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Abstract

Metaphors are often used by individuals facing illness and serve as expressions illuminating the profound nature of patients’ experiences. Metaphors are powerful expressions encapsulating emotional nuances, existential dilemmas, and transformative journeys through illness landscapes. As the French philosopher Ricoeur posits, metaphors are not mere linguistic devices but profound tools that enrich our understanding by bridging the gap between abstract concepts and lived realities. By examining and interpreting these metaphors, researchers can uncover layers of meaning that traditional analytical approaches might overlook, enriching our comprehension of the subjective dimensions of illness experiences. Therefore, this paper explores how metaphors function as interpretative tools in qualitative research and what meaning patients assign to their illness narratives through metaphors. An analytical approach consisting of three stages, Mimesis 1, Mimesis 2 and Mimesis 3, is introduced for interpreting narratives and metaphors and avoid premature closure of qualitative analysis. The final section presents practical guidance and suggestions for enhancing the quality of qualitative data analysis. The use of metaphors enables researchers to gain a deeper understanding of patients’ illness experiences while also compelling them to demonstrate to the reader how they arrived at the themes and arguments they present. Indeed, using metaphors in the analysis of qualitative research brings out the particular or singularity of a phenomenon or event. This uniqueness has deep connections to human experience, cognition, and existence. Metaphors can thus serve as a bridge between the unique and the universal, shedding light on the existential dimensions of human lived experiences. Therefore, researchers should actively use metaphors to interpret themes in qualitative data.

Keywords

qualitative research metaphor analysis narratives data analysis qualitative methods Ricoeur

Introduction

In a life with illness, patients’ experiences are particularly significant as they form the foundation of their subjective reality, influencing how they navigate the challenges of illness. To understand and address patients’ needs and desires to be seen and heard in their suffering and existential challenges, healthcare professionals must engage deeply with these experiences (Charon, 2017; Frank, 2013; Missel & Birkelund, 2019). This highlights the role of qualitative research, which offers rich insight by amplifying patients’ voices and perspectives (Beck et al., 2023; Damsgaard, 2021). Qualitative inquiry’s strength lies in capturing the depths of these experiences, moving beyond a simple catalogue of symptoms to explore the meanings illness weaves into each person’s life (Frank, 2012). Analysing patient narratives is essential, as they hold complex themes that require careful interpretation. Ricoeur’s perspective on texts as intricate, multilayered constructs supports the idea that texts demand careful interpretation to fully reveal their meaning (Kemp, 1984; Ricoeur, 1981, 1991b). His framework is particularly well-suited for this purpose, offering a structured yet flexible method for interpreting metaphors within patient narratives. As essential components of narrative construction, metaphors enable a profound exploration of the existential aspects of illness while also embracing the complexity and multiple meanings that arise through language. This makes it an ideal framework for analysing how patients use metaphors to articulate their experiences with illness.

By focusing on qualitative methods, we can identify not only symptoms and disease trajectories but also the deeper meaning illness holds for individuals. Patient narratives are rich data sources that require careful analysis to uncover the profound significance of their experiences (Ricoeur, 1976; Sandelowski, 2004, 2015). Transitioning from individual experiences to a detailed analysis of narratives allows researchers to reveal the subtle complexities of patients’ lived realities. Ricoeur’s insights, among others, deepen this understanding, emphasising that texts are a dynamic interaction of meanings and interpretations (Kemp, 1984; Ricoeur, 1976, 1981). His narrative philosophy on texts as a plurality of constructions aligns well with the complexities of qualitative data analysis. In this sense, a text can be understood as an intricate interplay of parts and wholes, where the meaning emerges through the reconstruction of its components, requiring careful judgment (Ricoeur, 1976). This perspective resonates deeply with qualitative data analysis, where researchers interpret individual narratives and metaphors to construct a comprehensive understanding of the patient’s experiences (Frank, 1994; Toombs, 2001). Premature closure of qualitative analysis can lead to superficial findings that fail to capture the richness of patients’ stories (Connelly & Peltzer, 2016; Inayat et al., 2024). Achieving high-quality qualitative data analysis requires methodological rigor and a deep commitment to interpreting the complexity of human experience, as emphasised by Ricoeur (Ricoeur, 1976).

Metaphors are often used by individuals facing illness and serve as expressions illuminating the’ profound nature of their experiences (Beck, 2021; Sexton & James, 2022). They help to transform the unknown into the known through comparison (Moring, 2001) and, as Ricoeur argues, are not just linguistic constructs but essential components of how we perceive reality (Ricoeur, 1997). Metaphors provide a symbolic language through which patients convey the ineffable aspects of their illness journey. Metaphors act as signposts that direct attention to the emotional and existential dimensions of illness (Rizzuto, 2001). Lakoff describes metaphors as a way of conceiving one thing in terms of another, and their primary function is to understand abstract, emotional, existential, or other experiences (Lakoff, 2013). Flaherty claimed that a metaphor is one of the magical features of our language as it increases our understanding by providing more abstract concepts or experiences, tastes, smells, colours, and emotional resonance (Flaherty, 2005). A large amount of information can be packed in a metaphor, and something new is created when a metaphor is understood (Ortony, 1993). Correspondingly, Ricoeur suggests that metaphors extend the range of meaningful expressions (Ricoeur, 1976). Therefore, analysing metaphors in qualitative research is essential for uncovering the nuanced meanings and subjective realities that patients face.

Ricoeur’s narrative and metaphor philosophy provides a framework beyond surface-level interpretations, providing a nuanced understanding of metaphors’ complex layers of meaning. His view of metaphors as tools for bridging the gap between abstract concepts and lived realities (Ricoeur, 1976, 1997) aligns with the aim of this paper, which is to examine how metaphors serve as interpretative tools in qualitative research. His approach provides a robust, interpretative tool for exploring the existential and emotional depths of illness, offering insights that traditional analytical approaches might overlook. This paper aims to enhance our understanding of how metaphors contribute to the broader discourse on illness, offering a more comprehensive and sensitive approach to explaining, understanding and conveying the complexities of lived experiences within healthcare settings.

