9.1 Introduction
This chapter considers how the experience of illness is represented discursively, focusing on two contexts: anxiety and cancer. Language can be used to represent a single health condition in a range of ways, which is likely to impact the actions that people take in relation to that health condition, with consequences for their well-being. A corpus linguistic approach, using a large quantity of texts, is aptly suited for identifying the different representations or discourses around a health condition, showing the language patterns associated with each of them, and their frequencies of occurrence.
We will first consider a more automatic way of identifying linguistic patterns around a health condition (anxiety), using a tool which identifies the grammatical relationships between a word and its collocates. Although we were not looking for specific forms of language, a common feature we found involved characterisations of anxiety through metaphors. In Section 9.3 we move on to an approach that is based on trying to use corpus techniques to actively identity metaphors.
9.2 Representing Anxiety
This section describes how representations of anxiety were analysed in a 21-million-word corpus of forum posts on the topic of anxiety (described in more detail in Collins and Baker, Reference Collins and Baker2023; see also Sections 5.2 and 7.3 in this book). The forum posts were saved in a single text file, then uploaded into Sketch Engine, an online corpus analysis tool which has several functions that are helpful in terms of identifying patterns in language use. For this study the focus was on the word anxiety, which was the twenty-fifth most frequent word in the corpus, occurring 146,874 times. It was the most frequent lexical (open-class) word (with the top 24 words all coming from closed-class categories such as articles like the and prepositions like of). The noun anxiety was also the top keyword when the corpus was compared against the English Web 2020 Corpus (consisting of 38 billion words of internet English collected between 2019 and 2021). However, for a more complete analysis, the researchers could have considered the related adjectival form anxious (which occurred 18,217 times). The adjectival form anxious suggests a state or feeling which might be temporary, and tends not to reference a medical condition, whereas the related noun form anxiety tends to suggest that something is more substantial than a feeling and is a term more widely used in medical discourse. It is notable that the noun form is more than eight times as frequent as the adjectival form in this forum.
Other forms, such as the adverb form anxiously or misspellings (e.g., anxiaty), were much less frequent (23 and 62 times, respectively) but might have been worth considering to account for every single case. For the purposes of this study, however, only the noun anxiety was considered.
9.2.1 Anxiety and Related Terms
Sketch Engine contains a function called Thesaurus, which is based on the theory of distributional semantics to identify synonyms. Thus, words that have similar meanings will share similar collocates. Entering anxiety into the Thesaurus produced a list of lexical items, in order of their proportion of shared collocates with anxiety. Sketch Engine has a large number of general reference corpora that can be useful to get an idea of how linguistic items typically behave. As such, the analysis began with an examination of anxiety in the English Web 2020 Corpus, which contains around a billion words of general English collected from the internet. In this corpus, the 10 words which had the most similar collocates to anxiety were depression, worry, fear, emotion, stress, anger, confusion, frustration, grief, and illness. Intuitively, this makes sense – anxiety is treated in similar ways as negative feelings or mental health conditions – and some of the words on this list (particularly worry and fear) are similar to anxiety and could be subjected to more detailed analyses themselves.
Having obtained an idea of the kind of words that are closest to anxiety in general English, it is now worth focussing in on how it is used in the corpus of forum posts. Here, the top-10 most similar items were symptom, thing, feeling, attack, I, fear, pain, thought, time, and problem. These words are somewhat different and perhaps less obvious candidates, compared to those elicited through the general corpus, and accordingly they indicate that people with anxiety might have different understandings of their condition. It is interesting, for example, that the word thing has similar collocates to anxiety in the forum, and concordance analyses found that about 10 per cent of uses of thing refer anaphorically to anxiety. For example,
Anxiety is an awful thing and a vicious circle.
The word thing is somewhat vague and general, in addition to being typical of informal ways of communicating. As we will see, there are other ways of conceptualising anxiety, which link to a range of discourses or ways of seeing the world. Therefore, in order to focus more on the collocates of anxiety itself, the Word Sketch tool in Sketch Engine was employed. This essentially identifies collocates of anxiety and then groups them into grammatical categories. Figure 9.1 shows a (partial) screenshot of a Word Sketch of the word anxiety.
