Metaphor in Health and Risk Communication
Abstract and Keywords
Metaphor equates two concepts or domains of concepts in an A is B form, such that a comparison is implied between the two parts leading to a transfer of features typically associated with B (called source) to A (called target). Metaphor is evident in written, spoken, gestural, and pictorial modalities. It is also present as latent patterns of thought in the form of conceptual mappings between domains of experience called conceptual metaphor. Metaphor is found commonly in a variety of health and risk communication contexts, including public discourse, public understanding and perceptions, medical encounters, and clinical assessment. Often metaphor use is beneficial to achieving desired message effects; however, sometimes its use in a message can lead to unintended undesirable effects. There is a general consensus, although not complete agreement, that metaphors in messages are processed through engagement with corresponding conceptual mappings. This matching process can be taken as a general principle for design of metaphor-based health and risk messages.
Keywords: linguistic metaphor, gestural metaphor, pictorial metaphor, conceptual mapping, conceptual metaphor, embodied metaphor, health/illness/risk as metaphor target and source, metaphor-based understanding of health and risk, linguistic-conceptual metaphor matching, metaphor framing
Metaphor is a matter of written, spoken, gestural, and pictorial communication as well as experience and thought. Its ubiquity in naturally occurring discourse, both nonconscious and strategic, is well documented in all health and risk communication contexts, from public to intrapersonal. It inhabits the spaces of discourse/communication and individual thought with equal ease and traverses their intersections effortlessly. This quality makes it unique among the many message and person variables that constitute health and risk communication: metaphor is a property of both messages and of thinking and message processing. No other variable occupies this dual role with as theoretical and methodological clarity as metaphor. This distinctive nature of metaphor has been probed by philosophers, rhetoricians, literary and cultural critics, linguists, psychologists, communication scholars, and others with an interest in its functioning and effective use. In this article I focus on the subset of issues and findings most germane to understanding its use and role in processing and design of health and risk communication. First, as a preliminary, I provide a definition and overview of metaphor in different communication modalities and then go over metaphor in thought. Next, I discuss metaphor in four health-related contexts—public discourse, public understanding and perceptions, medical encounters, and clinical assessment—and then I look at some unintended consequences of metaphor use. Following this, I discuss the different views of metaphor processing applicable to health and risk messages. Next I discuss metaphor-based message design for health and risk communication. Finally, I end with an overview of some current methodologies that may be useful for identifying and eliciting metaphor in the health and risk communication domain.
Linguistic, Gestural, and Pictorial Metaphors
Metaphor is traditionally considered a written or spoken linguistic expression of the form A is B, such that a comparison is implied between the two parts leading to a transfer of features typically associated with B to A (Billow, 1977; Ortony, 1975). The terms A and B are seen as representing different concepts or domains and are called target and source, respectively. Analogy, simile, and personification expressions may be seen as similar to metaphor in that they also involve comparison of concepts or systems of concepts (Gentner, 1983); in contrast, metaphor is considered generally distinct from idiom, metonymy, synecdoche, and symbol, because no comparisons are involved in these expressions. A metaphorical expression may be a single phrase or a sentence, or it may be spread over multiple sentences; in this variant, it is called an extended metaphor.
Metaphor is also traditionally classified into the category of figurative expressions and contrasted with literal expressions. Metaphorical comparisons (and other similar expressions) are seen as creating concepts or aspects of concepts that do not describe truth conditions or minimal/basic meanings of terms; in contrast, literal expressions adhere to description of truth conditions or presentation of minimalist meanings of terms. The figurative-literal demarcation is no longer seen as strict, especially in the examination of human cognition, which is the view this article takes.
The term metaphor, as described in its traditional sense above, denotes a particular language device or a characteristic of language; when used in this sense, metaphor is a language property observed in written and spoken communication and is properly called linguistic metaphor.
A distinction is usually made between novel and conventional (or conventionalized) linguistic metaphor. Novel linguistic metaphors are expressions whose equation of target with a source creates new perceptions about the target; conventional linguistic metaphors are metaphors that were once novel, but with repeated use have been completely absorbed into the conventions of everyday communication and thus are not immediately recognized as metaphors. Expressions such as “face of a clock,” “heart blockage,” “health going down,” “illness starting, illness ending,” “under stress,” and “simmering with anger” are seen as literal and not typically recognized as metaphors in everyday discourse. Conventional linguistic metaphors are different from clichéd metaphors, which, although also commonly used, are readily recognized as metaphorical expressions.
Spoken communication is often accompanied by nonverbal gestures. These nonverbal gestures can also be metaphorical and are called gestural metaphors (Cienki, 1998). People often use gestural metaphors to physically represent abstract concepts. For example, hand gestures can be used to convey abstract concepts through physical space (e.g., pinched finger and thumb to say “a small improvement”) and movement in physical space (e.g., hand movement to say health status going up or down).
