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Cultural competence and metaphor in mental healthcare interactions: A linguistic perspective
Patient Education and Counseling 102 (2019) 2192–2198
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Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Cultural competence and metaphor in mental healthcare interactions: A linguistic perspective Dalia Magaña Department of Literature, Languages & Cultures, School of Social Sciences, Humanities & Arts, University of California, Merced, 5200 N. Lake Road, Merced, CA 95343, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 December 2018 Received in revised form 10 June 2019 Accepted 12 June 2019
Objectives: The aim of this study is to understand how Spanish-speaking patients conceptualize mental health issues. This study uses a linguistic perspective to focus on how 23 Mexican-origin patients and their doctor talk about mental health during psychiatric interviews conducted in Spanish and how they negotiate cultural barriers. Methods: This work analyzes when the doctor and his patients reference metaphors (e.g. feeling “empty,” feeling “low”). Metaphors are pervasive in all cultures and languages and reveal important information about people’s attitudes and feelings about a range of conditions and circumstances. Results: This work demonstrates the role of metaphor and linguistic analysis in uncovering culturally based constructions of mental health. The results reveal that the doctor and patients reference different sets of metaphors, which, at times, causes miscommunication. Conclusions: Practitioner awareness of how patients use metaphorical expressions in health is crucial for promoting advanced cultural and linguistic competence and ultimately, patient-centered care. Practice implications: The main findings have implications for health communication with minority groups such as Spanish-speaking Latinos/as in the United States. Practitioners working with Spanishspeaking patients should be familiar with how Latinos/as conceptualize health and how to avoid or repair confusion caused by cultural barriers. © 2019 Elsevier B.V. All rights reserved.
Keywords: Linguistic analysis Patient-centered communication Conceptual metaphor Psychiatric interviews Cultural competence Latino mental healthcare
1. Introduction 1.1. Latinos/as, language/cultural barriers, and health disparities The Latino population faces numerous health disparities due in part to language and cultural barriers. Latinos/as are the largest minority group in the United States, at 17% of the total population or 54 million and growing [1]. Almost a third of this group is not fluent in English [1]. Language barriers have a direct impact on their healthcare and health outcomes and contribute to disparities. Although Latinos/as have a similar prevalence of depression as non-Latino Whites, Latinos/as have a lower likelihood of diagnosis and more rarely follow-up on appointments or receive treatment [2–4]. In dealing with depression, Latinos/as may experience stigma and embarrassment/shame (vergüenza) [5,6]. Latinos/as in the United States may also avoid seeking care because they have concerns about cultural misunderstandings and confronting racism [7]. Scholars attribute under-diagnosis and lower utilization rates among Latinos/as in part to the lack of culturally adapted
E-mail address: [email protected] (D. Magaña). https://doi.org/10.1016/j.pec.2019.06.010 0738-3991/© 2019 Elsevier B.V. All rights reserved.
and effective assessment tools reflecting knowledge of patients’ health beliefs [8,9]. Language plays a central role in healthcare disparities. Bilingual patients whose first language is Spanish are evaluated differently when evaluated in English versus Spanish [10]. In what Martínez [11] terms the linguistic gradient, language ability correlates with likelihood of seeking and receiving mental healthcare. For example, in one study, 43% of Latinos/as who spoke English only sought and received mental health care compared to 35% of bilingual Latinos/as and 8% of those with limited English proficiency [11,12]. For Spanish-dominant Latinos/as, low health literacy, the ability to obtain, process, and understand basic health information and appropriate services poses an additional barrier [13,14]. Unfortunately, those with low health literacy are less likely to obtain and engage in mental healthcare and have poorer health [14,15]. To confront some of these disparities, it is crucial to train providers in linguistically and culturally appropriate ways in order to strive to offer more adequate patient-centered care. This is particularly important given the underrepresentation of Latinos/as among practitioners. Only 5% of medical school graduates are Latino/a and that only 2% of full-time employed physicians are
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Hispanic [16]. Medical Spanish courses and materials have become more common, reflecting an understanding of the need to train providers to have language and cultural competence, but most target beginners [17]. Beginner instruction does not generally impart cultural competency, which requires in-depth, advanced understanding of language use. Cultural competency requires discussion of practical issues that medical professionals encounter. including knowledge about people’s social values and how people discuss issues in colloquial or regional ways, such as regionalisms and colloquialisms [17]. It is important to understand the local terms communities use when they describe their health concerns and social suffering [18,19]. As psychiatrist Carlat [20] recommends, colloquialisms can empower patients to speak about their issues during their medical encounters in spite of stigma. Local terms for health symptoms and conditions may vary according to ethnic/racial groups, even those who speak the same language. Mexican-origin people may ascribe depression to nervios, a broad category of mental health issues attributed to interpersonal imbalance [21,22]. Nervios symptoms include bouts of crying, tension, listlessness, loss of appetite, irritability, and sadness, meeting the clinical definition of depression [21]. Mental healthcare providers working with Mexican-origin groups benefit from possessing this knowledge, which enables them to offer culturally competent and patient-centered care. Few studies have investigated language and cultural barriers during medical interactions or how patients express their health concerns using linguistic approaches, though linguistic analysis promotes patient-centered care [23]. The current study uses a linguistic lens in order to offer insights about how Latinos/as communicate their mental health issues during a medical interview. By analyzing real-time health interactions, we can gain insights quantitative studies cannot, which can prove crucial for practitioners and policy makers alike [24]. This article focuses on the metaphorical language that Spanish-speaking patients in psychiatric care use as well as cultural barriers they face during a preliminary psychiatric consultation in Spanish. 2. Methods 2.1. Conceptual metaphor analysis Conceptual metaphor analysis is useful for this study because of the role of metaphorical expressions in constructing meaning and realizing it through language choices. These meanings give us insights into cultural constructions of mental health conditions and reveal ideological information. Lakoff and Johnson [25] propose that (conceptual) metaphor is a central element in mental representation. Conceptual metaphors, which are realized through metaphorical expressions, are key for understanding how speakers reference abstract concepts. According to this theory, metaphors connect two domains, the source domain and the target domain. The source domain is typically concrete while the target domain is more abstract. For example, in “Life is a journey” “life” would be the target domain while “journey” is the source domain. People reference metaphors to express their ideas and emotion, and to affect the views and attitudes of others [26]. Because of this, scholars in many fields use conceptual metaphor theory. People allude to metaphors to talk about and influence others on a range of topics including political elections [27], environmental issues [28], and immigration [29]. In the realm of health, conceptual metaphor theory has helped reveal how people with cancer discuss and cope with their disease experiences [30–32]. The theory has also been applied to medical interactions [33], psychiatric/therapeutic care [34], and depression [35,36]. Studies on metaphor in talk about depression have revealed that commonly used metaphorical expressions compare depression
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to darkness (e.g. feeling dark/feeling blue), weight (e.g. I feel weighted down/ heavy), descent (e.g. hitting rock bottom, spiraling down, feeling down), motion (retreating, withdrawing), a captor [37], and a physical container (breaking through) [36–38]. While many conceptual metaphors tend to be universal, they may also act as blueprints that speakers fill in depending on their cultural contexts; therefore, their use and interpretation can vary in different cultures [39]. In fact, misunderstanding metaphorical expressions is a major cause of communication barriers in medical interactions between English-speaking practitioners and Spanishspeaking patients [40]. Studies in mental health metaphors have mostly focused on English, but Reali et al. [41] analyze a corpus of written Spanish produced in Argentina, Chile, Colombia, and Mexico. Among the most frequently used metaphors was describing depression in relation to a place in space and to an opponent. However, because their data is based on a written corpus, it has little relevance to face-to-face encounters with healthcare practitioners. It also does not address the experiences of language minorities. This study looks at how a doctor and his patients allude to metaphors and whether they accept or reject each other’s metaphorical expressions in order to gain a better understanding of how rural Mexicans talk about their health. It aims to reveal the types of metaphors they reference to come to that understanding. Revealing how Spanish-speaking rural Mexicans talk about and conceptualize their health issues is an important way to learn more about cultural barriers in healthcare and a step towards determining how practitioners can best care for them. 2.2. Data and participants The data for this study consists of 23 psychiatric interviews that took place in an agricultural town in California. The interviews are a psychiatric assessment where the doctor assesses whether to recommend further mental healthcare. During the interview, the doctor collects patients’ medical history and then conducts a 20question diagnostic based on the Diagnostic and Statistical Manual of Mental Disorders IV1 (see [42] for more discussion of the interview genre). These interviews were video-recorded; however, I was not present during the recording. The recorded interviews were part of a larger study [43] and I received permission to conduct a secondary analysis.2 All participants whose videos were collected for this study had agreed to have their consultation sessions used for research and education purposes. The town where the interviews were conducted is rural and medically underserved, with a shortage of healthcare professionals [44]. Half of its population (63,651; 49%) is Hispanic [45]. The interviews range between 18 and 42 min in length. The total word count for the corpus is 83,169 words. All patients are of Mexican descent. About half are unemployed and the others work in manual or agricultural labor. The doctor who conducts the interviews works at the intersection of healthcare, technology, and cultural inclusiveness. He is Mexican, but of higher-class status than his patients due to his family background, level of education, and the social status of his job. At the time of the interviews, he had over 33 years of medical experience, including working with remote rural Mexican
1 The doctor uses the widely used screening M.I.N.I. SCREEN 5.0.0, DSM-IV 4/1/06, which has a standard set of questions that include metaphorical expressions 1) “Have you felt sad, low or depressed most of the time for the last two years? 2) “Have you ever had a period of time when you were feeling ‘up’ or ‘high’ or ‘hyper’ or so full of energy or full of yourself that you got into trouble, or that other people thought you were not your usual self?” The doctor translated the questions into Spanish and used most of the metaphorical expressions in the English version. 2 I also obtained IRB approval for this study.