Word Sketch of anxiety.
The Word Sketch contains several lists of words that collocate with anxiety, arranged in order of their collocational strength (with collocational scores hidden as the default), so the numbers in the table relate to the number of times a word collocates with the word anxiety. The first column shows nouns that are modified by the word anxiety, indicating noun phrases like anxiety disorder, anxiety attack, and anxiety symptoms. The second column shows words (usually adjectives) which modify anxiety (e.g., severe anxiety). The third column shows adjectives which occur after ‘anxiety is’. Due to mis-tagging, there are sometimes cases that appear in the wrong column (e.g., the word most should not be in the adjective predicates list). Finally, the fourth and fifth columns show verbs which collocate with anxiety, in the object or subject position, respectively. The fourth column indicates actions which are done to or acted upon anxiety (e.g., makes my anxiety), whereas the fifth column shows actions where anxiety is the doer (e.g., anxiety takes). The Word Sketch also contains additional columns under these ones (not shown in the figure) which denote further grammatical relationships such as ‘anxiety + and/or’ or ‘pronominal possessors of anxiety’.
This method of grouping collocates into grammatical categories can be helpful for analysts, as it enables them to spot words with similar meanings or functions more easily than a simple list of collocates. In order to identify the various ways that anxiety is represented, it is still necessary for humans to spend time analysing Word Sketch, exploring hypotheses about the ways that collocates position anxiety, through the examination of relevant concordance lines.
For example, in the third column, we can see a number of similar kinds of adjectives that are used to modify anxiety: bad, horrible, awful, hard, severe, terrible. Taken together, these words would suggest a discourse prosody (Stubbs, Reference Stubbs2001) which represents anxiety extremely negatively. Words in other columns also contribute towards this negative depiction (e.g., severe and bad also appear in the second column), while words like sufferers and problems in the first column contribute towards the same kind of picture. The word attack, in the first column, could also be interpreted as contributing to a negative representation of anxiety.
However, another set of words in the first column seem to represent anxiety somewhat differently: disorder, symptoms, meds, medication appear to function in a way which represents anxiety as a medical condition. It is most likely the case that the two representations (anxiety as bad, anxiety as a medical condition) are not incompatible. It is not surprising to see a medical condition also described as negative. But we should still bear in mind that these are separate (if related) representations, and not everything that is bad is a medical condition; some medical conditions can be seen as positive (e.g., genetic resistance to certain diseases, neurodiversity, or high pain tolerance).
9.2.2 Identifying Representations around Anxiety
The task of the researcher, then, is to consider the collocates in the Word Sketch and try to group them into ways that contribute towards discrete representations. Some words will be easier to categorise than others; some words might potentially contribute to more than one representation, depending on the context that they are used in; and for some words it might not be possible to identify a clear representation. The process of identifying categories and the words that go in them is therefore subjective, and it is unlikely that there will be a perfect way of doing it. It is important to try to apply a set of consistent and transparent guidelines when carrying out this kind of categorisation, and it is a good idea to work collaboratively, to help resolve difficult or ambiguous cases. While it is possible to categorise some words almost immediately (e.g., bad, horrible, and awful are fairly unambiguously negative), for other words, a detailed concordance analysis would be required. To be thorough, it is sensible to carry out concordance scans of all the words in the Word Sketch, just to confirm that a word is functioning in its expected way and something strange is not happening with it. Bear in mind, for example, that the Word Sketch shows all words in lowercase, but they might actually be realised with upper-case letters in the corpus. For instance, a word like bad could actually be an acronym (e.g., BAD can stand for a therapeutic approach known as behavioural activation for depression). In addition, negators may switch a collocate’s meaning to its opposite – so in some cases people may write ‘I don’t have bad anxiety’.
As a result of grouping collocates together, the researchers identified four pairs of representations around anxiety, each pair of representations being related to one another. These pairs were (1) medicalising versus non-medicalising, (2) catastrophising versus minimising, (3) anthropomorphising versus abstracting, and (4) owning versus distancing. We will take the third pair as an example, in order to illustrate how these representations were realised through language.