Pictures and images can also convey comparisons between different concepts or domains through juxtaposing or superimposing a target picture/image and a source picture/image (Forceville, 2002). These are called pictorial metaphors or visual metaphors (also sometimes image metaphor). Pictorial metaphors function similar to linguistic metaphors in that the juxtaposition or superimposition of a target and source leads to transfer of features typically associated with the source to the target. Similar to linguistic metaphors, pictorial metaphors can also be novel or clichéd and can also convey conventional metaphors (e.g., pictorial depiction of general health going up or down), although these are typically easy to label as metaphors.
Conceptual Mapping, Conceptual Metaphor, Embodied Metaphor
The contemporary view of metaphor (Lakoff & Johnson, 1980, 1999) sees it intimately as a matter of individual cognition, as opposed to primarily or only a matter of language, communication, or culture. Metaphor, in this view, is a matter of thought that leads to its presence in discourse.
According to this view, the cognitive system consists of correspondences or mappings between different domains of concepts or experiences, such that concepts or experiences that are abstract or amorphous in some way (target) are mapped to structural patterns of simpler or clearer experiences (source). As a result, prior knowledge in the conceptual system is organized as a system of conceptual mappings.
These conceptual mappings are called conceptual metaphors. For example, the complex domain of “relationship” (target) is understood using a mapping to the relatively simpler domain of “journey” (source), and the system of mappings between the two domains is preserved in long-term memory. Thus, the conceptual metaphor “illness is a journey” is a label for the mappings that exist in the long-term memory between the knowledge about the domains of “illness” and “journey,” namely, patient and medical provider correspond to travelers, illness corresponds to the vehicle, patient and medical provider common goals (e.g., curing of illness) correspond to their common destinations on the journey, and difficulties in the curing of illness correspond to impediments to travel in the journey.
A majority, if not all, of conceptual mappings and hence conceptual metaphors are seen as originating through embodied metaphors. In this formulation, conceptual mappings originate developmentally in early childhood experiences through co-activation of concrete, sensorimotor perceptual concepts (e.g., unpleasant tactile experience of a rough surface), and abstract concepts (e.g., inattention by caregiver) resulting in a conceptual mapping and conceptual metaphor of “rough person, rough day.” These early life conceptual mappings between bodily sensations and abstract concepts are coded in neural connections and serve to interpret and produce linguistic, gestural, and pictorial metaphors later in life.
A Note About Terminology: Discourse, Communication, Language
In this article for reasons of ease of reading, I will use the terms discourse and communication interchangeably. This is, however, not the case in the literature from several disciplines, especially linguistics and philosophy. As a broad stroke and glossing over many finer details, in these areas discourse is a body of textual output in particular domains (e.g., political discourse) and communication is the social context of discourse production and reception that includes the attitudes, beliefs, and perceptions of interactants. A third term, language, is sometimes inadvertently used interchangeably with discourse and communication; however, this is a narrowly defined concept that denotes the set of symbols and syntax that constitute sentences or groups of sentences.
After providing above an overview of the different ways metaphor appears in communication and thought in a general way, I next turn to discussing metaphor more specifically in the health and risk communication context. I will first examine contexts of use, then views of processing, and finally message design.
Contexts of Metaphor Use
In the A is B target-source equation, health/risk as a concept can be placed both as the target and as the source in different metaphors. Sometimes, at a societal discourse level, the health/risk-as-target and health/risk-as-source metaphors can interact to reinforce particular ways of seeing the world. Typically, health/risk occurs as the metaphor target, and its use in this sense is prevalent in contexts such as public discourse, public understanding and perceptions, medical encounters, and clinical assessment. It should, however, be noted that despite its prevalence, metaphor is not always benign and its use can sometimes lead to undesirable consequences.
Health/Risk as Target, as Source, and Their Interaction
Metaphors in the health and risk context can consider some aspect of health or health condition as the target (A) in the A is B equation. For example, the course of a disease is mapped to a journey (i.e., moving from well-being to ill health and back to well-being as movement from one point to another in physical space), or the treatment of an illness is mapped to a war (illness as an enemy that invades the body and is defeated by medical drugs). The focus of the article is on these metaphors.
However, sometimes health, illness, disease, and other terms from these domains, such as AIDS, cancer, obesity, psychiatric issues, and disability, can function as the source term (B) in the A is B equation. Called health or illness or disease metaphor, concepts from health/risk domains are mapped to other domains, such as the environment (e.g., environmental health), ecology (e.g., diseased ecosystems), society (e.g., ills of society), politics (e.g., diseased polity), and economy (e.g., economic health). Such metaphors occur in everyday discourse as well, often as conventional metaphors, to convey negative affect (e.g., cancerous policy, fat chance, crazy thought, lame idea).