Research Questions and Structure of the Paper

To provide greater clarity on the focus of this paper, the explicit primary and secondary research questions are:

Primary Research Question

• How do metaphors function as interpretative tools in qualitative research, and what meanings do patients assign to their illness narratives through metaphors?

Secondary Research Questions

• How can Ricoeur’s philosophy of narrative and metaphor enhance the analysis of metaphors in qualitative research?

• In what ways do metaphors help in uncovering the existential dimensions of illness in patients’ narratives?

• What is the role of mimesis (1, 2, and 3) in interpreting qualitative data and providing a comprehensive understanding of patients’ lived experiences?

These research questions are designed to explore the interpretative power of metaphors in qualitative data analysis, aligned with the theoretical framework of Ricoeur.

Ricoeur emphasises the necessity of combining phenomenological descriptions with hermeneutic interpretation, grasping a comprehensive understanding and meaning of humans’ lived experiences often expressed by metaphors (Ricoeur, 1976, 1981, 1997). Guided by Ricoeur’s philosophical and methodological insights, we explore the intricate relationship between events and their interpretative meanings in qualitative data analysis. The following sections are structured to lead the reader through a comprehensive exploration of the dynamic in the metaphor analysis. In the first section, we display details concerning trustworthiness. Secondly, we highlight metaphors’ critical role and delve into the relationship between events and meanings in qualitative data analysis, guided primarily by the philosophical insights of Ricoeur. Thirdly, we unfold the role of metaphors as powerful tools in qualitative data analysis. Fourthly, we delve deeper into understanding qualitative data, and we then introduce an analytical approach consisting of three stages: Mimesis 1, Mimesis 2, and Mimesis 3, which is a powerful tool for interpreting narratives and metaphors. Throughout the paper, we give examples of how metaphors can be analysed, focusing on the interpretative nature of qualitative inquiry, where raw transcribed data are analysed through the insightful use of metaphors. In the final section, we offer practical guidance and suggestions for enhancing the quality of qualitative data analysis grounded in a phenomenological hermeneutical approach. We also discuss methodological rigor and limitations. We hope this article will help researchers identify metaphors in their qualitative data and use them as a powerful tool for analysing and interpreting the deeper meanings embedded in experiences of illness.

Researcher Reflexivity and Trustworthiness

Reflexivity and trustworthiness concern the researcher’s background and knowledge construction (Malterud, 2001; Morse, 2015). This paper draws upon examples from the author’s research (Larsen et al., 2020, 2019; Laursen et al., 2019; Lehmkuhl et al., 2023; Sjeltoft et al., 2020). Each of the included studies explores research areas with little existing knowledge and with an inductive approach throughout the analysis. The three authors work in different hospitals and are experienced qualitative researchers, each with several years of experience in the systematic collection, organisation and interpretation of textual data from speech or observation. The three researchers are all committed to the accuracy of the meaning and understanding of data illuminated by rich empirical data. Consequently, the use of metaphors in the analysis has been discussed through prolonged engagement with data and continuous discussions among the authors. The paper’s trustworthiness is reinforced by including direct quotations to highlight the role of metaphors in the narrative. The findings provide purposeful examples of how metaphors can enrich qualitative analysis. Table 1 provides a detailed description of all the studies included.

Table 1.

The Original Studies.

Study	Purpose	Participants	Methods
Laursen et al. 2019: Table in the corner: a qualitative study of life situation and perspectives of the everyday lives of oesophageal cancer patients in palliative care.	To illuminate the ways in which incurable oesophageal cancer disrupts the patients’ lives and how the patients experience and adapt to life with the disease	17 patients receiving palliative care for esophageal cancer	Interviews
			Inductive analysis
			Sampled by convenience
Lehmkuhl et al. 2023: Getting the body back on track - Understanding the phenomenon of mobilisation when conscious and mechanically ventilated patients are mobilised in the intensive care unit.	To gain an in-depth understanding of the phenomenon of mobilisation when conscious and mechanically ventilated patients are mobilised in the intensive care unit	12 patients in the intensive care unit.	Participant observations and interviews
		Seven patients were interviewed twice.	Inductive analysis
		Seven patients were interviewed twice.	Purposeful sampling
Larsen et al. 2019: Encountering an alien world of disease and treatment. A qualitative study on oesophageal cancer patients’ experiences before start of treatment and the process of participation in treatment decisions.	To explore patients with esophageal cancer experiences before the start of treatment and the process of participation in treatment decisions	16 patients with esophageal cancer	Participant observations and interviews
			Inductive analysis
			Sampled by convenience
Larsen et al. 2020: Patients’ Experiences With Illness, Treatment, and Decision-Making for Esophageal Cancer: A Qualitative Study in a Danish Hospital Setting.	To explore patient experiences with illness, treatment and decision-making	16 patients with esophageal cancer	Participant observations and interviews
			Inductive analysis
			Sampled by convenience
Sjeltoft et al. 2020: A radical change: A qualitative study of patients’ experiences of eating and daily living through the first year after oesophageal resection.	The purpose of this study is to explore the lived experiences of patients in terms of eating and consequences in everyday life in the first year after oesophageal cancer surgery	13 patients after surgery for esophageal cancer	Interviews
			Inductive analysis
			Purposeful sampling

Metaphors’ Critical Role in the Illness Narrative

In qualitative research, the interplay between events and their meanings is crucial for understanding patients’ experiences (Missel & Birkelund, 2019; Simony et al., 2018). Ricoeur emphasises the transformative power of interpretation and narrative, highlighting that events gain significance through the stories we tell about them. This narrative process is essential for making sense of our experiences and forming identity (Ricoeur, 1984a, 1994). Events in qualitative research are the observable phenomena, actions, or experiences described by patients, collected through methods such as interviews, observations, and diaries (Missel & Birkelund, 2019; Simony et al., 2018). However, events alone do not convey meaning; they require interpretation within the broader context of patients’ lives (Geanellos, 2000; Ricoeur, 1976, 1981). This process of meaning-making involves analysing and interpreting raw data to uncover the significance patients ascribe to their experiences.