Table 9.1 shows a range of ways that anxiety is metaphorically represented through language as a living being, often a human being but sometimes as an animal or a supernatural entity. This kind of representation casts anxiety as having agency, carrying out actions and having its own thoughts and goals.
In some cases anxiety was personified, through the use of prenominal titles like Mr, which occurs 34 times as a collocate of anxiety.
Mr Anxiety has no regard for nice people or anyone eh?
A more common way that anxiety is anthropomorphised is by referring to it as a fantasy entity (beast, devil, monster, demon) or a malign human (bitch, culprit, enemy, liar, bully, trickster, fraud).
Anxiety is a beast with a nature all it’s own, but together we can learn to understand and embrace it for what it is
Table 9.1 also shows range of verb actions caried out by anxiety (verbs in their base form refer to all forms (e.g., try refers to try, tries, tried, and trying).
when your anxiety tries to come knocking, remind it of today
It’s just anxiety trying to creep in.
Anxiety is also described as having conscious thoughts and desires, deciding, wanting, and loving things. Although love appears to be a positive word, it is used to describe anxiety as desiring negative outcomes for the person experiencing it.
My anxiety loves to scare us and if you let it, its winning.
right now my anxiety wants to rear its ugly head but I refuse to let it get me down
Anxiety is similarly described as playing tricks, scaring, and exaggerating.
Anxiety plays mean tricks on the body so remember that
In addition, anxiety is assigned as the experiencer of the negative thought processes, as opposed to the person who experiences anxiety.
That is your anxiety thinking negative thoughts.
A less common set of verbs involve descriptions of anxiety as beating the poster. These verbs often occur with negativisers (such as no, not, or never), where posters exhort one another or themselves not to let anxiety beat them.
Anxiety well never win unless you let it.
sometimes it’s hard, but I’m not going to let this monster called anxiety beat me.
Other verbs in this representation describe anxiety as moving (creep, follow).
I would say it’s your health anxiety following you to the gym.
Been fine all day come tea time felt anxiety creeping up on me.
Finally, there is a set of verbs which position anxiety as the patient of an action. Posters talk about challenging, combatting, battling, and beating anxiety. These kinds of verbs cast resolution of anxiety in terms of beating an opponent. In the following excerpt, the poster acknowledges the metaphorical nature of the representation by putting the word weapons in quote marks.
As you know, there is no secret recipe for dealing with loss and tragedy, but providing yourself with an assortment of “weapons” to combat the anxiety is your best bet to defeat it!!
Viewing anxiety as a living being can be seen as management strategy for some posters. Chen, Chen, and Yang (Reference Chen, Chen and Yang2019) have described a study where individuals who were instructed to anthropomorphise sadness or happiness reported less experience of that emotion afterwards. They argue that the reduction of emotion occurs because anthropomorphic thinking increases the perceived distance between the self and the emotion, which results in a sense of detachment.
At other times, posters cast anxiety as an abstract state or entity (e.g., something which has no concrete state), as shown by the collocates in Table 9.2.
Rather than being a living or human entity, the words in this table represent anxiety through a range of different perspectives. For example, some posters metaphorically represent anxiety as an experience, journey, or story, which frames it as part of a person’s life narrative.
I guess we just have to accept it as a part of our anxiety journey
A less frequent category of words describe anxiety in terms of a negative and repetitive experience, using terms like cycle, loop, and spiral, a set of characterisations which are linked to acknowledging that negative representations can result in increased anxiety.
How do you stay positive and hopeful through this anxiety spiral?
Anxiety trap works in a similar way.
try focusing your attention on other things that can help you overcome the anxiety trap
In this category, words which involve increasing anxiety are also included, like heighten, worsen, raise, escalate, add, exacerbate, and spike. Again, these verbs are often used in explanatory contexts.
The more we focus on our bodily functions it can heighten your anxiety and make you feel worse.