As a societal process, the interaction of health and illness as a target and health and illness as a source in different metaphors can amplify certain meanings. For example, B. Meisenberg and W. Meisenberg (2015) discuss, in the domain of politics and public policy, how cancer is commonly used to describe threats (e.g., international terrorism) as serious, increasing, and deadly. The authors note that this cancer disease metaphor conveys to the public that intense and prolonged countermeasures are required on an ongoing basis; while this may be politically useful, the metaphor also conveys to people outdated notions of cancer therapy, that overly aggressive treatments, monitoring, and surgeries are required as a routine. Current best practices for dealing with a cancer diagnosis eschew such efforts and are moving toward a “wait-and-see” approach in many instances. Thus, as the authors conclude, the target and source may become interchangeable over time in societal discourse (terrorism is like cancer from political discourse; cancer is like terrorism from health and risk discourse) and detrimentally affect the general public’s views of cancer therapy.
The vast majority of metaphors of health and risk are found with health/risk and illness functioning as the target in the target-source equation. Such metaphors have been studied in a variety of communication contexts, which primarily include public discourse, public understanding and perceptions, medical encounters, and clinical assessment. Next, in each of these contexts, I selectively note mostly recent studies that are international in scope and which provide a sense of the range of work that may be considered commonplace in the context.
Analyses of public discourse show presence of novel linguistic metaphors as well as conventionalized linguistic metaphors that point to latent mappings between domains that tacitly structure the discourse. These metaphors have been shown to be embedded in media debates about health care policies; media coverage of diseases such as HIV/AIDS, SARS, influenza, cancer, osteoporosis, and diabetes; discourse emanating from government agencies and large healthcare institutions; and health-related scientific texts, such as on genetics, and medical education texts. Here I highlight some studies that offer critiques of such discourse.
Media coverage of health and risk often includes metaphors that function to shape the coverage, in ways perhaps that may be unintended. For example, a study (Collin & Hughes, 2011) of the coverage of hypertension in French-language Canadian newspapers showed that features of the disease, such as severity and unpredictability of consequences, were accentuated through metaphors and that excessive fear was created by some newspapers through use of fear-inducing metaphors and personifications. Similarly, another study (Burnett, Johnston, Corlett, & Kearney, 2014) examining British newspaper coverage of an outbreak of an intestinal infection Clostridium difficile showed use of monster and war metaphors that presented victims, villains, and heroes, which subsequently evoked heightened perceptions of vulnerability, impact, blame, and conflict. Another study (Bielenia-Grajewska, 2015), looking at risk cognition discourse in the context of food-borne illnesses, found in a sample of Italian newspapers extensive use of metaphors such as disease is a war, disease is a sport, disease is a physical entity, disease is a journey, and disease is a natural disaster that drew attention to different aspects of food-borne diseases and hence influenced risk cognitions sometimes contradictorily. Similarly, Tierney, Bevc, and Kuligowski’s (2006) analysis of U.S. newspaper reports of Hurricane Katarina showed the dominant metaphors for describing the disaster were civil unrest and urban warfare, which tended to make salient police and militaristic responses rather than humanitarian interventions.
Metaphors found in discourse related to public health interventions also may not always be beneficial. For example, Hawe (2015) argued that the standard pipeline metaphor of health interventions, where proven knowledge from laboratories and other research flows along a “pipe” to eventually reach its destination of practice in a target population, limits intervention effectiveness. Words such as “dissemination” and “diffusion” suggest that knowledge originates in one location and is moved to another location where it is put to practice; also, this process is associated with a fear that the integrity of the knowledge may be compromised in its flow and end use by practitioners. The author argued that instead of the pipeline metaphor, a complex systems approach, where the laboratory and intervention location are part of the same system and local-level adaptations are part of the system process, may yield better intervention results. Seeking a similar change in conceptualization of public health interventions, Dodge (2008) argued that current metaphors for youth violence, such as superpredator, quarantining the contagious, human as computer, and chronic disease, are inconsistent with scientific evidence about how chronic youth violence develops; in addition, these metaphors suggest inaccurate or harmful responses to the problem. He proposed new metaphors that more accurately reflect the science of child development to shape interventions: preventive dentistry, cardiovascular disease, injury and victims, and public education for illiteracy. In another instance, Jensen and King (2013) analyzed the Understanding AIDS document, the first and only direct mailing sent to every private home in the United States in 1988 by C. Everett Koop, the Surgeon General at that time, and showed how it constructed a heightened perception of risk of the disease through the use of what they called authoritative metaphors that compared AIDS to unprecedented plague and war. Along the same lines, Guttman (2014), looking at campaign materials for road safety from several countries, identified various metaphors and pointed out that these, along with other campaign messages, reinforce individual level cognition, affect, and risk conceptions instead of foregrounding the normative, structural, and cultural factors that undergird safety.
