negative feelings, but they can also be used in empowering ways. Journey metaphors can express and reinforce positive feelings, but can also be used in disempowering ways.
Violence metaphors are not by default negative and Journey metaphors are not by default a positive means of conceptualising cancer. A blanket rejection of Violence metaphors and an uncritical promotion of Journey metaphors would deprive patients of the positive functions of the former and ignore the potential pitfalls of the latter. Instead, greater awareness of the function (empowering or disempowering) of patients' metaphor use can lead to more effective communication about the experience of cancer.
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The Sketch Engine is a leading corpus tool, widely used in lexicography. Now, at 10 years old, it is mature software. The Sketch Engine website offers many ready-to-use corpora, and tools for users to build, upload and install their own corpora. The paper describes the core functions (word sketches, concordancing, thesaurus). It outlines the different kinds of users, and the approach taken to working with many different languages. It then reviews the kinds of corpora available in the Sketch Engine, gives a brief tour of some of the innovations from the last few years, and surveys other corpus tools and websites.
Metaphorical meaning can be analyzed as triggered by an apparent communicative breach, an incongruity that leads to a default of the presumptive interpretation of a vehicle. This breach can be solved through contextual renegotiations of meaning guided by the communicative intention, or rather the presumed purpose of the metaphorical utterance. This paper addresses the problem of analyzing the complex process of reasoning underlying the reconstruction of metaphorical meaning. This process will be described as a type of abductive argument, aimed at explaining how the vehicle can best contribute to the purpose of the utterance. This type of reasoning involves the analysis of the possible predicates that can be and usually are attributed to the vehicle, and the selection of the one (or ones) that can support the implicit conclusion constituting the communicative goal of the metaphorical utterance. Metaphorical meaning, in this perspective, becomes the outcome of a complex process of meaning reconstruction aimed at providing the best explanation of the function of the vehicle within a discourse move.
This article reports a study on metaphor comprehension by the international students whose first language is not English,
while attending undergraduate lectures at a British university. Study participants identified words or multiword items that
they found difficult in extracts from four academic lectures, and they interpreted metaphors from those extracts. Among the
items reported as difficult, we established the proportion of metaphorical items, plus the proportion of items composed only
of words familiar to the students. We developed a measure of the extent of students’ awareness of their metaphor interpretation
difficulties, plus a scheme for categorizing the most common types of metaphor misinterpretations. We found that, of the items
that were difficult though composed of familiar words, ∼40 per cent involved metaphor. Further, when the students misinterpreted
metaphors, they only seemed aware of having difficulty in ∼4 per cent of cases. As university lecturers use metaphors for
important functions, such as explaining and evaluating, such international students may thus be missing valuable learning
opportunities. Our error categorization scheme could be used in helping English learners with metaphor comprehension.
Contemporary metaphor research sees metaphor as conventional, automa-tic and unconscious. This raises the question when metaphors are used deliberately. It appears that all novel metaphors and some conventional metaphors are used deli-berately, and that this happens when they are intended to produce a change in the perspective of the addressee on the topic of a stretch of discourse. This typically happens for all metaphors that are expressed directly, such as extended non-literal comparisons and similes. Indirect metaphors can also be used deliberately, but this does not occur very frequently. The paper explains how these factors of metaphor interact with each other to produce deliberate or non-deliberate metaphor.
The default assumption in human communication is mutual intelligibility between interlocutors. Nevertheless, misunderstandings also occur, and languages have resources for managing these in communicative interaction. When speakers do not share a native language, misunderstandings are generally expected to arise more frequently than between native speakers of the same language. However, it is not clear that communication breakdown is more common among second language users; the anticipation of communicative difficulty may in itself offset much of the trouble, and speakers resort to proactive strategies. This paper investigates misunderstanding and its prevention among participants in university degree programs where English was used as a lingua franca. The findings suggest that speakers engage in various clarification and repair strategies in an apparent attempt to ensure the achievement of mutual intelligibility and thereby the achievement of important communicative goals.
The aim of this paper is to reflect on the necessity of pragmatic development of propositional forms and arrive at a better understanding of the level of meaning which Sperber and Wilson and Carston call 'explicature'. It is also argued that the pragmatically conveyed elements of explicatures are not cancellable-unlike conversational implicatures. While Capone (2003) addressed the issue of the cancellability of explicatures from a merely empirical point of view, in this paper a number of important theoretical questions are raised and discussed. In particular it is proposed that the analysis of the notion of intentionality, and the nature of pragmatic intrusion will settle the question of the cancellability of explicatures. An explicature can be considered a two-level entity. It consists of a logical form and a pragmatic increment that the logical form gives rise to in the context of an utterance. However, both the initial logical form and the pragmatic increment are the target of pragmatic processes. Consequently, we need a pragmatic process to promote the initial logical form to an intended interpretation and another pragmatic process to derive further increments starting from the initial logical form as promoted to an utterance interpretation.