It can be useful to obtain a more general sense of a word’s overall meaning by consulting a larger reference corpus. For example, escalate is used in the English Web 2020 Corpus to refer to abstract phenomena like tension, violence, conflict, war, crisis, confrontation, and dispute – it clearly has a semantic prosody for negative things, as well as abstract concepts.
The anxiety just escalates it by a million percent.
Subside also has a semantic prosody for abstract entities. In the English Web 2020 Corpus, things that subside include laughter, pain, swelling, anger, fever, storm, flood, and fighting.
I know when my anxiety subsides the symptoms will too.
Additionally, anxiety is represented as abstract negative phenomena – for example, as a repetitive process (circle, cycle), a place (hell), a bad dream (nightmare), or a contest (battle, game).
Anxiety is hell on earth
Anxiety is a circle and that is something we need to try to break out from.
Anxiety is just as mind game, and games were meant to be won.
Coming somewhere between the abstracting and anthropomorphising representations of anxiety is a much smaller third set which frames anxiety as a non-living object. For example, there are verb metaphors like fix and fuel which cast anxiety as something akin to a machine.
The fact that the medical profession only masks symptoms and has no conclusive understanding of the brain, basically means that you are paying for someone who has about as much chance as fixing anxiety as a plumber!!
I keep googling symptoms too which is fuelling my anxiety.
Finally, there are another set of verbs, often denoting physical violence, which characterise anxiety even more negatively, as an entity which physically abuses the sufferer. It is difficult to categorise these verbs as referring to an abstract, living, or non-living entity, as they tend to occur in general language use in a wide range of contexts. Some of these verbs are used in metaphorical ways to describe anxiety as appearing or worsening (e.g., kick in, flare, strike). These verbs can also index natural phenomena. For example, in the English Web 2020 Corpus, strike tends to be associated with lightning or earthquakes, although there are also references to human-made objects (bullet, missile, car) or abstract concepts (tragedy, disaster) striking.
sometimes anxiety strikes out of the blue for no reason
it’s not long before anxiety soon kicks in and wrecks everything again!
It is important to note that a single lexical item can invoke more than one kind of representation. For example, referring to anxiety as a disorder is a way of representing it as both an abstract concept and a medical condition, while calling anxiety a nightmare will represent it as an abstract concept and an extremely negative phenomena (a form of catastrophisation).
Identifying these kinds of representations is one stage of the analysis. We might want to consider the kinds of contexts that the different representations occur in. For example, the representations which describe anxiety as a living entity often tend to be used when posters provide one another with emotional support or advice on coping, while cases of catastrophisation of anxiety in the corpus tend to occur when people are seeking help. We may also want to consider which kinds of posters use certain types of representations (in terms of, say, demographic characteristics or the length of time they have spent on the forum). And we could also consider the ways that other posters respond to these representations: do they take them up themselves, reject them, or explicitly talk about their effectiveness in helping them resolve or manage their anxiety?
For medical practitioners, it could be argued that it is useful to have awareness of the ways that people use language to refer to anxiety. This could help practitioners reflect on the ways their clients represent anxiety and whether such representations are likely to help or hinder them. For example, there is some evidence that catastrophising is a positive predictor of anxiety (Chan et al., Reference Chan, Chan and Kwok2015). Practitioners could thus support clients in critically considering a range of possible representations of anxiety, helping them to shift their thinking about anxiety towards more constructive means. It should be borne in mind, however, that people are likely to respond differently to the same representation, so there will be no single ideal way of talking about anxiety that works for everyone. Instead, the analysis from the corpus of forum posts provides information about a range of possible representations and encourages awareness relating to the way that those representations impact our experience of health conditions. This sense of gaining a better understanding of the possible set of representations around illness, and their effects, continues in the following section.
9.3 Representing Cancer
In the previous section we showed how the corpus-based analysis of personal accounts of anxiety led to the identification of patterns of metaphor use that are relevant to understanding people’s lived experience. We now turn to a corpus-based study that focused on metaphor specifically, in relation to cancer: the ‘Metaphor in End-of-Life Care’ project (MELC; Semino et al., Reference Semino, Demjén, Hardie, Rayson and Payne2018), already discussed in Chapter 5. Here we show how the analysis of a corpus of online forum posts by patients revealed the ways in which metaphors to do with violent encounters (e.g., fights and wars) are used to represent different aspects of the experience of having cancer.