Public Understandings and Perceptions
Studies investigating the public’s talk and thinking reveal metaphor-based understandings that can provide input into development of public health communication and help explain public opinion. Similarly, studies of perceptions of metaphorical messages from health-related interventions can aid in the creation of more effective messages.
Examining metaphor-based knowledge structures may be especially useful for understanding culturally grounded perceptions related to public health issues. As an example, Dyall, Hawke, Herd, and Nahi (2012) found that for the Maori in New Zealand the metaphor of housework was most consonant with public health action regarding gambling. Similarly, Li, Lau, Holroyd, and Yi (2010), in their study of sociocultural facilitators and barriers to condom use among men who have sex with men in Guangzhou, China, found that a barrier was that condom use served as a metaphor of an inferior relationship that was distant and lacked intimacy. Along the same lines, Afifia et al. (2013) found that a facilitator for increasing use of waterpipe tobacco use, especially among women, was the metaphorical conceptualization of a waterpipe as a secret keeper and best friend, and comparison of smoking gatherings to get-togethers for playing backgammon and card games.
Research has also investigated how metaphor-based knowledge structures affect opinions of public policy. In a study (Barry, Brescoll, Brownell, & Schlesinger, 2009) examining how the public’s metaphor-based beliefs about the causes of obesity affect their support for obesity-related policies, a national U.S. survey found that metaphors people use to understand obesity (obesity as sinful behavior; as a disability; as a form of eating disorder; as a food addiction; as a reflection of time crunch; as a consequence of manipulation by commercial interests; and as a result of a toxic food environment) explained their level of support for 16 different policies (categorized as redistributive, compensatory, and price-raising after a factor analysis) to curb obesity beyond levels attributable solely to demographic, health, and political characteristics.
Research (Phillips, Guenzel, & Bergen, 2006) has also examined the discourse of opponents of anti-smoking campaigns and found metaphors that ridiculed harm reduction, such as the use of smokeless tobacco as an alternative to smoking compared to jumping from a 3-story building rather than 10 stories, or to shooting oneself in the foot rather than the head. The authors’ analysis showed how such metaphors mislead about the actual risk levels of smokeless tobacco use and how to counter them.
The public’s responses to strategically designed anti-smoking pictorial metaphorical messages are varied. In a study (Wakefield et al., 2013) pre-testing anti-smoking television advertisements with 18- to 34-year-old smokers in 10 low- to middle-income countries, a disgust-provoking metaphor to demonstrate tar accumulation in smokers’ lungs was generally perceived as effective across all countries, but the perception of effectiveness of a visual metaphor for lung disease was more variable, which the authors speculated may be due to a lack of understanding of a complex disease term that accompanied the visual component. Similarly, Cameron and Williams (2015) in their online survey of graphic anti-smoking warnings in the United Kingdom found that metaphors (e.g., a wrinkled apple to depict premature aging of skin caused by smoking) decreased perceived effectiveness. In contrast, a two-phase study (Hoek, Gifford, Maubach, & Newcombe, 2014) conducted with women in the United States who smoked during pregnancy showed that metaphors drawn from the women’s experiences (first phase) were quite effective as anti-smoking messages (second phase) in reducing counterargument and stimulating critical reflection and negative emotional response toward smoking.
A recent line of research has looked at metaphor in the context of increasing rates of participation in medical clinical trials, especially in underserved populations. Morgan, Mouton, Occa, and Potter (2016) in their study of verbal strategies used by recruiters for clinical trials in the United States found metaphor to be used commonly to convey potentially frightening medical procedures and tests in terms of more familiar or acceptable medical experiences. Krieger (2014) in a study with low-income older rural women in the United States who either had been diagnosed with cancer or were caregivers for a person with cancer found clinical trials to be perceived negatively metaphorically as treatment by trial and error, patients as guinea pigs, and treatment as last resort. The study also found unfavorable responses to recruitment messages that equated randomization with the roll of a die or used other gambling language. To increase understanding of randomization in the same population as the previous study, Krieger, Parrott, and Nussbaum (2011) conducted an experiment that tested three messages: low-literacy definition, standard metaphor (i.e., flip of a coin), and a culturally derived metaphor (i.e., sex of a baby). The results showed the last metaphor having the most effect under conditions of low attention to messages. Along the same lines, Gazzinelli et al.’s (2010) pre-post design study to investigate enhancing of comprehension of informed consent for a vaccine trial in rural Brazil through use culturally relevant analogies (daily experiences of cultivation of cassava, and the making of flour, sweets, and cheese) showed increased knowledge of the planned research protocol.