Metaphors, therefore, act as co-creators, letting a new world unfold, capturing complex emotions and experiences, and providing a richer understanding of patients’ perspectives. For example, Laursen and colleagues described in their qualitative study that patients with incurable oesophageal cancer describe the loss of control and confidence in their own body caused by symptoms and treatment as “being in a zombie-like state”, as expressed here:

“After I got the stent [in the oesophagus], I started coughing a lot, and it really hurts, and I can’t eat anything. Usually, it starts at night, which means that I don’t get any sleep. So, of course, I’m tired all the time. I feel like a zombie or whatever, you know, slipping into a sleep and then waking up and then falling asleep again. And when you are in pain and when you don’t sleep at night …, then there isn’t much dignity left.”(Laursen et al., 2019)

Here, the patients use metaphoric language to convey the struggle and transformative nature of their experience. To be in a zombie-like state carries a symbolic conveyance of being a patient being hit by activity loss and being homeless in their bodies. Ricoeur’s concept of narrative identity (Ricoeur, 1984a; 1991b) is especially useful in understanding how patients make sense of their illness. According to Ricoeur, individuals constitute their identities through the stories they tell about their lives (Ivic, 2009; Ricoeur, 1984a, 1994). This narrative construction allows patients to cope with their illnesses and share their experiences with others.

Metaphors as Powerful Tools for Conveying Complexity in Qualitative Data Analysis

Ricoeur argues that metaphors are not merely decorative language but fundamental to our understanding and interpretation of reality, enabling us to perceive one thing in terms of another and thereby reveal new meanings and insights (Ricoeur, 1976). This is illustrated in the research by Lehmkuhl and colleagues, which examined the experiences of intensive care patients with early rehabilitation. In one instance, a patient described his failing body during mobilisation:

“I was just like a long-legged stork; I would almost say … it was Bambi on slippery ice. They [the legs] shook and trembled and did strange things.” (Lehmkuhl et al., 2023)

The patient employed two consecutive metaphors to express his experience of bodily weakness during critical illness. This provides insight into the patients’ struggles with feeling betrayed by their weakened body, highlighting their sense of powerlessness and dependence on health professionals for support.

Symbols, like metaphors, play a significant role in qualitative research, though their distinct functions deserve recognition (Colman, 2011). While metaphors illuminate complex experiences using vivid language, symbols provide concrete representations of abstract ideas deeply embedded in cultural and personal meaning (Ricoeur, 1997). By recognising the unique contributions of metaphors and symbols, researchers can navigate the rich tapestry of qualitative data, utilising these tools to unveil the diverse layers of human experience (Gibbs, 1992). While both metaphors and symbols are valuable tools in qualitative research, our focus in this section will primarily be on the function of metaphors due to their distinct role in capturing and conveying subjective experiences. Unlike symbols, which rely on tangible representations, metaphors operate at a linguistic level, allowing patients to express their thoughts, emotions, and perceptions through the creative use of language (Butcher, 2024). Metaphors can encapsulate complex and abstract concepts within a single phrase or image, offering researchers rich insights into patients’ lived experiences.

While the classical rhetorical view of metaphors sees them primarily as simple substitutions for literal meanings, other contemporary theories, such as those from cognitive linguistics, often emphasise metaphor as a conceptual tool that structures thought and shapes perception (Lakoff, 2013). These approaches focus on how metaphors map one domain of experience onto another, creating a more cognitive understanding of metaphorical language. However, Ricoeur’s theory of metaphors (Ricoeur, 1997), with its tension-based framework, provides a more dynamic perspective, viewing metaphors as not just replacements but as complex structures that reveal new layers of meaning and insight. This tension between the literal and the figurative is central to Ricoeur’s view, allowing for a richer, more nuanced interpretation of how metaphors operate in human experience, especially within the context of illness. By drawing on Ricoeur’s narrative and metaphor philosophy, we can engage with metaphors not only as cognitive or rhetorical devices but as powerful tools for deepening our understanding of the subjective, existential dimensions of illness. Ricoeur’s tension theory of metaphors is built on six fundamental presuppositions (Ricoeur, 1976, 1997). Table 2 presents an overview.

Table 2.

Ricoeur’s Tension Theory of Metaphors.

Presuppositions	Explanation
1. A metaphor constitutes meaning as a whole	It arises from the tension between two contrasting terms within a sentence, not just as a substitution for literal meanings.
2. A metaphor is sustained by the tension between opposite interpretations	These opposite interpretations are leading to the emergence of new meanings
3. Metaphors bridge the gap between seemingly incompatible ideas, revealing hidden connections	They solve semantic puzzles and create new insights that defy conventional classifications
4. Metaphors are solutions to semantic dissonance, akin to unravelling a riddle	They arise from resolving conflicting meanings and offering fresh perspectives on experiences.
5. Real metaphors are untranslatable because they create their unique meanings	They go beyond mere associations and contribute new insights to our understanding of the world
6. Metaphors are not ornaments but convey something new about the world	They provide profound insights into human experiences, enriching qualitative data analysis.

Firstly, a metaphor is more than a displacement of the significance of words. It results from a tension between two terms in a sentence and only as a whole constitutes meaning (Ricoeur, 1976). Secondly, this tension between opposite interpretations sustains the metaphor, leading to the emergence of new meanings. An illustration of the use of metaphors in describing illness and treatment is shown in a study by Larsen and colleagues. Here, a patient with esophageal cancer used the metaphor “feeling like a chicken” to describe the awareness that esophageal cancer posed a threat and that a treatment course was anticipated with anxiety, as shown here:

“When you have a direct telephone number to the hospital, if you have a fever, then it is serious business. Normally, I am not a chicken, but now I am worried. It would be different if it was the third or fourth time of chemotherapy.” (Larsen et al., 2019)

The metaphor “chicken” conveyed that the patients anticipated the treatment course with anxiety and insecurity. This example shows that the metaphor bridges the gap between seemingly incompatible ideas, revealing hidden connections that defy conventional classification systems.