This paper has two main parts. The first is a critical survey of ways in which the explicit/implicit distinction has been and is currently construed in linguistic pragmatics, which reaches the conclusion that the distinction is not to be equated with a semantics/pragmatics distinction but rather concerns a division within communicated contents (or speaker meaning). The second part homes in on one particular way of drawing such a pragmatically-based distinction, the explicature/implicature distinction in Relevance Theory. According to this account, processes of pragmatic enrichment play a major role in the recovery of explicit content and only some of these processes are linguistically triggered, others being entirely pragmatically motivated. I conclude with a brief consideration of the language-communication relation and the limits on explicitness.
Research into metaphor has become one of the fastest-growing and important areas of language research over the past twenty years, and metaphor is now recognized as central to language and language use. The implications of these findings are only just beginning to be felt in applied linguistics and this is designed to convey the excitement of metaphor study to a wider applied linguistic audience of researchers, trainers, programme developers and postgraduate students. The authors of the 12 papers are all internationally active researchers, contributing from their various backgrounds to this lively collection. Researching and Applying Metaphor presents a series of case studies plus an innovative initial section which discusses key aspects of researching metaphor in use. It demonstrates how metaphor can be, and needs to be, researched using multiple methods of investigation.
Many scholars have shown the relevance of communication as an instrument of care by arguing that the quality of the doctor-patient relationship -Also based on the quality of verbal communication -Affects the engagement and outcomes of patients. This understanding of such therapeutic role of communication paves the way to a re-consideration of ethical questions in clinical contexts: if communication is a therapeutic instrument, then healthcare providers need to be able to properly use it. Our main aim in this contribution is to argue that it is possible and desirable to adopt and manage non-neutral communication strategies to safeguard patients' freedom and autonomy in making decisions. More specifically, we use a pragmatic-Argumentative model of verbal communication to deal with the topic of neutrality. Analyzing a case study from the context of Assisted Reproductive Technology (ART), we underline the highly ethical relevance of this medical context and stress the importance of an appropriate use of argumentative and communicative strategies to protect patients' values and decisions.
“Grace and I are trying to keep the vaccines minimal for Annie, if we can.”
This chapter describes the individual and social differences in language use. Social differences in language are those features of an individual's speech behavior that are shared by significant numbers of others and play a role in the signaling of common identity. The usual method of demonstrating this sharedness has been to focus on groups such as residence, class, or ethnic background and to isolate phonological, syntactic, or semantic indices that show a systematic relationship to the macro-sociological variables that partition such groups. Furthermore, the correlation of linguistic variables with social variables has begun from the assumption that social groups are identifiable and known. This, however, is an issue much in dispute in the social sciences. A key heuristic device in linguistic research has been the concept of starredness.
This chapter confronts the central problem in the current state of argumentation studies, that of clarifying the relationship between argument and evidence. This problem was posed in Chaps. 5 and 6, where the notions of argument and evidence were notably prominent in the use of forensic evidence in the case of the Leonardo Da Vinci portrait and also in the examples of evaluating scientific arguments from correlation to causation. It remains open to be seen how evidence is related to argument generally, as part of the project of argument evaluation. Because this is such a pervasive issue of high generality, it has been reserved for the last chapter. The solution proposed is to fit six argumentation schemes for epistemic defeasible reasoning into a cluster of schemes enabling the basic evidence in a case to generate indirect evidence by using other schemes. This division helps to explain an ambiguity in the use of the term ‘evidence’. Used in a broader sense, ‘evidence’ can include any argument presented to support or attack a claim. In a narrower sense, ‘evidence’ refers to particular kinds of arguments, such as those based on observations, factual findings, statistics, experimental tests or other scientific findings.
Effective communication is essential in developing rapport with patients, and many nursing roles such as patient assessment, education, and counselling consist only of dialogue. With increasing cultural diversity among nurses and patients in Australia, there are growing concerns relating to the potential for miscommunication, as differences in language and culture can cause misunderstandings which can have serious impacts on health outcomes and patient safety (Hamilton & Woodward-Kron, 2010). According to Grant and Luxford (2011) there is little research into the way health professionals approach working with cultural difference or how this impacts on their everyday practice. Furthermore, there has been minimal examination of intercultural nurse-patient communication from a linguistic perspective. Applying linguistic frameworks to nursing practice can help nurses understand what is happening in their communication with patients, particularly where people from different cultures are interacting. This paper discusses intercultural nurse-patient communication and refers to theoretical frameworks from applied linguistics to explain how miscommunication may occur. It illustrates how such approaches will help to raise awareness of underlying causes and potentially lead to more effective communication skills, therapeutic relationships and therefore patient satisfaction and safety.