Studies have also examined interpersonal discourse to identify metaphors used in the medical communication context. These analyses have uncovered metaphors and analogies in self-reports of symptoms provided by patients; explanations of disease and risks of procedures given to patients by physicians and nurses; communication by medical caregivers with patients, especially those at the end of life; sharing of information by patients with other patients in one-on-one and group settings; and information exchange among members of medical teams.
In a review of the literature on metaphor in cancer discourse by doctors, nurses, patients, and family caregivers, Harrington (2012) found military and journey comparisons to be most common along with natural disaster, animals, and plants; she also found that the use of metaphors leads to both positive and negative effects. Along the same lines, Casarett et al.’s (2010) analysis of 101 audio-recorded conversations between 94 patients and 57 physicians showed presence of 268 metaphors and analogies; in addition, patients’ rating of their physician’s communication skills showed that use of metaphors and analogies enhanced these judgments. A study (Gibbs & Franks, 2002) looking at patient use of metaphors found that to make personal and communicative sense of their life struggles and disruptions, cancer patients used multiple, even contradictory, metaphors to cope with the many negative aspects of their experience.
Studies have also looked at whether use of metaphors does indeed facilitate conveying of medical information. Galesic and Garcia-Retamero (2013) conducted two experiments with national probability samples in the United States and Germany to investigate communication of medical information to people with different levels of numeracy abilities through analogies for preventive treatment (e.g., Gritagrel is to stroke/Zendil is to gum inflammation as broccoli is to cancer; Gritagrel is to stroke/Zendil is to gum inflammation as flu vaccine is to flu) and a screening test (e.g., PSA test is to prostate cancer/mammography screening is to breast cancer as cough is to pneumonia; PSA test is to prostate cancer/mammography screening is to breast cancer as metal detector is to a weapon). The results overall showed that helpful analogies had a high similarity of relationships between objects in their target and source and those with highly familiar sources. Along the same lines, Barilli et al.’s (2010) experimental study in Italy of use of analogies by medical doctors to convey the small risk probabilities of contracting malaria and hepatitis A when traveling to Africa showed reduction of risk perceptions as expected, although only in some of the experimental conditions. An experimental study (Martin, Brower, Geralds, Gallagher, & Tellinghuisen, 2012) investigating metaphor usage in literature handed out by doctors found that use of a pictorial metaphor (e.g., speedometer) with narrative statement compared to a narrative statement alone fared better in enhancing the recall of the effects of a medication.
Exchanges in therapeutic or healing settings often instruct clients to develop a personal or life metaphor and use it in a deliberate manner to alter their subjective experience and behavior (e.g., McMullen, 2008; Tay, 2016). Such a metaphor is said to aid in self-awareness and self-understanding, communication and expression of mental states, and the re-formation of self-identity.
Studies have also looked at use of metaphors in medical work teams. Warne and Stark (2004) found metaphorical descriptions constructive for thinking about team formation, structure, and relationships with users of the team’s services. Similarly, Hilligoss (2014), looking at conceptual models governing patient handoffs by the emergency department to inpatient services at a hospital in the United States found four metaphors, sales, sports and games, packaging, and teamwork with corresponding interpretive frameworks of handoff as persuasion, handoff as competition, handoff as expectation matching, and handoff as collaboration.
Clinical Assessment Tool
Although not strictly a communication context, metaphor is also used as a tool in clinical assessment. It is used as a diagnostic to objectively assess the state of neurological diseases and to assist patients self-report their inner feelings states.
Processing and comprehension of linguistic metaphor, and other figurative language such as proverbs, has a long history in diagnostic measurement of abstract thinking in patients who suffer from impaired cognitive and language abilities. Research suggests that such patients’ inefficient processing of metaphorical and other figurative language, especially that is novel, may provide insight into the functioning and thereby diagnosis and intervention of their conditions, such as Alzheimer’s and dementia, Asperger syndrome and autistic spectrum disorders, schizophrenia spectrum disorders, and Tourette’s syndrome. For example, Rapp and Wild (2011) in their review of evidence examining nonliteral/figurative language (proverb, metaphor, metonymy, idiom, irony, sarcasm) comprehension in Alzheimer’s disease and related disorders found strong evidence of deficits in nonliteral language comprehension in dementias. They concluded that when applied correctly, nonliteral language is a useful diagnostic tool to evaluate language and abstract thinking in dementias.
Metaphor, almost always in the form of pictorial metaphor, is also used for chronic pain assessment and enhancing positive motivation for change. For example, Stones and Cole (2014) modified an existing tool to include metaphors (abstract circle, and concrete circle as a bus wheel to convey “move your bus of life”) to help patients talk about their chronic pain and its relationship to a range of other symptoms. The authors suggest that the tool could also be used to motivate change for management of not only chronic pain but also other similar conditions like irritable bowel syndrome. Similarly, Sensky and Büchi (2016) reviewed the Pictorial Representation of Illness and Self Measure (PRISM) tool for assessing subjective suffering and found it to be validated with patients in a variety of settings and cultures. The tool uses visual metaphors and yields both quantitative and qualitative measures of salient appraisals, beliefs, attitudes, and decision-making related to personal suffering. Pictorial metaphors can also be used for assessing suicide risk factors. For example, Alyami et al. (2016) developed an innovative visual metaphor–based tool for use by clinicians to explore suicide risk factors while conducting a clinical assessment.