Ricoeur suggests that metaphors serve as solutions to semantic puzzles rather than simply associations based on similarity (Ricoeur, 1976). He explains that metaphors reveal the appearance of kinship where ordinary vision does not perceive any relationship. In this sense, a metaphor uncovers a new hidden connection between terms that were previously overlooked or ignored by traditional methods of text analysis. Furthermore, Ricoeur argues that genuine metaphors are untranslatable because they generate unique meanings that provide fresh perspectives on the world rather than merely acting as decorative elements in discourse (Ricoeur, 1976). These real-life examples from qualitative research illustrate how metaphors encapsulate complex and multifaceted experiences, allowing patients to communicate their feelings and perspectives more comprehensively. Importantly, in this respect, researchers must pay careful attention to the metaphors used by patients, as they provide rich insights into their inner world (Ricoeur, 1976, 1997; Simms, 2003).

The Pursuit of Understanding

In phenomenological hermeneutical qualitative research, the pursuit of understanding transcends mere explanation, focusing on interpreting the nuanced meanings embedded within patients’ lived experiences. Building upon these foundations, this section explores how the interplay between explanation and understanding unfolds within qualitative data analysis, emphasising the pivotal role of metaphors in enriching this interpretative process.

Phenomenological hermeneutics traditionally distinguishes between explanation and understanding by prioritising the latter as a dynamic process of interpretation rather than a static act of causal analysis (Ray & Locsin, 2023). However, Ricoeur challenges the conventional dichotomy between explanation and understanding, offering a more integrated approach. Instead of viewing explanation as a mere causal act and understanding as an isolated interpretive task, Ricoeur suggests that understanding is a multifaceted, evolving process. His philosophical insights propose that understanding unfolds through a dialectical movement between explanation and interpretation, where these two modes of knowing are not separate or opposing methods but are intertwined and complementary (Ricoeur, 1976, 1981).

To set the scene and exemplify, we will start with an example from one of the author’s research (Laursen et al., 2019). In this study, it became apparent that eating difficulties forced patients with esophagal cancer to withdraw from social interactions, and one patient expressed the feeling of being “left at a table in the corner”. In this metaphorical expression, the patient’s experience of being relegated to a table in the corner symbolises feelings of isolation, neglect, and perhaps a sense of being overlooked amidst the activities of healthcare settings. Here, the authors let the metaphor make a convincing argument and explanation of what it is like to be terminally ill with esophageal cancer. The understanding of how the illness affects the patients’ social interactions and the feeling of isolation and neglect is unfolded through the metaphor.

According to Ricoeur (1976), the dialectical process of understanding involves an ongoing interaction in which explanation and interpretation work together to fully capture the richness of lived experiences. In line with this dynamic, we can interpret the patient’s metaphor as a solitary figure seated away from the centre of attention. The patient’s journey through palliative care is profoundly shaped by emotional and existential dimensions that cannot be fully understood through clinical observations alone. The metaphor of being “left at a table in a corner” reflects how patients in palliative care often experience feelings of marginalisation and a yearning for meaningful connection and care. It encapsulates the existential aspects of illness experience, highlighting the subjective reality of feeling sidelined within the healthcare environment. By engaging with metaphors like “left at a table in the corner”, qualitative researchers can explore the deeper layers of patients’ lived experiences, revealing meanings that extend beyond medical diagnostics. This metaphorical lens enriches qualitative analysis by offering insights into the emotional dimensions of illness, thereby providing a more comprehensive understanding of patient perspectives in palliative care. Building on this, we will now turn to Ricoeur’s philosophical reflections on understanding.

Engaging in critical reflection or interpretation of data consists of a dynamic interpretative reading (Geanellos, 2000; Ricoeur, 1976). Ricoeur suggests that understanding initially takes the form of a naïve grasping of the meaning of the text as a whole. At this stage, understanding is essentially a guess. As we delve deeper, comprehension evolves into a sophisticated mode of understanding supported by explanatory procedures (Ricoeur, 1976). This means that to understand the meaning of the text truly, we must move beyond merely repeating spoken words. Instead, we must generate a new event from the text, wherein the initial event has been objectified and transformed through interpretation.

The relationship between the whole and its parts demands judgment. This judgement operates through a circular process in which the assumption of a certain kind of whole is embedded in the recognition of its parts. It is through interpreting the details that we come to understand the whole. In data analysis, this process mirrors the hermeneutic circle where we constantly shift between understanding the parts and the whole, with each informing and refining the other, leading to a deeper, more comprehensive understanding. This circular movement is where metaphors emerge as potent tools, as highlighted in the earlier exploration of metaphor and symbol. Metaphors facilitate a deeper engagement with data by encapsulating complex meanings and emotions, transcending the limitations of literal language. They enable researchers to traverse between understanding the parts and reconstructing the whole narrative, thereby enriching the interpretative depth of qualitative analysis. Metaphors thus play a crucial role in bridging the gap between explanation and understanding within qualitative research. By identifying metaphors, researchers can reveal underlying pre-reflective meanings and nuances within the data, turning raw events into coherent narratives that reflect the lived experiences of patients. This transformative process enriches the quality of qualitative analysis and deepens our understanding of the complex nature of human experience.