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Table 1 Total mental health metaphorical expressions.
Doctor Patients Total
Table 2 Speech contribution.
Raw number
%/ 222
61 161 222
27% 73% 100%
communities, and had been living in the United States for three years. Including only one doctor in this study poses challenges addressed in the limitations, but also eliminates numerous variables. Multiple doctors would introduce variables such as gender, age, race, ethnicity, social status, personality, approach, technique, experience, etc. 2.3. Approach to data analysis To analyze conceptual metaphors this study used the widely used Metaphor Identification Procedure [46]. This approach involves becoming familiar with the data, looking for all possible metaphorical expressions attached to mental health instead of having an a-priori list of potential domains. This step is useful for discovering new metaphors or new ways of expressing them. The discourse context was taken into account and the metaphorical expression was checked for a more basic meaning; if the metaphorical expression was used in relation to mental health (including symptoms and medication use), it was coded as a such in a codebook. For example, “[La depresión] me atacó muy fuerte y, y duré tanto tomando” (Depression attacked me really hard and I spent so much time drinking) was coded as an instance of an opponent metaphor. A bilingual research assistant checked the codebook. Our agreement level was 98%.3
Doctor Patients Total
average per consultation
% of words spoken
1,066 2,550 3616
29.5 70.5 100
Table 3 Metaphor categories (and subcategories) by percentage. Source domains
Patient %/ 161
Doctor %/ 61
1. Traveler nervios (nerves) are travelers depression is a traveler anxiety is a traveler thoughts are travelers 2. Opponent nervios are opponents depression is an opponent anxiety is an opponent another symptom is an opponent 3. Directional happy/hyper is ascent descend is depression 4. Body is a container (e.g. for emotions) 5. Objects / people symptoms are objects symptoms are people 6. Journey anxiety is a journey depression is a journey 7. Other
36.5
7
31.5
1.5
2
51
4
26
11
10
7
1.5
8
3
3.2. Traveler metaphor 3. Results 3.1. Overview The total number of metaphorical expressions that referenced metaphors in relation to mental health is 222. As Table 1 shows, patients contribute 161 or 73% of all metaphorical expressions, while the doctor contributes 61 or 27% . The ratio of metaphors to overall spoken words is similar for doctors and patients, however. Patients spoke about 2,550 words per consultation (70.5%), while the doctor spoke about 1,066 per consultation (29.5%) as seen in Table 2. Table 3 summarizes the recurring metaphorical categories that appear in the data. The frequencies represent the percentage amount used in each category by patients and the doctor (i.e. out of 161 for patients and 61 for the doctor). As shown, the doctor and his patients reference contrasting metaphorical categories; in other words, no source domain has equal use among interlocutors. The majority of metaphorical expressions patients use are in the traveler and opponent categories. They also use the objects/people and journey metaphorical expressions, but to a lesser extent. The doctor uses the directional and the body is a container metaphor more often than patients. The following sections will explain these categories in greater detail.
3
Initially, there were four disagreements, which we resolved by consulting an expert in conceptual metaphor theory. Three were metaphorical expressions wrongly placed in the opponent category instead of the traveler category, and one was not specifically referencing mental health.
The most common mental health metaphorical category was that the symptoms or the disease are travelers that can travel, arrive, and enter. (These examples include metaphorical expressions in other categories, which have not been underlined here.) Patients use travel metaphors frequently but the doctor uses them only rarely. This construction involves personification where human qualities are given to nonhuman entities, in order for people to talk about something abstract in more concrete terms. Specifically, people talk about nervios, depression, anxiety (mainly panic attacks), and mental health symptoms as travelers that invade the person’s body (see examples 1 and 2) and enters their bodies (see examples 3–5) in Table 4. The English translations miss the metaphorical meaning of these statements; for this reason, a literal translation is also included in parenthesis. For instance, “me entra depresión” is translated as “I get depression,” but its literal meaning is “depression enters me.” That is, in the Spanish version “depression” enters the passive patient. In its English translation, the person becomes or gets the condition or symptom. The fact that patients represent themselves as passive subjects and the disease as an external visitor reveals important information that may influence treatment. When patients use the traveler metaphor they may personify mental health symptoms and diseases, but not necessarily as invaders. By contrast the opponent category figures symptoms and conditions as negative and violent. 3.3. Opponent metaphor Patients often used opponent metaphors, but the doctor only used one only once. Patients use opponent metaphorical
D. Magaña / Patient Education and Counseling 102 (2019) 2192–2198 Table 4 Examples of traveler metaphor.
Table 5 Examples of opponent metaphor.
1) Patient 1 (female, late 40s):
1) Patient 1 (female, late 40s):
Me llegaron los nervios. (Nerves came to me). I got nervios.
Me empezó a agarrar los nervios bien feo. (Nerves started to grab me really badly). I started getting nerves really badly.
1) Patient 22 (male, mid 30s):
1) Patient 23 (male, mid 60s):
Yo no quiero que me vayan a llegar los ataques y no pueda tomarme mi pastilla por tener cerveza en mi sistema. (I would hate for an attack to arrive and to not be able to take my pill because I have alcohol in my system.) I would hate to have a panic attack and to not be able to take my pill because I have alcohol in my system.
Me agarra un dolor aquí en el cerebro. (Pain grabs me here, in my brain). I get pain, here, in my brain.
1) Patient 5 (female, mid 30s): Eso fue después, como a los tres años de que me entró [la depresión]. (That happened afterwards, like three years after depression entered me.) That happened afterwards, like three years after I became depressed.