In addition to being a resource, metaphor can be a liability. Public understandings, especially of scientific and technical issues, can be incorrect, which can lead to unintended impacts of messages. For example, Bostrom (2008), investigating how people mentally modeled risks associated with lead paint hazard, smallpox disease and vaccine, and global climate change found frequent use of analogical and other comparisons to familiar issues (e.g., lead paint with mercury; smallpox with chickenpox). However, these comparisons led to often erroneous inferences about the risks and options for testing and mitigating the risks.
As noted above, studies in the public discourse context foreground the problematic metaphorical content of messages, assuming that such content can lead to undesirable effects in the public such as promoting unnecessary fear, heightening stigma, and reproducing myths. Unlike this situation where there is a match between problematic content and problematic effects, there are circumstances where intended positive metaphorical content can lead to unintended detrimental effects. As an example, Lubinga, Maes, and Jansen’s (2016) experimental study with young women in South Africa using a novel metaphor-based message advocating faithfulness to one sexual partner as a means of HIV prevention showed that conversations about the metaphorical meaning of the message did not decrease undesirable beliefs and in fact reinforced one such belief. Similarly, Basso and Oullier’s (2011) cautionary analysis of what they called a puzzling (i.e., novel) anti-smoking pictorial metaphor in France comparing the tobacco industry to a sexual predator showed that the advertisement perhaps damaged the anti-smoking cause and had to be rapidly pulled from circulation because its meaning was not compatible with cultural norms of public discourse, even though the message did not necessarily cause any consternation in the target audience of young people.
Views on Metaphor Processing
As seen above, metaphor is pervasive in a variety of health and risk communication contexts. However, there is no agreement among researchers yet about the cognitive mechanisms that are engaged to interpret metaphorical messages. Next, I provide an overview of the main views of metaphor processing as applicable to health and risk communication.
Is all metaphor in communication processed by cross-domain conceptual mappings? An answer in the affirmative is fairly widespread; however, some researchers have taken the opposite position that most of metaphor in communication is processed similar to how meanings of ambiguous nonmetaphorical words are deciphered, that is, through the process of lexical disambiguation that applies in general to all ambiguous language. Several strong theoretical critiques and a few empirical studies provide support to this alternate position; on the other hand, the results of a large number of empirical studies support the view that the cognitive mechanism for understanding and producing all metaphors is conceptual mappings.
Studies using health-related topics and experimental stimuli show that conceptual mappings are evoked during metaphor interpretation. The exact process proposed is that metaphor-in-message concords with metaphor-as-conceptual-mappings, leading to interpretation of the metaphorical message; if there is no concord, metaphor interpretation does not occur. Labeling this process variously as metaphor fit, metaphor matching, metaphor resonance, metaphor coherence, and metaphor framing, several studies (e.g., Chen, McGlone, & Bell, 2015, looking at colon cancer; Keefer, Landau, Sullivan, & Rothschild, 2014, looking at depression; Sopory, 2005, looking at alcohol effects) have found full or partial evidence for this process by showing that people can conceptualize abstract ideas in terms of bodily states (i.e., embodied metaphors), even if they are not currently experiencing those bodily states. Examining only language-based (and not bodily state) metaphorical framing, Hauser and Schwarz (2015) experimentally investigated whether use of enemy and war metaphors would affect intentions to undertake cancer prevention behaviors such as avoiding smoking, alcohol, and fatty foods, which are self-limiting actions not consistent with actively fighting an enemy. Results showed that, as expected, such metaphors decreased prevention intentions; however, when the metaphorical language was modified to imply prevention as a means of fighting an enemy, prevention intentions were enhanced. Similarly, Scherer, Scherer, and Fagerlin (2015), looking at flu vaccination, found that both novel metaphors (flu as a wild beast that preys on the body; as a riot that revolts against the body) and conventional metaphors (e.g., flu as an attacking army that invades the body) increased behavioral intentions toward getting a flu vaccination
The embodied metaphor perspective has also been integrated with health-related theories. Kaspar (2015) investigated the influence of the conceptual metaphor “heavy is important” by manipulating the feeling of amount of weight held in hands (light, heavy clipboard) and then seeing its effect on the ratings of the cognitive components of the protection motivation theory (e.g., perceived severity) in the context of skin cancer prevention. The results showed that the sensing of higher weight increased the importance of several, but not of all, components as hypothesized.