In the following section, we delve deeper into the process of narrative construction, exploring how patients weave together metaphors to configure their lived experiences into coherent and meaningful accounts. To further elucidate the process of transforming events into meaningful narratives, we turn to the concept of mimesis as expounded by Ricoeur. Mimesis, in essence, involves representing reality through narrative (Ricoeur, 1984a, 1984b). Unlike the aesthetic use of mimesis, where representation often imitates or replicates reality, Ricoeur’s interpretation of mimesis is grounded in the lived experience. For Ricoeur, mimesis is not about constructing an idealised or fictional version of reality but about engaging with reality as it is experienced, interpreting and narrating events to make sense of them within the context of human life. In the context of phenomenologically hermeneutically informed qualitative research, mimesis is manifested in the way patients craft narratives from their lived experiences, configuring raw events into coherent and meaningful stories (Ricoeur, 1981, 1984a). This process underscores the importance of interpretation and understanding in transforming lived experiences into narratives that reflect the subjective reality of the patient’s lifeworld.

Analytical Approach and Interpretation of Metaphors

The phenomenological hermeneutical approach is a methodological framework for qualitative data analysis, which has been applied in many research studies to interpret complex human experiences (Charalambous et al., 2008; Ivic, 2009; Lindseth & Norberg, 2022; Missel & Birkelund, 2019; Simony et al., 2018; Singsuriya, 2015). Central to this approach is recognising the profound significance of interpreting lived experiences and unearthing the deeper layers of meaning inherent in qualitative data. At its core, the use of metaphors emerges as a vital aspect of this methodological paradigm (Ricoeur, 1976, 1997). Metaphors serve as potent vehicles for expression and comprehension within qualitative inquiry underpinned by phenomenology and hermeneutics. Through the use of metaphors, patients imbue their narratives with richness, nuance, and emotional resonance, thereby offering researchers profound insights into the intricacies of human existence (Butcher, 2024).

Ricoeur argues that interpretation involves moving beyond the surface level of the text (or data) to uncover the deeper meanings and intentions behind it (Ricoeur, 1981). The interpretative process consists of three stages: Prefiguration (mimesis 1), configuration (mimesis 2), and refiguration (mimesis 3). These stages mirror the process of mimesis, which refers to representing reality through narrative (Ricoeur, 1984a, 1984b, 1988, 1991a). In the context of Ricoeur’s narrative philosophy, mimesis involves the creation and interpretation of narratives that reflect the human experience.

In mimesis 1, individuals’ lived experiences are shaped by cultural narratives and personal histories. This stage sets the context for how individuals perceive and describe their experiences. In mimesis 2, individuals craft narratives from their experiences, with metaphors as significant tools for expression and comprehension. These metaphors infuse narratives with depth and richness, enabling patients to articulate the complexities of their lived experiences in a manner that resonates emotionally and conceptually (Ricoeur, 1976, 1997). At this stage, patients construct their narratives by intertwining metaphors and using familiar imagery to express complex emotions, sensations, and existential reflections. Viewed through the lens of the phenomenological hermeneutical approach, metaphors in mimesis 2 serve as windows into individuals’ lived experiences, providing researchers with deep insights into the complexities of human existence. By attentively engaging with these metaphors during analysis, researchers can uncover the nuances of meaning encoded within patients’ narratives, enriching the interpretive process and ultimately leading to a deeper understanding of the phenomena under study. In mimesis 3, the reader or researcher understands the interpreted narrative. Here, metaphors maintain their influence, though in a somewhat altered role. As the researcher engages with the interpreted narrative, metaphors act as bridges, helping to integrate these narratives into the researcher’s framework of understanding (Ricoeur, 1976, 1981, 1984a, 1997). These metaphors help researchers grasp the essence of the lived experiences conveyed within the narratives. At this stage, metaphors enrich the researcher’s comprehension of the interpreted narrative and influence their perception of the initial experiences.

By viewing the data through the lens of metaphors, researchers can empathetically engage with the patients’ subjective realities, gaining a deeper understanding of the complexities of human experience. For an example of this approach, consider the metaphor “feeling abandoned and at sea” used by a patient living with incurable esophageal cancer, as highlighted in one of the author’s research:

“When I started getting worse, I thought, who should I contact? If you rang up, anyone could pick up the phone. That’s what it felt like to me, anyway. It felt like there was no one specific to refer to, someone who knew my case. I felt abandoned – at sea. There was no one to talk to” (Laursen et al., 2019).

Prefiguration (mimesis 1) is the patient’s cultural background and personal history shaping her illness perception. The metaphor draws from her understanding of maritime imagery, symbolising stability and control amidst chaos. At the configuration (mimesis 2) stage, the patient constructs her narrative using the metaphor. “Feeling abandoned and at sea”. The metaphor encapsulates the patient’s sense of chaos and helplessness, conveying the emotional challenge of managing her illness when continuity is lacking in the healthcare system. The refiguration (mimesis 3) stage involves our interpretation as researchers. The metaphor helps us understand her emotional and existential state, bridging the gap between her subjective experience and our comprehension. Our interpretations reveal how treatment programs have been designed based on the average patient, failing to consider individual situations and needs. In the healthcare system, patients lose control over their situation, undermining their potential to reduce or minimise their vulnerability. This detailed example demonstrates how the phenomenological hermeneutical approach can be applied to analyse metaphors, providing a deeper understanding of patients’ experiences. An illustrative view of this analytical approach to qualitative data in the light of phenomenology and hermeneutics is shown in Table 3.

Table 3.

Stages of the Phenomenological Hermeneutical Approach to Qualitative Data Analysis.

Stage	Description	Role of metaphor
Prefiguration (mimesis 1)	Cultural background and personal history shape the perception of illness.	Metaphors draw from cultural and personal narratives, setting the stage for how experiences are perceived and described.
Configuration (mimesis 2)	Patients construct narratives using metaphors to convey lived experiences.	Metaphors serve as tools for expression, enriching narratives with emotional and conceptual depth. Patients use metaphors to articulate the complexities and nuances of their experiences.
Refiguration (mimesis 3)	Researchers interpret narratives, uncovering deeper meanings encoded within metaphors.	Metaphors bridge the gap between subjective experiences and researchers’ comprehension. They aid in understanding the emotional and existential aspects of patient experiences.