The background and inspiration for this study was a long-standing debate on the dominance of what have been variously called ‘war’, ‘military’, ‘fight’, or ‘battle’ metaphors for cancer. Except for quotations, we will follow Semino and colleagues (2018) in subsuming all such metaphors under the label ‘Violence’ metaphors.
At the end of the 1970s, sociologist Susan Sontag (Reference Sontag1979) famously objected to the use of what she called ‘military’ metaphors for being ill with cancer and tuberculosis, and argued for the elimination of metaphors from communication about cancer. Since then, Violence metaphors have been similarly criticised by patients, health professionals, and researchers from different disciplines (e.g., Miller, Reference Miller2010; Granger, Reference Granger2014). Critics pointed out that within these metaphors, the patient is either implicitly placed in the passive position of battleground or described as a fighter who is in an antagonistic relationship with the illness and thus their own body. Most importantly, within these metaphors, not recovering and eventually dying of cancer constitute ‘losing the battle’, which may suggest that the person is somehow responsible for their own condition and death. For example, Jane Granger, a UK doctor who was diagnosed with incurable cancer in her early 30s, wrote the following 2 years before her death:
‘She lost her brave fight.’ If anyone mutters those words after my death, wherever I am, I will curse them. … I do not want to feel a failure about something beyond my control. I refuse to believe my death will be because I didn’t battle hard enough.
Indeed, policy documents in the UK, such as the 2007 National Health Service Cancer Reform Strategy (2007) and the Cancer Strategy for England (2015–20), have avoided military metaphors in policy documents and adopted instead the metaphor of the ‘cancer journey’, with different care ‘pathways’ for different patients.
It has also been pointed out that Violence metaphors can be highly meaningful and motivating for some patients. For example, Reisfield and Wilson (Reference Reisfield and Wilson2004) discuss the case of a patient who, as a professional war historian, found military imagery particularly appropriate and used it extensively and creatively in his own correspondence. In a 2013 TED Talk, Amanda Bennett, a Pulitzer Prize–winning journalist whose husband died of cancer, argues for what she calls a ‘heroic narrative of death’, in which people with cancer and their families persist in hoping for a positive outcome until death (www.ted.com/talks/amanda_bennett_we_need_a_heroic_narrative_for_death?language=en).
In this context, the MELC team set out to use corpus methods to systematically analyse the ways in which metaphors generally, and Violence metaphors in particular, are used for the experience of cancer. The team then considered the implications of the findings for the experiences of patients in particular.
9.3.1 Creating a Cancer-Related Corpus and Identifying Metaphors
The MELC team collected a 1.5-million-word corpus consisting of interviews with and online writing by members of three stakeholder groups in cancer care: patients with cancer, unpaid family carers, and healthcare professionals. An overview of the MELC corpus is provided in Table 9.3 (Semino et al., Reference Semino, Demjén, Hardie, Rayson and Payne2018: 50).
More specifically, the interviews involved
29 patients who had been diagnosed with advanced cancer (Payne et al., Reference Payne, Chapman, Froggatt, Gott and Chung2008);
17 unpaid carers who looked after a family member with a diagnosis of advanced cancer (Payne et al., Reference Payne, Ingleton, Nolan and O’Brien2009); and
16 senior healthcare professionals working in hospice or palliative care.
The online writing was produced in the period from 2007 to 2012 by
56 patients and 56 family carers writing on one particular UK-based online forum dedicated to cancer; and
307 healthcare professionals, writing on online forums or blogs.