Collaborative goal setting in patient–provider communication with chronic patients is the phase in which – after collecting the data regarding the patient’s health – it is necessary to make a decision regarding the best therapy and behaviors the patient should adopt until the next encounter. Although it is considered a pivotal phase of shared decision making, there remain a few open questions regarding its components and its efficacy: What are the factors that improve or impede agreement on treatment goals and strategies?; What are the ‘success conditions’ of collaborative goal setting?; How can physicians effectively help patients make their
preferences explicit and then co-construct with them informed preferences to help them reach
their therapeutic goals? Using the theoretical framework of dialogue types, an approach developed
in the field of Argumentation Theory, it will be possible to formulate hypotheses on the ‘success conditions’ and effects on patient commitment of collaborative goal setting.
The paper discusses the differences between intracultural communication and inter-cultural communication from a socio-cognitive perspective that treats this relationship as a continuum rather than a dichotomy. Movement on the continuum, and differences between the two phenomena are affected by different factors that will be discussed in the paper. The hypothetical left end of the continuum is intracultural communication and the right end is intercultural communication. Neither exists in pure form. The question is to which end a given communicative situation is closer to and what characteristics it is dominated by. While moving on toward the right end communication becomes less dependent on standards, norms, frames, core common ground and formulaic language and is characterized more by emergent common ground, ad hoc generated rather than formulaic expressions, norm creating attempts and individual creativity in solving communication problems.
To what extent do communicative principles constrain the comprehension of simple metaphors? We argue that the comprehension of metaphor depends on communicative principles in exactly the same way that literal comprehension depends on them. We support our claims with our experimental findings that indicate equivalent processing for literal and metaphorical language. We then outline our theory of metaphor comprehension, which accounts for a variety of metaphoric phenomena and explains why people use metaphors.
My purpose in this article is to describe how and why theories of metaphor vary in the ways they do. I argue that theories of metaphor differ precisely because they emphasize different temporal stages in the process of understanding metaphorical expressions. The different temporal points at which theories propose that a metaphor has been understood, ranging from the first milliseconds of processing to extended, reflective analysis, distinguish rival accounts of metaphor. In this respect, metaphor theories do not necessarily compete with one another, but can best be evaluated through an appreciation of the specific time-course that underlies metaphor understanding. My discussion reviews some of the major theoretical approaches to metaphor and reveals their (mostly implicit) assumptions about the time-course of interpretation. I suggest that most theories of metaphor draw unjustified conclusions about the entire time-course of metaphor understanding because of the particular temporal stage of understanding that each attempts to describe. Thinking about metaphor in terms of the time-course of comprehension should permit much of the theoretical pluralism presently seen in the multidisciplinary study of metaphor.
This paper examines the role of mutual knowledge in a psychological theory of conversational inference. Contrary to recent proposals, I argue that speakers and listeners must coordinate what they mutually know in order to comprehend utterances. Mutual knowledge is not only a result of comprehension, but it is a prerequisite for it as well. I review recent arguments on this issue and outline why mutual knowledge is necessary for listeners to draw the right inferences from what is said in conversation. This is especially important if a theory of conversational inference is to meet the criteria of a psychologically real model of human languange behavior.
This book presents a complete method for the identification of metaphor in language at the level of word use. It is based on extensive methodological and empirical corpus-linguistic research in two languages, English and Dutch. The method is formulated as an explicit manual of instructions covering one chapter, the method being a development and refinement of the popular MIP procedure presented by the Pragglejaz Group in 2007. The extended version is called MIPVU, as it was developed at VU University Amsterdam. Its application is demonstrated in five case studies addressing metaphor in English news texts, conversations, fiction, and academic texts, and Dutch news texts and conversations. Two methodological chapters follow reporting a series of successful reliability tests and a series of post hoc troubleshooting exercises. The final chapter presents a first empirical analysis of the findings, and shows what this type of methodological attention can mean for research and theory.
Children's interpretations of metaphors used in a science text and their teacher's use of explanatory metaphor are analysed and compared to identify key processes in metaphor understanding and to suggest factors that contribute to successful use of metaphor in learning science. The research adopts a Vygotskian socio-cognitive approach to metaphor in discourse. Participants are children in Years 5 and 6, aged around 10 years, and their teacher, in a UK school. The data include think-aloud protocols and teacher-led classroom discourse, analysed for metaphor processing. Sample episodes from the data are used to illustrate how conceptual knowledge is used to interpret metaphor, and how the learning potential of metaphor may be rendered ineffective by interpretation problems or by the choice of metaphor. The mediation of metaphor by a skilled teacher reveals strategies for avoiding such problems and maximising the impact of metaphor on the learning of the formalised concepts of science.