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1) Patient 16 (female, early 50s): Ese dolor [en el pecho], cuando iba manejando como que me ataca. Como que me ataca, como que me pega. (That [chest] pain, as I was driving, I felt like it was attacking me. I feel like it attacks me, and like it hits me.) As I was driving, I got that [chest] pain. I feel like it attacks and hits me. 1) Patient 19 (female, mid 30s):
1) Patient 7 (male, mid 40s): Nomás se me llega el tiempo que yo les mando dinero y me entra una desesperación. (Just as time arrives for me to send them money desperation enters my body). As the time for me to send money to my parents gets closer, I get really desperate. 1) Patient 16 (female, early 50s): Me empezó a entrar mucha, mucha, mucha depresión. (A lot, a lot of depression started to enter my body). I started to get very, very depressed.
expressions to talk about mental health as an enemy that is capable of capturing, attacking, and hitting them as Table 5 shows. They talk about nervios or headaches “grabbing them violently” as the word agarrar implies in Mexican Spanish (see examples 6 and 7), chest pains “hitting and/or attacking them” (8), and depression “hitting or attacking them” (9 and 10). As with the traveler metaphor, people personify the symptoms or the disease, but when they use opponent metaphors, they describe a violent opponent who attacks them. This figuring of the patient as a passive subject points to a linguistic difference: Spanish is a less agentive language than English [47]. 3.4. Directional metaphor The doctor contributed almost all of the metaphorical expressions in this category because it appears in a routine question in the diagnostic he used towards the end of the interviews. This section of the interview included a question where the doctor asks whether patients felt “up” or “high.” Thus, euphoria/excitement is “up” represents most uses of the directional metaphor. Descend is “less” only occurs in a couple of instances and were also contributed by the doctor. English language speakers often use directional metaphors to refer to happiness/euphoria as “up” and sadness/depression as “down.” The literal translation of “feeling up/high” is “sentirse subido,” but in Spanish the metaphor refers to having an inflated ego. Perhaps for this reason the doctor routinely code-switches into English when he asks this question. Because the doctor often repeated this metaphorical expression across patients, this section features one extended example (Table 6). The question concerns signs of mania and thus the doctor asked whether patients had felt so euphoric that it caused them problems or manifested in socially inappropriate behavior such as arguing with strangers. Several patients misunderstood the question, which disrupted the flow of the diagnostic section. In
A veces este, me pega mucho [la depresión]. (Sometimes depression hits me a lot). Sometimes depression hits me hard. 1) Patient 21 (male, late 40s): [La depresión] me atacó muy fuerte y, y duré tanto tomando. (Depression attacked me really hard and I spent so long drinking). I got very depressed and I drank for a long time.
the following example, either the metaphorical use of euphoria is “up,” the codeswitch, or both confused a patient. The patient’s admission that people have fought with him may suggest that he does argue with strangers. The metaphoric use of euphoria is “up” also causes miscommunication with several other patients. Patient 17 (male, early 50 s), changes his answer after he fully understands the question from yes to no once the doctor clarifies that it refers to making trouble. The same metaphorical expression seems to have confused patient 13 (male, mid 30 s). An earlier statement “hablo cosas que no debo hablar; luego me arrepiento” (I say things I shouldn’t say; then later I regret it) suggests the patient had experienced this symptom. When asked about being “up,” the patient answers no, but then says, “yes” when the doctor follows up with, “And have you ever felt very angry for several days, or had fights or disagreements with people outside your family?” The patient admits that he has said curse words to people he does not know. Patients rarely alluded to the directional metaphor. While common in English-language conceptualizations of depression or mania, the directional metaphor requires a reinterpretation into Spanish, at least for this group of Spanish speakers (working-class Mexican immigrants in rural California). The doctor uses the metaphor which reflects English-language conceptualizations of mental health in spite of being of Mexican origin and a native Spanish speaker, and thus must repair the breakdown in communication by further negotiating the question with patients. 3.5. Body is a container metaphor As with the directional metaphor, the doctor contributes most of the metaphorical constructions of “body is a container” as he uses them in the diagnostic section of the interview. The metaphor the “body is a container” is often referenced to describe emotions. Examples in English include being filled with anger, blowing off steam, bursting with joy, and exploding in reaction to something
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Table 6 Example of directional metaphor.
Table 7 Example of body as a container metaphor. 1) Consultation with Patient 19 (female, mid 30s):
?
?
D: Cómo es la depresión? Como tristeza o como vacío? Cómo? What is depression like? Like sadness or emptiness? Like what? P: Eh, yo no sé qué será vacío, pero yo siento como que mi estómago me brinca mucho y como que me tiembla. Mucho dolor de cabeza. Uhm, I don’t know what emptiness is, but I feel like my stomach jumps a lot and like it shakes. A lot of headaches. D: hmm [nods]
P: Yo no entiendo qué palabra es. Es que yo no entiendo las palabras. Es que yo no tengo cabeza para–me dicen las palabras y no las . . . I don’t understand that word. I just don’t understand [English] words. My head doesn’t work that way [literally, I don’t have a head for] . . . they tell me the words and I don’t . . . ?
?
D: Eres peleonero? Te peleas con la gente que no es parte de tu familia? Are you a troublemaker? Do you fight with other people who are not part of your family? P: Me han peleado. People have fought me.
P: A veces me siento como bien aguados mis pies. Sometimes I feel like my legs [literally, feet but gestures at her legs] are like jelly [literally, wobbly]. ?
?
D: No? Has estado así muy como muy high? No? Have you ever been like very high?
?
P: [silence] [confusion]
?
D: Alguna vez en tu vida te sentiste así como muy high, muy up, como si pudieras hacer cualquier cosa y que te hayas metido en problemas con la ley o algo así? Has there been a time your life when you felt like very high or very up, like you could do anything and that it got you in trouble with the law or something like that?
?
1) Consultation with patient 7 (male, mid 40s):
D: hmm [nods], Como débil? Like weak? P: Sí. Y, este, incluso, nomás quiero estar acostada. No salgo nada. No tengo ganas. La mera verdad, me da hasta pena decirle, no tengo ganas ni de bañarme. Yes. And, in fact, sometimes I just want to be in bed all day. I don’t go out at all. I don’t feel like it. The truth is, I even feel embarrassed to tell you, but sometimes I don’t even feel like showering. D: hmm [nods]
?
D: O sea en la calle. Si vas a la calle, a una tienda y alguien no te trata bien, te peleas? Like out in the streets. If you go out, to the store and someone doesn’t treat you right, do you argue with them? P: [Shakes head].
[25,48]. English speakers often describe “emptiness” as a symptom of depression, using the body is a container metaphor. Although some varieties of Spanish use this metaphor may be referenced and websites and medical brochures translated from English often use it, the Spanish-speaking patients in this study rarely refer to it. In a couple of cases patients do not understand this metaphorical expression when the doctor uses it, as illustrated in the example in Table 7 (an interaction with patient 19, a woman in her mid 30 s). After the patient mentions that she has been depressed, the doctor probes further and asks her to describe the symptoms, giving her the options of “sadness” and “emptiness” to start. She states directly that she does not know what emptiness means and instead offers her own interpretation, mentioning that she feels shaking sensations in her stomach or has headaches or weak legs (using the word for feet, but touching her legs) and has lost interest in routine activities including getting out of bed and showering. While it may be useful for doctors treating Spanish-speaking Latinos/as to use the body is a container metaphor if its prevalence in the English language has affected their patients, it is also critical for providers to have linguistic awareness of alternative and localspecific ways to ask about depression symptoms. 3.6. Objectification and personification metaphor Describing mental health diseases and symptoms as objects or people was balanced between patients and the doctors. This metaphorical expression differed from opponent or traveler metaphors. This category includes describing panic attacks as personified in that they can “wake up,” “calm down,” saying the brain is not being “helpful,” the mind as being “weak,” and depression as being “strong.” One patient who experiences panic attacks explains that his panic attacks “wake up” and “calm down,” figuring himself as the passive target of the panic attacks. Another
P: Es una cosa bien horrible. It’s a very horrible thing.