The MELC corpus was too large to be analysed manually for the use of metaphor. On the other hand, no automated system for metaphor identification was deemed appropriate for the purposes of the project (e.g., Dunn, Reference Dunn and Gelbukh2013). The team thus adopted a combination of manual and computational analysis. They created a sample corpus consisting of approximately 90,000 words (i.e., approximately 15,000 words from each of the six sections of the corpus outlined in Table 9.3) and employed existing metaphor identification procedures (Pragglejaz Group, 2007; Steen et al., Reference Steen, Dorst, Herrmann, Kaal, Krennmayr and Pasma2010) to manually code this corpus for all instances of linguistic metaphors relevant to the experience of cancer. The linguistic metaphors were also tagged for the semantic domains that corresponded to their literal meanings – for example, Violence for ‘battle’, Journey for ‘path’ and Sports for ‘marathon’. A tailor-made database was then employed to match the expressions included under each semantic grouping to the semantic domains in the USAS semantic tagger, which is implemented in the online corpus analysis tool Wmatrix (Rayson, Reference Rayson2008), as explained in Chapter 7.
More specifically, during the manual analysis of the sample corpus, the team classified as Violence metaphors
any metaphorical expressions or similes whose literal meanings suggest scenarios in which, prototypically, a human agent intentionally causes physical harm to another human, with or without weapons. Less prototypical scenarios involve non-human agents, the threat or consequences of violence, or non-physical harm.
The linguistic metaphors that fit this definition were then matched with the corresponding USAS semantic tags in Wmatrix by means of the database mentioned earlier. This revealed that the following USAS semantic domains included expressions that could be used metaphorically to describe the experience of cancer in terms of various kinds of violent encounters (Semino et al., Reference Semino, Demjén, Hardie, Rayson and Payne2018: 100):
G3 (Warfare): for example, fight as a verb; battle
E3– (Violent/angry): for example, hit; attack
S8+ (Helping): for example, defend; protect
S8– (Hindering): for example, fight as a noun
X8+ (Trying hard): for example, struggle
A1.1.1 (General actions, making): for example, blast and confront
A1.1.2 (Damaging and destroying): for example, destroy; shatter
The team then analysed all concordance lines for each of these semantic domains in the complete corpus and identified all instances where the relevant lexical item was used metaphorically to capture some aspect of the experience of cancer. The use of semantic domain concordances meant that it was possible to identify metaphorical expressions that did not occur in the sample corpus. This does not of course mean that all Violence metaphors in the analysis would have been captured. However, as described in the following sections, a substantial number of instances were identified, and the fact that the same approach was adopted for all sections of the corpus also means that comparisons were possible.
9.3.2 Violence Metaphors and Different Stakeholder Groups
In this section we report the most relevant findings with regard to Violence metaphors. We begin with quantitative findings and then move on to qualitative observations.
The MELC team found that Violence and Journey metaphors were the most frequently used types of metaphors in all sections of the corpus (Semino et al., Reference Semino, Demjén, Hardie, Rayson and Payne2018: 84) and that Violence metaphors were the most frequently used by patients in particular.
Table 9.4 and Figure 9.2 (from Semino et al., Reference Semino, Demjén, Hardie, Rayson and Payne2018: 101–2) provide raw and normalised frequencies for Violence metaphors in the three groups of people and two genres included in the MELC corpus.
Frequencies of Violence metaphors in the corpus per 1,000 words.
Figure 9.2 Long description
The y-axis denotes frequency points from 0 to 2.25 in increments of 0.45, and the x-axis denotes the three groups: Patients, Carers, and Professionals. It reads as follows. Patients: 0.71 for Interviews and 1.8 for Online. Crers: 0/98 for Interviews and 1.61 for Online. 0.81 for Interviews and 1.33 for Online.
Violence metaphors are used by members of all three groups in both genres. However, in the online data, patients use Violence metaphors more frequently than family carers and healthcare professionals, with 1.8 instances per 1,000 words versus 1.61 and 1.33, respectively, for carers and professionals. Semino and colleagues (Reference Semino, Demjén, Hardie, Rayson and Payne2018: 102) report that this difference across the three groups is statistically significant (using a log likelihood test for uniformity: p < 0.05, 2 d.f., log likelihood = 23.22).
