How people talk or write about something can tell us as much about what they think and feel as the content of what they're actually saying. This is especially true in contexts where experiences are complex, emotional, subjective and potentially taboo, such as health and illness. When it comes to such experiences, the how often involves metaphor. Metaphor is a way of talking and thinking about one thing in terms of another, which can convey meanings indirectly but also vividly and concisely.
In the context of cancer, the 'war metaphor' has had a lot of bad press recently.
'"She lost her brave fight." If anyone mutters those words after my death, wherever I am, I will curse them,' began Kate Granger's piece in the Guardian in 2014. War metaphors describing the experience of patients are systematically avoided in UK policy documents on cancer, such as the Cancer Reform Strategy 2007. And the healthcare professionals interviewed in course of the Metaphor in End-of-Life Care (MELC) project, an ESRC-funded study at Lancaster University that I was part of, were all too aware of the burden that battling, fighting, beating and the like place on their patients.
But do these metaphors deserve such ostracism? And if so, what should replace them?
Received wisdom suggests replacing 'wars' with 'journeys': it's not a battle or a fight, but perhaps a difficult road. You don't win or lose, but go through it and move on, or accept that you've come to the end of the road. But is that better? And is it right for everyone?
As with so many other things, it turns out: there are no simple answers or clear-cut rules. Different metaphors are appropriate for different people at different times, so it is important to have multiple options.
The MELC team, led by Elena Semino, scrutinised 1.5 million words spoken and written by terminal cancer patients, their carers and healthcare professionals who work with them. Among other things we wanted to see how war and journey metaphors are actually used.
Unsurprisingly, there is evidence to suggest that military metaphors are indeed unhelpful at times. Patients in a military frame describe feeling inadequate if they do not get better: 'I feel such a failure that I am not winning this battle'; and use war metaphors to suggest that they don't feel in control, describing themselves as 'time bombs' while in remission, for example.
And yes, there is also evidence for the positive spin that journey metaphors facilitate: 'My journey may not be smooth but it certainly makes me look up and take notice of the scenery!'
However, we found that the difference between helpful and unhelpful expressions was not about the war versus journey contrast. The key distinction was between metaphors that empower and those that disempower the patient.
Empowerment and disempowerment in this context refers to the degree of agency that the metaphor suggests a patient has, combined with whether or not the patient actually wants to have agency in that particular instance. Agency can consist of the ability to control or influence events, and is empowering when patients actually want to have this ability.
As much as military metaphors can imply that a patient is inadequate if they do not get better or that they have absolutely no control over whether and when a cancer comes back, they can also be used self-motivationally, to present a heroic sense of self.
A cancer patient proudly comments that 'my consultants recognised that I was a born fighter'. Another says: 'I want to fight it. I don't want it to beat me, I want to beat it.'
And just as military metaphors can be empowering, journey metaphors can suggest an absence of agency, where patients would want to have it: 'I have not done so well with my own “cancer journey" through the wilderness of my own local hospitals' or 'How the hell am I supposed to know how to navigate this road I do not even want to be on'.
Moreover, military and journey metaphors are far from the only choices. Cancer can be like a 'fairground ride', a 'garden that has become overgrown with weeds', or an 'unwelcome lodger'.
It's not that fight metaphors should be rehabilitated or journey metaphors discouraged: both can do as much harm as good and nobody should be forced to see themselves in any particular way. Instead it is important to be aware of the potential (dis)empowering functions of all metaphors and to make sure that there is enough variety and choice for vulnerable people to be able to decide for themselves what to do with their cancer.
- The Metaphor in End-of-Life Care project ran at Lancaster University from 2013-2014 and was funded by UK's Economic and Social Research Council (Ref. ES/J007927/1). For more information, see the MELC project website.
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Following her cancer diagnosis in 2012, former OU lecturer Jill Reynolds wrote a series of articles about life with cancer. Read Jill's blog