patient says that his “brain must be weak,” again separating a body part from himself. Patients distance themselves from mental health symptoms by objectifying and personifying them. Personifying abstract concepts helps people understand them better because it allows people to make sense of a phenomenon in terms of something familiar to us: human characteristics [25]. Patients with cancer often use this strategy as well [31–33]. 3.7. Journey metaphor Patients used journey in reference to mental health 11 times, while the doctor only used it once. Reserach shows these metaphorical expressions are common among cancer patients who often talk about treatment as a “path” to recovery [49,50]. This metaphor can also imply difficulties, for instance, people may reference the “obstacles” they face along that “path.” For example, a patient in her late 20 s who suggests that recovery from depression is a journey says that she needs other people in order to “keep going on” in life’s path and to deal with her depression. Her statement is more group/community-oriented than individualistic. She says she blocks herself from “moving on” in life’s journey. The journey metaphors patients reference do not necessarily imply hope or positivity as in language used in motivation slogans like “The journey of a thousand steps begins with a single step,” but rather patients use it to underscore the difficulty of their situations. The journeys people they reference are necessarily not a linear or progressive, but difficult. 4. Discussion and conclusion 4.1. Discussion This study explored doctor–patient interactions to analyze how patients and a doctor talk about and understand mental health issues. The focus was specifically on how speakers used metaphorical expressions. These expressions reveal a culturally informed conceptualization of health conditions. This study
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reveals contrasting references to conceptual metaphors between a doctor and his patients. Because they appeared in his diagnostic questions, the doctor referenced a directional metaphor or body is a container frequently while patients rarely did. Patients often personified mental health issues and symptoms (as traveler, opponent, or simply as having volition), but the doctor did not. This contrast in metaphorical uses signals that the interlocutors did not influence each other’s use. At times distinct metaphorical references caused misunderstandings. Patients use metaphorical expressions that reveal important information about how they understand health issues as well as their concerns and fears. For one thing, they use both grammatical and metaphorical resources to distance themselves from mental health conditions. For another, they often talk about mental health issues and their symptoms as a violent enemy, as in the statement, “Me atacaron los nervios./ Nerves attacked me.” Much like patients with cancer, patients in this study may be expressing fear and vulnerability by framing mental health diseases as an enemy [51]. People often personify depression, anxiety, and their symptoms to describe them in more familiar terms. Objectification and personification also signals how Mexican patients in this study understand depression—as a health or social condition rather, than tied to their ontology. Few studies have been dedicated to metaphors in mental health discourse in Spanish and the one exception did not take place in an English-dominant context (however, see [41]). The linguistic approach in this study uncovers cultural barriers and illustrates how they are repaired. Specifically, this work revealed instances where patients misunderstand some of the metaphorical expressions the doctor used that are direct translations from English or that he expressed using an English word. These metaphorical uses at times lead to miscommunication, which the doctor had to negotiate. For instance, when the use of “up” or “down,” common metaphorical representations in depression discourse in Englishlanguage conceptualizations [36–38,52,53], confuses patients, it becomes clear that these metaphorical expressions are not used in relation to mental health in the patients’ rural Spanish. The difficulty may be due to the fact that the doctor had only been practicing in the United States for a few years. Although he has experience working with rural Mexican communities in Mexico and does not have trouble understanding patients’ metaphorical conceptualizations of mental health symptom and diseases, he may have overestimated how much the English language (and its metaphors) affects people’s understanding of mental health.
health literacy. While it is crucial for minority groups to have the linguistic tools to access mental health and engage in mental health treatment, it is also important for practitioners to be aware of how local groups of speakers they serve conceptualize mental health issues in their language and in their culture. This can help ameliorate the cultural barriers language minority communities face. Practitioner awareness is particularly crucial given the stigma and cultural construct of vergüenza (embarrassment) towards mental health issues among Latino groups. Based on this understanding we can work towards models that would guide treatment and self-management and influence medical adherence. If we understand more about how different patient groups conceptualize their health, we can give doctors more tools to be culturally and linguistically competent providers. This is also a step towards providing more patient-centered care for medically underserved groups.
4.2. Limitations
References
This study has several limitations including its small sample size and a limited number of participants. Including one doctor as part of the study eliminates social variables, but also makes it difficult to point to the idiosyncrasies during the interactions. However, since the metaphorical expressions the doctor uses are directly from a widely used mental health diagnostic, his metaphorical references to mental health are not idiosyncratic. Future research might use a larger corpus and use statistical analysis to corroborate the findings suggested here. Future research should also include other Spanish-speaking groups because the language use can vary across ethnicities and socioeconomic class. 4.3. Conclusions We can continue gaining cultural knowledge by studying how local speakers express their ailments across different contextualized communication (e.g. during medical visits, in health narratives, and in interactions with family members). This knowledge could also shed some light on the disparities in mental
4.4. Practice implications Based on the findings in this article it is noteworthy to point out that pedagogical implications for medical Spanish should be informed by how successful interactions take place (including how miscommunication is repaired). It is important to draw knowledge for best patient-centered care practices using control groups, surveys, and interviews, but also from authentic medical interactions. This study reveals that there is value in colloquial knowledge and health metaphors in professional contexts where Spanish is spoken. It is important that language classrooms on medical Spanish also promote local varieties of the language. This is important because research into the role of successful patient– provider communication suggests that positive interactions with health professionals contribute to patient adherence [54,55]. Acknowledgements I am sincerely grateful to Cecilia Colombi, Glenn Martínez and Alberto Odor for their guidance on this project and to Teenie Matlock for her mentorship. I appreciate the opportunity to have collaborated with Oana David, Gloria Quintana, and Teenie Matlock on other related projects. I deeply thank Mauricio Martinez for assistance with coding and EpsteinWords for editing services. I am grateful to the anonymous reviewers of this paper and journal editor for their constructive suggestions.
[1] U.S. Census Bureau, American Community Survey 5-Year Estimates (2012– 2016), (2016) . (Accessed 11 April 2018) https://www.census.gov/acs/www/ data/data-tables-and-tools/data-profiles/2016/. [2] S. Wassertheil-Smoller, E.M. Arredondo, J. Cai, S.F. Castaneda, J.P. Choca, L.C. Gallo, et al., Depression, anxiety, antidepressant use, and cardiovascular disease among Hispanic men and women of different national backgrounds: results from the Hispanic Community Health Study/Study of Latinos, Ann. Epidemiol. 24 (2014) 822–830. [3] M. Alegría, P. Chatterji, K. Wells, Z. Cao, C.N. Chen, D. Takeuchi, J. Jackson, et al., Disparity in depression treatment among racial and ethnic minority populations in the United States, Psychiatr. Serv. 59 (2008) 1264–1272. [4] American Psychological Association, Closing the gap for Latino patients, 36 (2005) , pp. 58. (Accessed 20 April 2018) https://www.apa.org/monitor/jan05/ closingthegap.aspx. [5] E. Nadeem, J.M. Lange, D. Edge, M. Fongwa, T. Belin, J. Miranda, Does stigma keep poor young immigrant and US-born black and Latina women from seeking mental health care? Psychiatr. Serv. 58 (2007) 1547–1554. [6] J.A. Marquez, J.I. Ramírez García, Family caregivers’ narratives of mental health treatment usage processes by their Latino adult relatives with serious and persistent mental illness, J. Fam. Psychol. 27 (2013) 398–408, doi:http://dx.doi. org/10.1037/a0032868. [7] M. Rastogi, N. Massey-Hastings, E. Wieling, Barriers to seeking mental health services in the Latino/a community: a qualitative analysis, J. Syst. Ther. 31 (2012) 1–17, doi:http://dx.doi.org/10.1521/jsyt.2012.31.4.1. [8] E. Colon, A. Giachello, L. McIver, G. Pacheco, L. Vela, Diabetes and depression in the Hispanic/Latino community, Clin. Diabetes 31 (2013) 43–45.