The MELC team considered all instances of Violence metaphors in order to establish how they are used in context. This led to two main findings. First, there is no single Violence or War metaphor where the disease is an enemy that needs to fought by the patient or by healthcare professionals, as implicitly suggested by previous literature. On the contrary, patients in particular use Violence metaphors to talk about different aspects of their experience of illness, including the relationship with cancer, the effects of treatment, and the patients’ relationship with the healthcare system. Second, while there is evidence in the MELC corpus of the potentially harmful consequences of Violence metaphors, there is also evidence that they can be meaningful and motivating for some patients, at least some of the time. The MELC team expressed this contrast in terms of the concept of ‘(dis)empowerment’, defined as ‘the process through which linguistic choices reflect, facilitate and/or undermine different kinds and degrees of agency, validation, evaluation and control, with implications for identities, emotions and relationships’ (Semino et al., Reference Semino, Demjén, Hardie, Rayson and Payne2018: 7).
Whether a Violence metaphor or, in fact, any metaphor is empowering or disempowering depends on who uses it and how in a specific context (Semino et al., Reference Semino, Demjén and Hampe2017).
In the next section we consider the different aspects of the cancer experience that patients use Violence metaphors for in the MELC data, with special emphasis on the contrast between empowering and disempowering uses (Semino et al., Reference Semino, Demjén, Hardie, Rayson and Payne2018: 105ff.).
9.3.3 Violence Metaphors and Different Aspects of Patients’ Experiences with Cancer
Violence metaphors are used by some patients in the MELC corpus to portray their relationship with cancer as antagonistic and competitive, and to express their determination to recover. These are the kinds of Violence metaphors that had been the focus of previous studies:
I don’t intend to give up; I don’t intend to give in. No I want to fight it. I don’t want it to beat me, I want to beat it.
I have not hunkered down in my trench to just merely defend myself against the demon but have picked up my sword and taken the fight to the demon
In both examples, the patient places themselves in an empowered position; they present themselves as active and focussed, and as hopeful about their outlook.
The potential for Violence metaphors to be used in empowering ways is particularly evident when patients describe themselves as fighters:
I was also fortunate that my Consultants recognised that I was a born fighter and saw my determination
This metaphorical use of fighter does not so much evoke an oppositional scenario with the illness as the enemy but rather presents the person as optimistic and ready to do everything they can to get better (cf. determination in the provided extract).
Semino and colleagues (Reference Semino, Demjén, Hardie, Rayson and Payne2018) also notice that some empowering uses of Violence metaphors involve humour, as mentioned in Chapter 5:
Don’t let the Demon get you down, spit it in it’s eye and give it a swift kick up the wahoola.
Here the cancer is menacingly described as a ‘Demon’, but the use of ‘wahoola’ as part of a Violence metaphor involving physical struggle makes light of what is otherwise a serious situation. The cancer is personified as the butt of the joke, thereby placing the patient in the empowered position of making fun of the illness. The MELC team showed more broadly how this kind of humour was employed by patients in the online data to release tension, demystify the illness, and strengthen the social bonds among contributors to the forum (Semino et al., Reference Semino, Demjén, Hardie, Rayson and Payne2018: 233ff.; see also Semino and Demjén, Reference Semino, Demjén and Hampe2017).
In contrast, when Violence metaphors are used to express the fear or prospect of not recovering, the patient is placed in a disempowered position:
I feel such a failure that I am not winning this battle
I sometimes worry about being so positive or feel I am being cocky when I say I will fight this as I think oh my god what if I don’t win people will think ah see I knew she couldn’t do it!
In both examples provided, not getting better (and therefore potentially dying of cancer), is metaphorically described as ‘not winning’, as part of Violence metaphors (cf. battle and fight in the extracts provided). In addition, in both cases, the person suggests that they feel responsible for not recovering or anticipates that others will see them as responsible. This is where Violence metaphors can do harm, as suggested by their critics. In a violent confrontation – whether a physical struggle or a battle between armies – the party that is defeated is typically perceived to weaker, less determined, or less well organised. Within a violence framing for illness, these associations are attributed to the person who does not recover, resulting in the person feeling ‘a failure’ or anticipating embarrassment for not getting better, when in fact they bear no responsibility for the course of their illness.