Metaphors play a crucial role in the phenomenological hermeneutical approach, facilitating a dynamic and reflective interpretation process through the mimesis stages. According to Ricoeur, metaphors are fundamental for making meaning of lived experiences, enabling individuals to understand and convey complex aspects of their existence by relating them to more familiar and concrete experiences, facilitating a deeper understanding of subjective realities (Ricoeur, 1976, 1997; Singsuriya, 2015). Thus, in this framework inspired by Ricoeur, mimesis not only aids in the representation of reality through narrative but also guides the interpretative journey, allowing researchers to uncover layers of meaning embedded within patients’ experiences.

Recommendations for Improving the Qualitative Metaphor Analysis

As we have argued in this paper, Ricoeur’s philosophy emphasises the depth of understanding that can be achieved through the careful interpretation of metaphors (Ricoeur, 1997). Below, we illustrate this with analytical examples from our research, demonstrating how to interpret and integrate metaphors comprehensively.

Identifying Metaphors in the Data

We begin by thoroughly reading through the data to identify metaphors used by patients. This involves looking for figurative expressions in the text that go beyond literal descriptions, such as those found in patients’ experiences of illness, rather than literal phrases. These metaphors often manifest as vivid descriptions that resonate deeply with the patient’s lived reality, and they offer insights into the emotional and existential dimensions of their experiences.

For example, a participant in a study by Larsen et al. described the struggle with eating after esophageal cancer surgery:

“Even though I did not like the eating part, I said to myself that I must eat. Otherwise, I would run into a blind alley. I cannot say, today I am tired. I need to set goals every day, also to overcome my fatigue. You can say that it is my part of it.” (Larsen et al., 2020)

The metaphor “blind alley” expands from the patients’ understanding of eating as something you can do in a right or wrong way. This metaphor encapsulates how meals and eating are no longer an automatic procedure but an event with either success or failure for the patient and an event riddled with anxiety. After identifying such metaphors, we categorise them into broader themes that emerge from the data. For instance, metaphors like “blind alley” can interpretively be categorised under themes of struggle, etc. This interpretive categorising process helps structure the data and identify the recurring themes patients use to express their experiences.

Analyse the Metaphor’s Meaning

Once metaphors are identified and categorised, we analyse and interpret their deeper meanings. We explore what the metaphor reveals about the participant’s perceptions and emotions, namely, the feelings of being trapped or facing insurmountable obstacles in the illness process. In the example mentioned above, the metaphor of a “blind alley” suggests that eating is not just a physical act but a significant moment of decision and consequence for the patient’s recovery journey. It portrays eating as a battleground and an event riddled with struggle and fight, and associated with patients’ progress and recovery. Therefore, difficulties with eating are viewed as an obstacle to overcome and something the patient is obligated to do. The metaphor helps us to understand the worries associated with eating for patients surgically treated for esophageal cancer, and the anxiety and nervousness connected with eating as it symbolises recovery and a return to everyday life. If the patient can overcome eating difficulties, this means hope for the future and progress.

Integrating Metaphors into Broader Analytical Themes

At this stage, we synthesise the individual metaphors into broader analytical themes. We explore how each metaphor relates to other data points and interpret its significance within the larger narrative of the patient’s illness experience. For instance, in a study of patients’ lived experiences regarding eating and consequences in everyday life in the first year after esophageal cancer surgery, a thematic metaphor emerged from the narratives collected, termed “a nutritional jungle”. This metaphor was based on patients’ expressions of nutritional challenges, as shown here:

“You don’t have an idea of how much of the different foods you need, especially when your appetite is low or you feel nauseous. Is it o.k. to eat this? Or should I take supplements? I think it was good to talk to a nutrition nurse about it.” (Sjeltoft et al., 2020)

The metaphor “a nutritional jungle” vividly encapsulates the patients’ experience of feeling overwhelmed and disoriented in their new dietary landscape. It reflects their struggle to navigate a complex and often confusing environment where they must determine what to eat, how much, and when, all while adapting to significant changes in their body post-surgery. The metaphor of “a nutritional jungle” conveys the sense of being lost or challenged in a dense, tangled terrain of dietary choices and restrictions, highlighting patients’ profound adjustments and uncertainties in managing their nutrition in this transformed state.

Constructing New Metaphors as Themes

Beyond identifying metaphors, we consider constructing new metaphors that emerge from synthesising various patient narratives. Researchers can develop thematic constructs that offer a comprehensive understanding of complex experiences by creatively combining and interpreting multiple metaphors. This approach enriches the interpretative depth of qualitative analysis and provides a nuanced portrayal of how patients conceptualise and articulate their illness experiences. For instance, when patients illuminate how they handle the uncertainty connected to cancer diagnoses and treatment, one participant in Larsen et al.’s study described it like this:

“We do not know what we are supposed to do tomorrow, we do not know if we are going to do anything tomorrow. We do not know anything. This is really the worst part of it - the waiting and not knowing when the treatment starts.” (Larsen et al., 2019)

This quote illustrates the vulnerability and powerlessness concerning the future and the thoughts and uncertainty the patients have to endure. Other participants in the study had similar expressions, leading to the theme entitled “being in no man’s land”. Here, the author uses the metaphor of being in no man’s land to describe the anxiety and powerlessness patients endure when they are put in a waiting position. This helps construct and present a comprehensive understanding of the participant’s experience, capturing complex emotions of existence in connection with a cancer diagnosis.