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[32] D. Magaña, Praying to win this battle: cancer metaphors in Latina and Spanish Women’s Narratives, Health Commun. (2019), doi:http://dx.doi.org/10.1080/ 10410236.2019.1582310. [33] C.E. Rees, L.V. Knight, C.E. Wilkinson, Doctors being up there and we being down here: a metaphorical analysis of talk about student/doctor–patient relationships, Soc. Sci. Med. 65 (2007) 725–737, doi:http://dx.doi.org/10.1016/ j.socscimed.2007.03.044. [34] D. Tay, Using metaphor in healthcare: mental health, in: E. Semino, Z. Demjén (Eds.), The Routledge Handbook of Metaphor and Language, Routledge, London, 2017, pp. 371–384. [35] S. Fullagar, W. O’Brien, Immobility, battles, and the journey of feeling alive: women’s metaphors of self-transformation through depression and recovery, Qual. Health Res. 22 (2012) 1063–1072. [36] S.W. Jackson, Melancholia and Depression: From Hippocratic Times to Modern Times, Yale University Press, 1986. [37] L.M. McMullen, J.B. Conway, Conventional metaphors for depression, in: S. Fussell (Ed.), The Verbal Communication of Emotions, Psychology Press, New York, 2002, pp. 167–181. [38] J. Charteris-Black, Shattering the bell jar: metaphor, gender, and depression, Metaphor Symb. 27 (2012) 199–216. [39] Z. Kövecses, Metaphor in Culture: Universality and Variation, Cambridge University Press, 2005. [40] V. Elderkin-Thompson, R.C. Silver, H. Waitzkin, When nurses double as interpreters: a study of Spanish-speaking patients in a US primary care setting, Soc. Sci. Med. 52 (2001) 1343–1358, doi:http://dx.doi.org/10.1016/S0277-9536 (00)00234-3. [41] F. Reali, T. Soriano, D. Rodríguez, How we think about depression: the role of linguistic framing, Rev. Latinoam. Psicol. 48 (2016) 127–136. [42] D. Magaña, Modality resources in Spanish during psychiatric interviews with Mexican patients, Commun. Med. 13 (2017) 291–305. [43] A. Odor, P. Yellowlees, D. Hilty, M.B. Parish, N. Nafiz, A.M. Iosif, PsychVACS: a system for asynchronous telepsychiatry, Telemed. J. E. 17 (2011) 299–303. [44] P.M. Yellowlees, A. Odor, M.B. Parish, A.M. Iosif, K. Haught, D. Hilty, A feasibility study of the use of asynchronous telepsychiatry for psychiatric consultations, Psychiatr. Serv. 61 (2010) 838–840. [45] U.S. Census Bureau, Quickfacts, (2017) . (Accessed 31 August 2018) https:// www.census.gov/quickfacts/fact/table/visaliacitycalifornia/PST045217. [46] Pragglejaz Group, MIP: A method for identifying metaphorically used words in discourse, Metaphor Symb. 22 (2007) 1–39. [47] C.M. Fausey, L. Boroditsky, English and Spanish speakers remember causal agents differently, Proceedings of the Annual Meeting of the Cognitive Science Society, (2008) , pp. 205–210. Retrieved from https://escholarship.org/uc/ item/4425600t. [48] Z. Kövecses, Metaphor: a Practical Introduction, Oxford University Press, 2010. [49] E. Semino, Z. Demjén, J. Demmen, An integrated approach to Metaphor and framing in cognition, discourse, and practice with an application to metaphors for cancer, Appl. Linguist. (2016) 1–22. [50] D. Magaña, T. Matlock, How Spanish speakers use metaphor to describe their experiences with cancer, Discourse Commun. 12 (2018) 627–644, doi:http:// dx.doi.org/10.1177/1750481318771446. [51] C. Skott, Expressive metaphors in cancer narratives, Cancer Nurs. 25 (2002) 230–235. [52] Z. Demjén, Motion and conflicted self metaphors in Sylvia Plath’s’ Smith Journal’, Metaphor. Soc. World 1 (2011) 7–25. [53] Z. Demjén, Sylvia Plath and the Language of Affective States: Written Discourse and the Experience of Depression, Bloomsbury Publishing, 2015. [54] M.C. Hansen, L.J. Cabassa, Pathways to depression care: help-seeking experiences of low-income Latinos with diabetes and depression, J. Immigr. Minor. Health 14 (2012) 1097–1106. [55] A. Interian, A. Ang, M.A. Gara, M.A. Rodriguez, W.A. Vega, The long-term trajectory of depression among Latinos in primary care and its relationship to depression care disparities, Gen. Hosp. Psychiatr. 33 (2011) 94–101.
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Cultural competence and metaphor in mental healthcare interactions: A linguistic perspective Dalia Magaña Department of Literature, Languages & Cultures, School of Social Sciences, Humanities & Arts, University of California, Merced, 5200 N. Lake Road, Merced, CA 95343, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 December 2018 Received in revised form 10 June 2019 Accepted 12 June 2019
Objectives: The aim of this study is to understand how Spanish-speaking patients conceptualize mental health issues. This study uses a linguistic perspective to focus on how 23 Mexican-origin patients and their doctor talk about mental health during psychiatric interviews conducted in Spanish and how they negotiate cultural barriers. Methods: This work analyzes when the doctor and his patients reference metaphors (e.g. feeling “empty,” feeling “low”). Metaphors are pervasive in all cultures and languages and reveal important information about people’s attitudes and feelings about a range of conditions and circumstances. Results: This work demonstrates the role of metaphor and linguistic analysis in uncovering culturally based constructions of mental health. The results reveal that the doctor and patients reference different sets of metaphors, which, at times, causes miscommunication. Conclusions: Practitioner awareness of how patients use metaphorical expressions in health is crucial for promoting advanced cultural and linguistic competence and ultimately, patient-centered care. Practice implications: The main findings have implications for health communication with minority groups such as Spanish-speaking Latinos/as in the United States. Practitioners working with Spanishspeaking patients should be familiar with how Latinos/as conceptualize health and how to avoid or repair confusion caused by cultural barriers. © 2019 Elsevier B.V. All rights reserved.
Keywords: Linguistic analysis Patient-centered communication Conceptual metaphor Psychiatric interviews Cultural competence Latino mental healthcare
1. Introduction 1.1. Latinos/as, language/cultural barriers, and health disparities The Latino population faces numerous health disparities due in part to language and cultural barriers. Latinos/as are the largest minority group in the United States, at 17% of the total population or 54 million and growing [1]. Almost a third of this group is not fluent in English [1]. Language barriers have a direct impact on their healthcare and health outcomes and contribute to disparities. Although Latinos/as have a similar prevalence of depression as non-Latino Whites, Latinos/as have a lower likelihood of diagnosis and more rarely follow-up on appointments or receive treatment [2–4]. In dealing with depression, Latinos/as may experience stigma and embarrassment/shame (vergüenza) [5,6]. Latinos/as in the United States may also avoid seeking care because they have concerns about cultural misunderstandings and confronting racism [7]. Scholars attribute under-diagnosis and lower utilization rates among Latinos/as in part to the lack of culturally adapted
E-mail address: [email protected] (D. Magaña). https://doi.org/10.1016/j.pec.2019.06.010 0738-3991/© 2019 Elsevier B.V. All rights reserved.