El Refaie (2015) extended this metaphor matching perspective to propose a four-level metaphor coherence processing framework for creating effective health campaigns. According to this yet-untested proposal, a successful metaphor coheres in four ways during its processing: experientially, with embodied experience and cultural knowledge; internally, being logical and consistent in its implications; externally, in its relationship with the rest of the message/text; and narratively, with the overall story being told by the message/text in its totality.
Studies have also used general social psychological and communication theories and models of message processing to explain the specific effects of metaphors. Sopory and Dillard (2002) in their meta-analysis of metaphor and persuasion identified six processing explanations for the persuasive advantage of metaphor over literal language: pleasure or relief, communicator credibility, reduced counterarguments, resource-matching, stimulated elaboration, and superior organization. The meta-analysis provided the most support for the last view. Research in the health domain uses these explanations and variants to shed light on metaphor processing. For example, Cameron and Williams (2015) in their study to ascertain effective features of graphic anti-smoking warnings hypothesized and then found that metaphorical images were ineffective due to positive reactions (i.e., pleasure), which reduced effectiveness in discouraging smoking. Hoeken, Swanepoel, Saal, and Jansen (2009) proposed that metaphors not only stimulate individual pleasure and cognitive elaboration because they pose a puzzle to be solved, they also stimulate conversations about the metaphor meaning that can lead to enhanced health campaign effectiveness. Investigating a process not covered in the meta-analysis, He, Chen, and Alden (2010) in their study of use of concrete and abstract metaphors in anti-smoking messages found that concrete metaphors exert their effects through mental imagery.
Recently, Ottati, Renstrom, and Price (2014) proposed a model of metaphor processing in the political domain that may have utility for health and risk communication. Called the metaphor framing model, it includes two basic cognitive processing steps, metaphor activation and application. In the first step, the root metaphor (i.e., metaphorical conceptual structure) is activated by the metaphorical message. Based on the content of a message, the model posits five routes to activation: root metaphor explicitly stated, surface metaphorical cues, surface metaphorical cues implied, nonmessage priming of metaphor (e.g., priming of bodily states prior to message reception), and individual difference chronic accessibility of metaphor. In the second step, the activated root metaphor and all its implications are applied to the issue at hand, leading to two sorts of effects—on judgments and process styles. The effect on judgment can be through five routes: direct application, selective processing, guided interpretation, guided attribution, and metaphor rejection. The effect on process style can be through two routes: motivation to systematically process and ability to systematically process. What this model proposes is that, although metaphorical conceptual structures may be implicated in the interpretation of linguistic metaphors, the process whereby any message effects may be realized is not a matter of just linguistic-conceptual metaphor matching. The activation of a conceptual metaphor may depend on several factors, not all of which are message-related. Once activated, the conceptual metaphor can have varied, as opposed to a singular, effects dependent on different conditions. It could be that the model presents an unnecessarily complex view of metaphor processing that may not be borne out after testing. However, at the minimum the model alerts us to closely analyze the health and risk communication situation where a metaphor-based message is to be employed.
Metaphor-Based Message Design
Metaphorical design decisions to increase message effectiveness are often linked to the theoretical commitments implied by a processing perspective. By far, the conceptual mappings/conceptual metaphor perspective dominates in determining the content of metaphor-using messages. On the basis of the theoretical commitment that metaphoric message content will be interpreted by a conceptual metaphor, the standard blueprint for designing a message is that the metaphorical language should cleanly match a conceptual metaphor. The key, here, then for message design in the health and risk communication context is to accurately identify the specific conceptual mappings that operate in the discourse and minds of the target audience of a message.
While designing a message, it is important to keep in mind that the conceptual mappings can be entrenched and fluently accessible or entrenched but available only after priming; can be embodied in bodily states and the embodied metaphors can be primed prior to message reception or evoked by the message itself; and instead of being retrieved from memory can be dynamically created based on novel information in a message. Of particular importance is remaining aware that ongoing sensorimotor (i.e., bodily) experiences may have an appreciable influence on the interpretation of metaphoric messages. This may be especially salient in medical and therapeutic settings.
Metaphorical message design considerations can also be guided by empirical results and not by the implications of a theory or model. For example, the results of the Sopory and Dillard (2002; see also Van Stee, 2016) meta-analysis showed that a novel metaphor placed at the start of a message as opposed to at the message end was more persuasive. Thus, a message designer could take this empirical finding to create an effective metaphorical message without recourse to a theory.
Message design decisions also should take into account the presence of moderator and mediator variables that may point to boundary conditions for desired effects in particular processing contexts. Such variables may be of two strains: variables that take as a starting point a theory that has been applied to a wide variety of messages and that hence is seen applicable to metaphor as well, and variables that take a characteristic of metaphors as a starting point and then show how they speak to this characteristic. Although both types may be suitable to take into account for message design parameters, the latter type has a greater potential to advance explanations of metaphor processing.