Comprehensive Understanding of Lived Experiences in Metaphors

By following this step-by-step approach, inspired by Ricoeur’s phenomenological hermeneutical philosophy, researchers can effectively incorporate and interpret metaphors in qualitative data analysis, leading to more nuanced and insightful themes and findings. Metaphors contribute to the vividness and presence of an experience. However, we must ask: Does this metaphor illuminate an aspect of meaning that captures what the experience was truly like? The goal of the text is to gain a deeply embedded meaning. Maintaining a critical distance in interpreting the text is essential to comprehensively understand lived experiences in metaphors (Dreyer & Pedersen, 2010; Ricoeur, 1981). According to Ricoeur, critical interpretation is an in-depth interpretation that points towards a new understanding of the human lifeworld (Ricoeur, 1976, 1984a). In the description of illness metaphors such as illness as disruption, being in a zombie-like state, being like Bambi on slippery ice, feeling abandoned and at sea and being in no man’s land, the meaning of illness was expressed. All of these phenomena point towards a new understanding of patients’ life-world when expressing experiences with their illness, and let us grasp the patients’ particular concerns of living with illness. Thus, understanding metaphors serves as a reflection on the meaning of illness.

Contextualising Findings

The final step in this Ricoeur-inspired qualitative metaphor analytical process involves placing the identified themes and metaphors within their sociocultural context. This is a critical stage in understanding how cultural attitudes, societal norms, and broader social narratives shape patients’ metaphors to describe their illness experiences (Frank, 2012, 2013). By considering the cultural and social influences, researchers can better understand the meanings embedded in the metaphors and how these reflect patients’ lived realities within a particular context. For instance, the metaphor “nutritional jungle” does not just represent the patient’s confusion and disorientation regarding their new dietary needs after surgery. It also reflects a broader societal view of food as more than just sustenance; food is often conceptualised as a tool for healing, recovery, or even a form of medicine in many cultures (Winkelman, 2008). This metaphor, therefore, connects the individual experience of navigating post-surgery nutrition with broader cultural expectations about food’s role in health management. Contextualising the metaphor in this way helps to illustrate how patients’ experiences are shaped not only by their personal circumstances but also by societal attitudes toward health, illness, and recovery. It shows how the “nutritional jungle” is not just a personal struggle but also part of a larger societal framework in which patients must navigate complex and sometimes contradictory messages about what constitutes proper care and recovery.

Contextualising findings requires the researcher to reflect on how the metaphors interact with broader cultural narratives (Frank, 2012; Morris, 2000; Ricoeur, 1981). For example, metaphors like “fighting a battle” or “winning the war” are common in illness narratives and can be understood through the lens of societal norms that acknowledge strength, resilience, and triumph over adversity. These metaphors align with Western ideals of overcoming obstacles through personal will and effort, influencing how patients view their journey toward recovery. In contrast, other cultures may frame illness as something to live with rather than fight against, leading to different metaphorical expressions (Frank, 2013; Winkelman, 2008). By contextualising metaphors within their sociocultural backdrop, we not only deepen our understanding of the metaphors themselves but also gain insight into how societal values and cultural expectations shape how illness is experienced and narrated. This broader contextualisation makes the findings more relevant for the specific patient group studied and for understanding the collective and cultural dimensions of illness and recovery across different populations. An illustrative view of guiding steps for a Ricoeur-inspired qualitative metaphor analysis is shown in Table 4.

Table 4.

Guiding Steps for a Ricoeur-Inspired Qualitative metaphor Analysis.

Step	Description
Identifying metaphors in the data	Begin by thoroughly reading through the data to identify metaphors used by patients. Look for phrases and expressions that describe experiences in figurative terms rather than literally.
Identifying metaphors in the data	Example: In a study by Larsen et al. (2020), a patient described the struggle with eating after esophageal cancer surgery using the metaphor of a “blind alley,” highlighting the significant decisions and outcomes associated with meals.
Analysing the metaphor’s meaning	Once identified, analyse and break down the metaphor to uncover its deeper meanings. Consider what the metaphor reveals about the patient’s perceptions and emotions.
Analysing the metaphor’s meaning	Example: The metaphor of a “blind alley” suggests that eating is not just a physical act but a decisive event filled with struggle and significance for the patient’s recovery journey.
Integrating metaphors into broader analytical themes	Incorporate identified metaphors into broader analytical themes emerging from the data. Explore how each metaphor relates to other data points and interpret its significance within the larger narrative of the patient’s illness experience.
Integrating metaphors into broader analytical themes	Example: The metaphor of “a nutritional jungle” conveys how patients feel insecure and are having a hard time with the nutritional challenges after surgery for esophageal cancer (Sjeltoft et al., 2020)
Constructing new metaphors as themes	Move beyond identifying metaphors to construct new ones synthesised from various patient narratives. Develop thematic constructs that offer a comprehensive understanding of complex experiences and enrich the interpretative depth of qualitative analysis.
Constructing new metaphors as themes	Example: A metaphor like “being in no man’s land” describes the uncertainty of waiting for cancer treatment and captures emotional turmoil and powerlessness during the diagnosis-to-treatment period (Larsen et al., 2019).
Comprehensive understanding of lived experiences in metaphors	Adopt a structured approach inspired by Ricoeur’s hermeneutical philosophy to effectively incorporate and interpret metaphors in qualitative data analysis. This methodological rigour leads to nuanced and insightful themes and findings, enhancing the vividness and presence of patient experiences.
Contextualising findings	Place the identified themes and metaphors within a sociocultural context, examining how cultural attitudes, societal norms, and social narratives influence the metaphors patients use. By contextualising metaphors, a deeper insight into how personal and societal factors shape patients’ experiences will enrich the interpretation of illness narratives.

Methodological Rigor and Limitations

Identifying metaphorically used words in a large text may be something the researcher has ready intuitions about, but justifying those intuitions and being consistent in how they are applied to individual words in context is tricky and challenging work. Metaphor identification is crucial to the latter analysis because metaphor use is often subtle and beyond people’s conscious awareness. According to Malterud, the researcher’s position and perspectives will always affect what they are studying, which commits the researcher to establish meta-positions and share preconceptions (Malterud, 2001). The authors of this article believe that metaphor analysis can help researchers establish methodological rigor. Furthermore, metaphor analysis is a way of conceiving one concept in terms of another and serves as a function of understanding (Lakoff, 2013). However, the qualitative researcher must still consider the researcher’s role in the research process and involve honest reflexivity (Morse, 2015). This must include reflections about arguments in presenting themes and show rich empirical data material. Thick and rich data refer to the complete data set, meaning that data quality is also linked with the number of interviews and/or participants. Our metaphorical analysis in this paper is based on 81 interviews among 58 participants who all have experiences with illness and hospitals.