and effective assessment tools reflecting knowledge of patients’ health beliefs [8,9]. Language plays a central role in healthcare disparities. Bilingual patients whose first language is Spanish are evaluated differently when evaluated in English versus Spanish [10]. In what Martínez [11] terms the linguistic gradient, language ability correlates with likelihood of seeking and receiving mental healthcare. For example, in one study, 43% of Latinos/as who spoke English only sought and received mental health care compared to 35% of bilingual Latinos/as and 8% of those with limited English proficiency [11,12]. For Spanish-dominant Latinos/as, low health literacy, the ability to obtain, process, and understand basic health information and appropriate services poses an additional barrier [13,14]. Unfortunately, those with low health literacy are less likely to obtain and engage in mental healthcare and have poorer health [14,15]. To confront some of these disparities, it is crucial to train providers in linguistically and culturally appropriate ways in order to strive to offer more adequate patient-centered care. This is particularly important given the underrepresentation of Latinos/as among practitioners. Only 5% of medical school graduates are Latino/a and that only 2% of full-time employed physicians are
D. Magaña / Patient Education and Counseling 102 (2019) 2192–2198
Hispanic [16]. Medical Spanish courses and materials have become more common, reflecting an understanding of the need to train providers to have language and cultural competence, but most target beginners [17]. Beginner instruction does not generally impart cultural competency, which requires in-depth, advanced understanding of language use. Cultural competency requires discussion of practical issues that medical professionals encounter. including knowledge about people’s social values and how people discuss issues in colloquial or regional ways, such as regionalisms and colloquialisms [17]. It is important to understand the local terms communities use when they describe their health concerns and social suffering [18,19]. As psychiatrist Carlat [20] recommends, colloquialisms can empower patients to speak about their issues during their medical encounters in spite of stigma. Local terms for health symptoms and conditions may vary according to ethnic/racial groups, even those who speak the same language. Mexican-origin people may ascribe depression to nervios, a broad category of mental health issues attributed to interpersonal imbalance [21,22]. Nervios symptoms include bouts of crying, tension, listlessness, loss of appetite, irritability, and sadness, meeting the clinical definition of depression [21]. Mental healthcare providers working with Mexican-origin groups benefit from possessing this knowledge, which enables them to offer culturally competent and patient-centered care. Few studies have investigated language and cultural barriers during medical interactions or how patients express their health concerns using linguistic approaches, though linguistic analysis promotes patient-centered care [23]. The current study uses a linguistic lens in order to offer insights about how Latinos/as communicate their mental health issues during a medical interview. By analyzing real-time health interactions, we can gain insights quantitative studies cannot, which can prove crucial for practitioners and policy makers alike [24]. This article focuses on the metaphorical language that Spanish-speaking patients in psychiatric care use as well as cultural barriers they face during a preliminary psychiatric consultation in Spanish. 2. Methods 2.1. Conceptual metaphor analysis Conceptual metaphor analysis is useful for this study because of the role of metaphorical expressions in constructing meaning and realizing it through language choices. These meanings give us insights into cultural constructions of mental health conditions and reveal ideological information. Lakoff and Johnson [25] propose that (conceptual) metaphor is a central element in mental representation. Conceptual metaphors, which are realized through metaphorical expressions, are key for understanding how speakers reference abstract concepts. According to this theory, metaphors connect two domains, the source domain and the target domain. The source domain is typically concrete while the target domain is more abstract. For example, in “Life is a journey” “life” would be the target domain while “journey” is the source domain. People reference metaphors to express their ideas and emotion, and to affect the views and attitudes of others [26]. Because of this, scholars in many fields use conceptual metaphor theory. People allude to metaphors to talk about and influence others on a range of topics including political elections [27], environmental issues [28], and immigration [29]. In the realm of health, conceptual metaphor theory has helped reveal how people with cancer discuss and cope with their disease experiences [30–32]. The theory has also been applied to medical interactions [33], psychiatric/therapeutic care [34], and depression [35,36]. Studies on metaphor in talk about depression have revealed that commonly used metaphorical expressions compare depression
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to darkness (e.g. feeling dark/feeling blue), weight (e.g. I feel weighted down/ heavy), descent (e.g. hitting rock bottom, spiraling down, feeling down), motion (retreating, withdrawing), a captor [37], and a physical container (breaking through) [36–38]. While many conceptual metaphors tend to be universal, they may also act as blueprints that speakers fill in depending on their cultural contexts; therefore, their use and interpretation can vary in different cultures [39]. In fact, misunderstanding metaphorical expressions is a major cause of communication barriers in medical interactions between English-speaking practitioners and Spanishspeaking patients [40]. Studies in mental health metaphors have mostly focused on English, but Reali et al. [41] analyze a corpus of written Spanish produced in Argentina, Chile, Colombia, and Mexico. Among the most frequently used metaphors was describing depression in relation to a place in space and to an opponent. However, because their data is based on a written corpus, it has little relevance to face-to-face encounters with healthcare practitioners. It also does not address the experiences of language minorities. This study looks at how a doctor and his patients allude to metaphors and whether they accept or reject each other’s metaphorical expressions in order to gain a better understanding of how rural Mexicans talk about their health. It aims to reveal the types of metaphors they reference to come to that understanding. Revealing how Spanish-speaking rural Mexicans talk about and conceptualize their health issues is an important way to learn more about cultural barriers in healthcare and a step towards determining how practitioners can best care for them. 2.2. Data and participants The data for this study consists of 23 psychiatric interviews that took place in an agricultural town in California. The interviews are a psychiatric assessment where the doctor assesses whether to recommend further mental healthcare. During the interview, the doctor collects patients’ medical history and then conducts a 20question diagnostic based on the Diagnostic and Statistical Manual of Mental Disorders IV1 (see [42] for more discussion of the interview genre). These interviews were video-recorded; however, I was not present during the recording. The recorded interviews were part of a larger study [43] and I received permission to conduct a secondary analysis.2 All participants whose videos were collected for this study had agreed to have their consultation sessions used for research and education purposes. The town where the interviews were conducted is rural and medically underserved, with a shortage of healthcare professionals [44]. Half of its population (63,651; 49%) is Hispanic [45]. The interviews range between 18 and 42 min in length. The total word count for the corpus is 83,169 words. All patients are of Mexican descent. About half are unemployed and the others work in manual or agricultural labor. The doctor who conducts the interviews works at the intersection of healthcare, technology, and cultural inclusiveness. He is Mexican, but of higher-class status than his patients due to his family background, level of education, and the social status of his job. At the time of the interviews, he had over 33 years of medical experience, including working with remote rural Mexican
1 The doctor uses the widely used screening M.I.N.I. SCREEN 5.0.0, DSM-IV 4/1/06, which has a standard set of questions that include metaphorical expressions 1) “Have you felt sad, low or depressed most of the time for the last two years? 2) “Have you ever had a period of time when you were feeling ‘up’ or ‘high’ or ‘hyper’ or so full of energy or full of yourself that you got into trouble, or that other people thought you were not your usual self?” The doctor translated the questions into Spanish and used most of the metaphorical expressions in the English version. 2 I also obtained IRB approval for this study.
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Table 1 Total mental health metaphorical expressions.
Doctor Patients Total
Table 2 Speech contribution.
Raw number
%/ 222
61 161 222
27% 73% 100%
communities, and had been living in the United States for three years. Including only one doctor in this study poses challenges addressed in the limitations, but also eliminates numerous variables. Multiple doctors would introduce variables such as gender, age, race, ethnicity, social status, personality, approach, technique, experience, etc. 2.3. Approach to data analysis To analyze conceptual metaphors this study used the widely used Metaphor Identification Procedure [46]. This approach involves becoming familiar with the data, looking for all possible metaphorical expressions attached to mental health instead of having an a-priori list of potential domains. This step is useful for discovering new metaphors or new ways of expressing them. The discourse context was taken into account and the metaphorical expression was checked for a more basic meaning; if the metaphorical expression was used in relation to mental health (including symptoms and medication use), it was coded as a such in a codebook. For example, “[La depresión] me atacó muy fuerte y, y duré tanto tomando” (Depression attacked me really hard and I spent so much time drinking) was coded as an instance of an opponent metaphor. A bilingual research assistant checked the codebook. Our agreement level was 98%.3
Doctor Patients Total
average per consultation
% of words spoken
1,066 2,550 3616
29.5 70.5 100
Table 3 Metaphor categories (and subcategories) by percentage. Source domains
Patient %/ 161
Doctor %/ 61
1. Traveler nervios (nerves) are travelers depression is a traveler anxiety is a traveler thoughts are travelers 2. Opponent nervios are opponents depression is an opponent anxiety is an opponent another symptom is an opponent 3. Directional happy/hyper is ascent descend is depression 4. Body is a container (e.g. for emotions) 5. Objects / people symptoms are objects symptoms are people 6. Journey anxiety is a journey depression is a journey 7. Other
36.5
7
31.5
1.5
2
51
4
26
11
10
7
1.5
8
3
3.2. Traveler metaphor 3. Results 3.1. Overview The total number of metaphorical expressions that referenced metaphors in relation to mental health is 222. As Table 1 shows, patients contribute 161 or 73% of all metaphorical expressions, while the doctor contributes 61 or 27% . The ratio of metaphors to overall spoken words is similar for doctors and patients, however. Patients spoke about 2,550 words per consultation (70.5%), while the doctor spoke about 1,066 per consultation (29.5%) as seen in Table 2. Table 3 summarizes the recurring metaphorical categories that appear in the data. The frequencies represent the percentage amount used in each category by patients and the doctor (i.e. out of 161 for patients and 61 for the doctor). As shown, the doctor and his patients reference contrasting metaphorical categories; in other words, no source domain has equal use among interlocutors. The majority of metaphorical expressions patients use are in the traveler and opponent categories. They also use the objects/people and journey metaphorical expressions, but to a lesser extent. The doctor uses the directional and the body is a container metaphor more often than patients. The following sections will explain these categories in greater detail.
3
Initially, there were four disagreements, which we resolved by consulting an expert in conceptual metaphor theory. Three were metaphorical expressions wrongly placed in the opponent category instead of the traveler category, and one was not specifically referencing mental health.