Message design considerations also include choice of linguistic and pictorial metaphors, as well as mixed linguistic-pictorial metaphors where the linguistic component may convey additional information or clarify the meaning of the pictorial metaphor. When designing video messages (i.e., moving images as opposed to static images in pictorial metaphors), designers should remain sensitive to gestural metaphors and how these might evoke conceptual mappings that may enhance or inhibit message effects.
Metaphor Identification and Elicitation
As suggested by the above sections, health and risk communication researchers need to identify metaphor, especially conventional, to analyze written, spoken, and pictorial discourse as well as to create metaphor-based messages. Metaphor can be identified using general intuitive processes, such as thematic analysis, developed in qualitative research or by rigorous systematic methods developed for this specific purpose in metaphor studies. Here I provide an overview, as a brief introduction, to some rigorous metaphor analysis methodologies developed in the areas of cognitive linguistics and corpus analysis that health and risk communication scholars interested in metaphor research may want to adopt.
The Metaphor Identification Procedure (MIP; Pragglejaz Group, 2007) focuses on identifying metaphorically used words in discourse. The method consists of recognizing the “metaphorical potential” of linguistic expressions on the basis of a simple semantic test: a word is considered metaphorical when its most basic, physical, or concrete sense stands in contrast to its current in-sentence contextual meaning and a meaningful comparison is drawn with other words. A version of the MIP called Metaphor Identification in Language (MIPVU; VU standing for Vrije Universiteit, the university at which this method was developed; Steen et al., 2010) also focuses on the metaphorical potential of linguistic expressions used in discourse and identifies metaphor-related words on the basis of contrast and comparison between the basic and the contextual sense of an expression. The procedure is more systematic and explicit in its decisions than MIP, leading to greater reliability. In addition to individual metaphorically used words, it also allows annotation of more complex forms of metaphor. The MIPVU also facilitates identification of metaphors that may be operating as mental entities through a five-step method. The steps are: identification of metaphor-related words; identification of metaphor-related propositions; identification of open metaphorical comparison; identification of comparison/analogical structures; and identification of cross-domain mappings, which indicate mental structures.
The Metaphor-led Discourse Analysis (MLDA) method, also called the discourse dynamics approach, for metaphor identification (Cameron et al., 2009) is based on the complexity/dynamic systems perspective. The procedure has four steps: transcription of discourse; metaphor identification; coding of metaphors; and finding patterns of metaphor use from coded data. In this approach, connections between people’s ideas, attitudes, values, and language use are explained through patterns of linked linguistic metaphors found in discourse data. The method requires reasoning for all decisions at all stages to be made explicit to maximize the trustworthiness of the results.
The two approaches may be considered complementary but with different emphases. The MIPVU focuses on individual words and clauses as the unit of analysis to identify words used metaphorically which have a basic meaning. The MLDA, instead of identifying metaphorically used words, focuses on single and multi-word units that serve as source for a metaphor.
The intent of the above methodologies is to discover metaphor in corpora of texts and discourse that has been generated as naturally as possible and has not been guided toward metaphor production in any manner. In contrast, the Zaltman Metaphor Elicitation Technique (ZMET; Zaltman & Coulter, 1995) explicitly seeks metaphorical verbalizations. This technique, based on sets of visual images that respondents employ as metaphorical sources, uses visual projection with semi-structured in-depth interviews to facilitate respondents’ generation of narratives to explain their personal constructs, ideas, feelings, and perceptions related to objects, topics, and issues. The metaphorical projections are used to identify key themes. In the health and risk context, Calder and Aitken (2008) have used the technique to identify themes related to knowledge and perceptions of dangers of skin tanning, and Hernandez (2013) have used the method to elicit nonsmoking college students’ perceptions of graphic health warnings related to smoking.
Metaphors are routinely used in all health and risk communication contexts, from public to interpersonal to intrapersonal, to enable a message achieve its intended outcomes. Research to date has broadly supported the view that a substantial proportion of thinking, perhaps all of it, is metaphorically structured through conceptual mappings and metaphorical messages derive their effects through engagement with these mental structures.
For health and risk communication researchers, the challenge will be to determine how to theoretically bring together the conceptual metaphor view with what is known about message effects, processing, and design in communication and social psychological research. At this time, we can safely say that a general principle of metaphor message design is matching of metaphorical message content with corresponding conceptual mappings. There is sufficient accumulated evidence showing that basic metaphoric schemes found in discourse correspond to such themes in thought that rest on embodied metaphors, which originate from early childhood experience and perhaps also from exposure to metaphoric discourse during this period. However, at this time we are far from clearly knowing the boundary conditions that offer theoretically firm guidance on effective message design.
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