High-quality interviews are richly detailed, and when they happen, the researcher has learned something beneath the surface of the person with whom you are talking (Kvale & Brinkmann, 2014). Getting to the core of people is not easy, and it is essential that the interviewers can hear data and provide good interview questions, capturing fine-grained levels of meaning. The three authors have all been part of the data collection together with other researchers in the studies, ensuring data appropriateness and prolonged engagement with the data material.

Ricoeur’s philosophy of narrative and metaphor offers a distinctive advantage over other theoretical frameworks. In contrast, cognitive linguistics often treats metaphors as cognitive tools that structure thought and shape perception (Lakoff, 2013), while Ricoeur’s approach delves deeper into metaphor’s existential and narrative dimensions. On the other hand, Gadamer’s hermeneutics emphasises the fusion of horizons and the importance of preconceptions in interpretation (Gadamer, 2013). In contrast, Ricoeur’s framework provides a more structured approach to understanding how metaphors function within narratives. Ricoeur’s dialectical process of interpretation allows for a dynamic interplay between explanation and understanding, whereas Gadamer’s approach is more focused on the historical and dialogical nature of understanding. Additionally, social constructionist theories which frequently highlight the influence of social interactions in shaping knowledge and meaning (Berger, 1971), provide valuable insights into the collective construction of reality. However, they may not fully capture the richness of individual subjective experiences that Ricoeur’s approach fascilitates. Unlike these theories, Ricoeur’s framework encourages a deep, individualised analysis of the metaphorical language that individuals use to navigate their lived experiences. Ricoeur’s approach is particularly well-suited for examining the rich, nuanced meanings embedded in patients’ illness narratives. By choosing Ricoeur’s framework, we align ourselves with a philosophy that recognises the power of metaphors in human experience and provides the methodological tools to unpack and interpret these metaphors in a way that respects the depth and complexity of individuals’ narratives.

While this paper highlights the potential of metaphors as powerful tools for interpreting qualitative data, drawing on Ricoeur’s philosophical framework, this approach also has limitations. First, while we have suggested a structured approach to identify and interpret metaphors, the process remains inherently subjective. The researcher’s perspective and pre-understandings play a significant role in how metaphors are identified, categorised, and interpreted (Gadamer, 2013). Despite efforts to maintain reflexivity and transparency, the interpretative nature of this approach means that the researcher's subjectivity can inevitably influence both the analysis and interpretations. This introduces the risk of either overly superficial readings or profound interpretations, where the nuances of the data might be underexplored or overemphasised. Additionally, the reliance on interview data means that the richness of patients’ metaphors is shaped by the specific context in which the interviews took place, including cultural, social, and temporal factors (Seidman, 2013). The diversity of these contextual factors may impact how metaphors are expressed, limiting their transferability across different settings and populations.

Another limitation concerns the transferability of the findings (Polit & Beck, 2021). While our suggested analysis offers valuable insights into the role of metaphors in illness narratives, these insights are grounded in a specific group of patients and may not apply to all populations. The cultural and contextual relevance of the metaphors may vary depending on the patients’ backgrounds, the healthcare setting, and other situational factors (Berger, 1971). While using metaphors in qualitative research provides a nuanced and sensitive approach to understanding illness experiences, researchers must remain mindful of the methodological and contextual limitations when concluding. Nevertheless, by grounding our qualitative analysis in Ricoeur’s philosophy of narrative and metaphor, we have demonstrated how this approach can enrich our understanding of the complexities of lived experiences and their sociocultural dimensions.

Implications for Future Qualitative Research

For researchers, the methodological power of examining the function of metaphors in qualitative research in patients’ illness experiences serves as convincing arguments. Using metaphors actively in interpreting themes gives a comprehensive account of the studied phenomenon, and we can gain a deeper appreciation for their unique capacity to illuminate the multifaceted dimensions of human illness experiences. However, the qualitative researcher must engage deeply with the data collection, and one of the main goals of excellent qualitative research is that qualitative inquiry is more than a collection of technical skills or strategies and requires a team effort.

Final Remarks

Metaphors naturally bring attention to the concerns of living with illness, allowing individuals to reflect on and recreate their experiences. Qualitative data analysis is an intense and iterative process that requires careful thought. The use of metaphors enables researchers to gain a deeper understanding of patients’ illness experiences while also compelling them to demonstrate to the reader how they arrived at the themes and arguments they present. In qualitative analysis, metaphors can make the unique more comprehensible, emphasising the singularity of a phenomenon or event. This uniqueness is deeply connected to human experience, cognition, and existence. Metaphors thus serve as a bridge between the unique and the universal, shedding light on the existential dimensions of human lived experiences. They allow for a deeper understanding of the shared, yet often hidden, aspects of life, helping us recognise and relate to the universal themes that shape individual and collective experiences. Ricoeur’s philosophy of narrative and metaphor aligns with this perspective, highlighting the role of metaphors in linking individual experience with universal understanding. He suggests that metaphors do more than represent abstract concepts - they provide profound insights into the lived reality of individuals. Through Ricoeur’s approach and the role of mimesis in interpreting metaphors, metaphors become tools not only for linguistic expression but also for capturing the existential and emotional depths of human experience, particularly in the context of illness.

Footnotes

Acknowledgements

We would like to thank the authors of the original studies for sharing their data for this methodological article. We would also like to thank all patients who have shared their stories.

ORCID iD

Malene Kaas Larsen

Ethical Statement

Funding

The authors received no financial support for the research,authorship,and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Data Availability Statement

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. *

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