The most common mental health metaphorical category was that the symptoms or the disease are travelers that can travel, arrive, and enter. (These examples include metaphorical expressions in other categories, which have not been underlined here.) Patients use travel metaphors frequently but the doctor uses them only rarely. This construction involves personification where human qualities are given to nonhuman entities, in order for people to talk about something abstract in more concrete terms. Specifically, people talk about nervios, depression, anxiety (mainly panic attacks), and mental health symptoms as travelers that invade the person’s body (see examples 1 and 2) and enters their bodies (see examples 3–5) in Table 4. The English translations miss the metaphorical meaning of these statements; for this reason, a literal translation is also included in parenthesis. For instance, “me entra depresión” is translated as “I get depression,” but its literal meaning is “depression enters me.” That is, in the Spanish version “depression” enters the passive patient. In its English translation, the person becomes or gets the condition or symptom. The fact that patients represent themselves as passive subjects and the disease as an external visitor reveals important information that may influence treatment. When patients use the traveler metaphor they may personify mental health symptoms and diseases, but not necessarily as invaders. By contrast the opponent category figures symptoms and conditions as negative and violent. 3.3. Opponent metaphor Patients often used opponent metaphors, but the doctor only used one only once. Patients use opponent metaphorical
D. Magaña / Patient Education and Counseling 102 (2019) 2192–2198 Table 4 Examples of traveler metaphor.
Table 5 Examples of opponent metaphor.
1) Patient 1 (female, late 40s):
1) Patient 1 (female, late 40s):
Me llegaron los nervios. (Nerves came to me). I got nervios.
Me empezó a agarrar los nervios bien feo. (Nerves started to grab me really badly). I started getting nerves really badly.
1) Patient 22 (male, mid 30s):
1) Patient 23 (male, mid 60s):
Yo no quiero que me vayan a llegar los ataques y no pueda tomarme mi pastilla por tener cerveza en mi sistema. (I would hate for an attack to arrive and to not be able to take my pill because I have alcohol in my system.) I would hate to have a panic attack and to not be able to take my pill because I have alcohol in my system.
Me agarra un dolor aquí en el cerebro. (Pain grabs me here, in my brain). I get pain, here, in my brain.
1) Patient 5 (female, mid 30s): Eso fue después, como a los tres años de que me entró [la depresión]. (That happened afterwards, like three years after depression entered me.) That happened afterwards, like three years after I became depressed.
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1) Patient 16 (female, early 50s): Ese dolor [en el pecho], cuando iba manejando como que me ataca. Como que me ataca, como que me pega. (That [chest] pain, as I was driving, I felt like it was attacking me. I feel like it attacks me, and like it hits me.) As I was driving, I got that [chest] pain. I feel like it attacks and hits me. 1) Patient 19 (female, mid 30s):
1) Patient 7 (male, mid 40s): Nomás se me llega el tiempo que yo les mando dinero y me entra una desesperación. (Just as time arrives for me to send them money desperation enters my body). As the time for me to send money to my parents gets closer, I get really desperate. 1) Patient 16 (female, early 50s): Me empezó a entrar mucha, mucha, mucha depresión. (A lot, a lot of depression started to enter my body). I started to get very, very depressed.
expressions to talk about mental health as an enemy that is capable of capturing, attacking, and hitting them as Table 5 shows. They talk about nervios or headaches “grabbing them violently” as the word agarrar implies in Mexican Spanish (see examples 6 and 7), chest pains “hitting and/or attacking them” (8), and depression “hitting or attacking them” (9 and 10). As with the traveler metaphor, people personify the symptoms or the disease, but when they use opponent metaphors, they describe a violent opponent who attacks them. This figuring of the patient as a passive subject points to a linguistic difference: Spanish is a less agentive language than English [47]. 3.4. Directional metaphor The doctor contributed almost all of the metaphorical expressions in this category because it appears in a routine question in the diagnostic he used towards the end of the interviews. This section of the interview included a question where the doctor asks whether patients felt “up” or “high.” Thus, euphoria/excitement is “up” represents most uses of the directional metaphor. Descend is “less” only occurs in a couple of instances and were also contributed by the doctor. English language speakers often use directional metaphors to refer to happiness/euphoria as “up” and sadness/depression as “down.” The literal translation of “feeling up/high” is “sentirse subido,” but in Spanish the metaphor refers to having an inflated ego. Perhaps for this reason the doctor routinely code-switches into English when he asks this question. Because the doctor often repeated this metaphorical expression across patients, this section features one extended example (Table 6). The question concerns signs of mania and thus the doctor asked whether patients had felt so euphoric that it caused them problems or manifested in socially inappropriate behavior such as arguing with strangers. Several patients misunderstood the question, which disrupted the flow of the diagnostic section. In
A veces este, me pega mucho [la depresión]. (Sometimes depression hits me a lot). Sometimes depression hits me hard. 1) Patient 21 (male, late 40s): [La depresión] me atacó muy fuerte y, y duré tanto tomando. (Depression attacked me really hard and I spent so long drinking). I got very depressed and I drank for a long time.
the following example, either the metaphorical use of euphoria is “up,” the codeswitch, or both confused a patient. The patient’s admission that people have fought with him may suggest that he does argue with strangers. The metaphoric use of euphoria is “up” also causes miscommunication with several other patients. Patient 17 (male, early 50 s), changes his answer after he fully understands the question from yes to no once the doctor clarifies that it refers to making trouble. The same metaphorical expression seems to have confused patient 13 (male, mid 30 s). An earlier statement “hablo cosas que no debo hablar; luego me arrepiento” (I say things I shouldn’t say; then later I regret it) suggests the patient had experienced this symptom. When asked about being “up,” the patient answers no, but then says, “yes” when the doctor follows up with, “And have you ever felt very angry for several days, or had fights or disagreements with people outside your family?” The patient admits that he has said curse words to people he does not know. Patients rarely alluded to the directional metaphor. While common in English-language conceptualizations of depression or mania, the directional metaphor requires a reinterpretation into Spanish, at least for this group of Spanish speakers (working-class Mexican immigrants in rural California). The doctor uses the metaphor which reflects English-language conceptualizations of mental health in spite of being of Mexican origin and a native Spanish speaker, and thus must repair the breakdown in communication by further negotiating the question with patients. 3.5. Body is a container metaphor As with the directional metaphor, the doctor contributes most of the metaphorical constructions of “body is a container” as he uses them in the diagnostic section of the interview. The metaphor the “body is a container” is often referenced to describe emotions. Examples in English include being filled with anger, blowing off steam, bursting with joy, and exploding in reaction to something
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Table 6 Example of directional metaphor.
Table 7 Example of body as a container metaphor. 1) Consultation with Patient 19 (female, mid 30s):
?
?
D: Cómo es la depresión? Como tristeza o como vacío? Cómo? What is depression like? Like sadness or emptiness? Like what? P: Eh, yo no sé qué será vacío, pero yo siento como que mi estómago me brinca mucho y como que me tiembla. Mucho dolor de cabeza. Uhm, I don’t know what emptiness is, but I feel like my stomach jumps a lot and like it shakes. A lot of headaches. D: hmm [nods]
P: Yo no entiendo qué palabra es. Es que yo no entiendo las palabras. Es que yo no tengo cabeza para–me dicen las palabras y no las . . . I don’t understand that word. I just don’t understand [English] words. My head doesn’t work that way [literally, I don’t have a head for] . . . they tell me the words and I don’t . . . ?
?
D: Eres peleonero? Te peleas con la gente que no es parte de tu familia? Are you a troublemaker? Do you fight with other people who are not part of your family? P: Me han peleado. People have fought me.
P: A veces me siento como bien aguados mis pies. Sometimes I feel like my legs [literally, feet but gestures at her legs] are like jelly [literally, wobbly]. ?
?
D: No? Has estado así muy como muy high? No? Have you ever been like very high?
?
P: [silence] [confusion]
?
D: Alguna vez en tu vida te sentiste así como muy high, muy up, como si pudieras hacer cualquier cosa y que te hayas metido en problemas con la ley o algo así? Has there been a time your life when you felt like very high or very up, like you could do anything and that it got you in trouble with the law or something like that?