In the following example, in contrast, the patient is implicitly disempowered in relation to the healthcare system, as they are not being provided with the treatment (armour) that they believe they need to get better:
it must be dispiriting when you are battling as hard as you can, not to be given the armour to fight in
The MELC team noticed that the term battle, as a noun or as a verb, had a tendency to be used to suggest disempowerment, either because of extreme difficulties experienced by patients or the unsuccessful outcome of treatment (Semino et al., Reference Semino, Demjén, Hardie, Rayson and Payne2018: 109).
While it was previously known that Violence metaphors were frequently used to talk about having cancer and trying to get better, the analysis of the MELC corpus also revealed the use of Violence metaphors for the effects that cancer treatment has on the patient. In such cases the violence-related metaphorical expressions evoke scenarios dealing with personal physical aggression, such as ‘a battering from chemo’, ‘a “hammering” from medication’, or various uses of the verb ‘hit’:
They hit me with radiation for 10 days.
what did i think all my normal little cells were doing after being hit by a sledgehammer of both toxic chemicals and radiation
Here the process of being treated with radiotherapy and/or chemotherapy is presented as being on the receiving end of a violent attack. The emphasis is not so much on ‘losing’ against the aggressor but on the damage that results from the attack, especially where the metaphorical expressions suggest extreme violence, as in the case of ‘hit by a sledgehammer’. Cancer treatment is well known to have major side effects, especially in the case of chemotherapy. The use of Violence metaphors for treatment suggests the seriousness of these side effects while also conveying a sense of helplessness and disempowerment in the context of medical interventions that are intended to help the person recover or live longer.
The analysis of the MELC corpus also revealed instances of Violence metaphors where the two opponents were the patient and the healthcare system:
that first lady that was well publicised about fighting and getting the Herceptin
I will fight for Avastin.
These uses of Violence metaphors reflect the perception of difficulty and effort involved in obtaining the treatment that the patients feel they need. With regard to (dis)empowerment, on the one hand the patients place themselves in the active position of agents advocating for themselves. However, they are not in fact empowered, partly for having to argue for their own treatment at a point of extreme vulnerability, and partly because the decision-making power with regard to that treatment ultimately lies with health professionals and policy makers.
As we showed in Chapter 5, a different use of Violence metaphors for the patient’s relationship with the health system involves empowerment through humour (Semino et al., Reference Semino, Demjén, Hardie, Rayson and Payne2018: 252–5). A group of contributors to a particular thread dedicated to cancer-related humour describe themselves as a small army aiming to ‘liberate’ specific individuals from the hospital and even give each other military titles and promotions to higher ranks. This long-running collaborative joke shows the power of the combination of metaphor and humour to create distance, at least temporarily, from a situation of hardship, and to foster emotional closeness with others in the same situation.
Overall, the use of corpus methods to systematically study the Violence metaphors used by patients revealed a greater variety of uses than had been previously noticed. Among other things, this shows how patients may feel in a situation where they are ‘fighting’ on several fronts – against the illness, against the treatment, and against the healthcare system. On the other hand, while Violence metaphors can be disempowering, they can also be used in empowering ways, especially when they are combined with humour.
9.4 Conclusion
It matters if you talk about anxiety in terms of having an illness or disease or if you say you are an anxious kind of person. And it matters if you view cancer in terms of battling it or as going on a journey. This chapter has offered two techniques for analysing the ways that patients understand health conditions and their relationship to them, arguably an important component of helping patients understand, accept, and manage those conditions. The first was focused on identifying different representations around a single word in a corpus (anxiety); the second involved analysing an entire corpus while focusing on a difficult-to-find linguistic phenomenon (metaphor). Both techniques utilised quantitative and qualitative approaches, using corpus tools like Word Sketch (Sketch Engine) and Wmatrix, which were then combined with more detailed analyses of concordance lines and consideration of context. In the following chapter, we continue the consideration of representation but now move away from health conditions to the people who experience them.
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