?
1) Consultation with patient 7 (male, mid 40s):
D: hmm [nods], Como débil? Like weak? P: Sí. Y, este, incluso, nomás quiero estar acostada. No salgo nada. No tengo ganas. La mera verdad, me da hasta pena decirle, no tengo ganas ni de bañarme. Yes. And, in fact, sometimes I just want to be in bed all day. I don’t go out at all. I don’t feel like it. The truth is, I even feel embarrassed to tell you, but sometimes I don’t even feel like showering. D: hmm [nods]
?
D: O sea en la calle. Si vas a la calle, a una tienda y alguien no te trata bien, te peleas? Like out in the streets. If you go out, to the store and someone doesn’t treat you right, do you argue with them? P: [Shakes head].
[25,48]. English speakers often describe “emptiness” as a symptom of depression, using the body is a container metaphor. Although some varieties of Spanish use this metaphor may be referenced and websites and medical brochures translated from English often use it, the Spanish-speaking patients in this study rarely refer to it. In a couple of cases patients do not understand this metaphorical expression when the doctor uses it, as illustrated in the example in Table 7 (an interaction with patient 19, a woman in her mid 30 s). After the patient mentions that she has been depressed, the doctor probes further and asks her to describe the symptoms, giving her the options of “sadness” and “emptiness” to start. She states directly that she does not know what emptiness means and instead offers her own interpretation, mentioning that she feels shaking sensations in her stomach or has headaches or weak legs (using the word for feet, but touching her legs) and has lost interest in routine activities including getting out of bed and showering. While it may be useful for doctors treating Spanish-speaking Latinos/as to use the body is a container metaphor if its prevalence in the English language has affected their patients, it is also critical for providers to have linguistic awareness of alternative and localspecific ways to ask about depression symptoms. 3.6. Objectification and personification metaphor Describing mental health diseases and symptoms as objects or people was balanced between patients and the doctors. This metaphorical expression differed from opponent or traveler metaphors. This category includes describing panic attacks as personified in that they can “wake up,” “calm down,” saying the brain is not being “helpful,” the mind as being “weak,” and depression as being “strong.” One patient who experiences panic attacks explains that his panic attacks “wake up” and “calm down,” figuring himself as the passive target of the panic attacks. Another
P: Es una cosa bien horrible. It’s a very horrible thing.
patient says that his “brain must be weak,” again separating a body part from himself. Patients distance themselves from mental health symptoms by objectifying and personifying them. Personifying abstract concepts helps people understand them better because it allows people to make sense of a phenomenon in terms of something familiar to us: human characteristics [25]. Patients with cancer often use this strategy as well [31–33]. 3.7. Journey metaphor Patients used journey in reference to mental health 11 times, while the doctor only used it once. Reserach shows these metaphorical expressions are common among cancer patients who often talk about treatment as a “path” to recovery [49,50]. This metaphor can also imply difficulties, for instance, people may reference the “obstacles” they face along that “path.” For example, a patient in her late 20 s who suggests that recovery from depression is a journey says that she needs other people in order to “keep going on” in life’s path and to deal with her depression. Her statement is more group/community-oriented than individualistic. She says she blocks herself from “moving on” in life’s journey. The journey metaphors patients reference do not necessarily imply hope or positivity as in language used in motivation slogans like “The journey of a thousand steps begins with a single step,” but rather patients use it to underscore the difficulty of their situations. The journeys people they reference are necessarily not a linear or progressive, but difficult. 4. Discussion and conclusion 4.1. Discussion This study explored doctor–patient interactions to analyze how patients and a doctor talk about and understand mental health issues. The focus was specifically on how speakers used metaphorical expressions. These expressions reveal a culturally informed conceptualization of health conditions. This study
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reveals contrasting references to conceptual metaphors between a doctor and his patients. Because they appeared in his diagnostic questions, the doctor referenced a directional metaphor or body is a container frequently while patients rarely did. Patients often personified mental health issues and symptoms (as traveler, opponent, or simply as having volition), but the doctor did not. This contrast in metaphorical uses signals that the interlocutors did not influence each other’s use. At times distinct metaphorical references caused misunderstandings. Patients use metaphorical expressions that reveal important information about how they understand health issues as well as their concerns and fears. For one thing, they use both grammatical and metaphorical resources to distance themselves from mental health conditions. For another, they often talk about mental health issues and their symptoms as a violent enemy, as in the statement, “Me atacaron los nervios./ Nerves attacked me.” Much like patients with cancer, patients in this study may be expressing fear and vulnerability by framing mental health diseases as an enemy [51]. People often personify depression, anxiety, and their symptoms to describe them in more familiar terms. Objectification and personification also signals how Mexican patients in this study understand depression—as a health or social condition rather, than tied to their ontology. Few studies have been dedicated to metaphors in mental health discourse in Spanish and the one exception did not take place in an English-dominant context (however, see [41]). The linguistic approach in this study uncovers cultural barriers and illustrates how they are repaired. Specifically, this work revealed instances where patients misunderstand some of the metaphorical expressions the doctor used that are direct translations from English or that he expressed using an English word. These metaphorical uses at times lead to miscommunication, which the doctor had to negotiate. For instance, when the use of “up” or “down,” common metaphorical representations in depression discourse in Englishlanguage conceptualizations [36–38,52,53], confuses patients, it becomes clear that these metaphorical expressions are not used in relation to mental health in the patients’ rural Spanish. The difficulty may be due to the fact that the doctor had only been practicing in the United States for a few years. Although he has experience working with rural Mexican communities in Mexico and does not have trouble understanding patients’ metaphorical conceptualizations of mental health symptom and diseases, he may have overestimated how much the English language (and its metaphors) affects people’s understanding of mental health.
health literacy. While it is crucial for minority groups to have the linguistic tools to access mental health and engage in mental health treatment, it is also important for practitioners to be aware of how local groups of speakers they serve conceptualize mental health issues in their language and in their culture. This can help ameliorate the cultural barriers language minority communities face. Practitioner awareness is particularly crucial given the stigma and cultural construct of vergüenza (embarrassment) towards mental health issues among Latino groups. Based on this understanding we can work towards models that would guide treatment and self-management and influence medical adherence. If we understand more about how different patient groups conceptualize their health, we can give doctors more tools to be culturally and linguistically competent providers. This is also a step towards providing more patient-centered care for medically underserved groups.
4.2. Limitations
References
This study has several limitations including its small sample size and a limited number of participants. Including one doctor as part of the study eliminates social variables, but also makes it difficult to point to the idiosyncrasies during the interactions. However, since the metaphorical expressions the doctor uses are directly from a widely used mental health diagnostic, his metaphorical references to mental health are not idiosyncratic. Future research might use a larger corpus and use statistical analysis to corroborate the findings suggested here. Future research should also include other Spanish-speaking groups because the language use can vary across ethnicities and socioeconomic class. 4.3. Conclusions We can continue gaining cultural knowledge by studying how local speakers express their ailments across different contextualized communication (e.g. during medical visits, in health narratives, and in interactions with family members). This knowledge could also shed some light on the disparities in mental
4.4. Practice implications Based on the findings in this article it is noteworthy to point out that pedagogical implications for medical Spanish should be informed by how successful interactions take place (including how miscommunication is repaired). It is important to draw knowledge for best patient-centered care practices using control groups, surveys, and interviews, but also from authentic medical interactions. This study reveals that there is value in colloquial knowledge and health metaphors in professional contexts where Spanish is spoken. It is important that language classrooms on medical Spanish also promote local varieties of the language. This is important because research into the role of successful patient– provider communication suggests that positive interactions with health professionals contribute to patient adherence [54,55]. Acknowledgements I am sincerely grateful to Cecilia Colombi, Glenn Martínez and Alberto Odor for their guidance on this project and to Teenie Matlock for her mentorship. I appreciate the opportunity to have collaborated with Oana David, Gloria Quintana, and Teenie Matlock on other related projects. I deeply thank Mauricio Martinez for assistance with coding and EpsteinWords for editing services. I am grateful to the anonymous reviewers of this paper and journal editor for their constructive suggestions.
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