Telling stories about illness is to give voice to the body … the body sets in motion the need for new stories when disease disrupts old stories.
Frank (1995)
Introduction
Many of my colleagues will be pleased to know Chapter 6 does not address the grammar and structure of language: that is, it is not concerned with The cold blooded murder of the English tongue (Professor Henry Higgins, My Fair Lady), although I have done my best to preserve the English tongue—you will not find any ‘weasel words’ (Watson 2004), tense disagreement, dangling participles, split infinitives or ‘undefined this’, in my chapters. Likewise, the chapter does not concern linguistics. It discusses the power and drama of language, what language is, how it shapes people’s thoughts and behaviours, and the social context in which language is used.
What is language?
It should be easy to provide a precise definition of ‘language’, but definitions differ depending on whom one asks. For example, The Shorter Oxford Dictionary provides several meanings for ‘language’ including:
The whole body of words and methods of combining them used by a nation, people or race. A method of expression other than by words…. Ability to speak a foreign tongue … style of composition.
Writers, philosophers and linguists use other ‘definitions’, for example:
- Speech is a complex activity encompassing the means of persuasion, the language and the proper arrangement of the various parts of the speech. (Aristotle translated by Roberts 1954).
- Language is the dress of thought. (Samuel Johnson’s 1709–1784 translation of Quintillian’s witticism).
- Language is a collection and unconscious art. (Charles Darwin 1871)
- The shape of thought. (Whorf 1956).
- To write jargon is like perpetually shuffling around in the fog and cotton wool of abstract terms. (Sir Arthur Quiller-Couch 1916).
The last comment is particularly pertinent to diabetes education. If we do not use clear, unambiguous language, written and spoken, tailored to the particular individual or group, they will ‘shuffle around in the fog’ and the educator may not even be aware the fog exists. Creating fog is particularly easy when the educator and the person with diabetes do not speak the same language or have different literacy and numeracy skills, goals and experiences of diabetes (see Chapter 13). Recognising and clearing the fog relies on excellent communication skills to arrive at a shared understanding/meaning.
A composite definition of language might be:
The process humans use to communicate thoughts, feelings and ideas using voice, sounds, gestures and written or pictorial symbols. The system includes rules for combining components such as words, gestures (coverbal behaviours), paralingual sounds (phonetics), and body language to arrive at a shared understanding or common meaning.
Different parts of the brain are involved in different aspects of language. Damage in any of these areas could affect other areas and communication:
- Wernicke’s area — Comprehension
- Upper temporal lobe — Auditory reception
- Broca’s area in the frontal lobe — Encoding speech
- Exner’s area in the frontal lobe — Motor control of writing
- Part of the parietal lobe — Manual signing
- Occipital lobe — Visual input (Crystal 2006, pp. 171–179)
In addition, the mid-superior temporal sulcus, rostral prefrontal cortex and the frontal and temporal cortex are involved with social cognition. These regions are important for a variety of communication behaviours such as interpreting facial expressions, gestures, theory of mind and predicting the behaviour of other people (Johnson 2011).
Components of language
The main components of language are speech, gestures, paralingual sounds, and body language.
Paralingual sounds
Paralingual sounds (sometimes called phonetics) are vocal noises superimposed on speech. They have some, but not all, of the properties of language, for example laughing and crying while speaking (Crystal 2006, p. 14). Paralingual sounds add ‘emotional colour’ to speech to make it more interesting. Paralingual sounds serve a similar purpose to gestures and body language. One can almost hear the paralingual sounds in some writing, particularly when it is spoken, for example many Dr Seuss books.
Gestures
Humans use many gestures to communicate and emphasise spoken language; although gestures are a form of sign language, few have a formal structure and range. Auslan, a sign language, does have a defined structure and complexity. Different gestures and symbols have different meanings in different cultures and languages.
Speakers use several types of gestures:
- Emblems/symbolic gestures, many of which are universally understood such as ‘thumbs up’.
- Batons/beats, simple repetitive rhythmic hand movements that coordinate with the tempo of the sentence.
- Gesticulations, which often accompany spontaneous speech. Gesticulations vary and are usually non-repetitive and might be related to the content of the message (Krauss and Chiu 1997).
Diabetes educators could use relevant gestures to support and emphasise diabetes education messages, but overuse can be distracting and defeat the purpose.
Words
Words are a key aspect of language in addition to gestures and paralingual sounds, and can be spoken or written. Words are just nouns, pronouns, verbs, adjectives or adverbs until the writer, speaker and listener give them meaning, but the meaning each person attaches to the word, might be, and often is, different. In addition, meaning is influenced by whether and how the word is spoken or written and environmental and other factors such as body language, which is discussed later in the chapter.
Spoken
The speaker’s voice (diction, tone, pitch, range), speaking speed, where the speaker places the emphasis, punctuation, where and how words fit in the speech, paralingual sounds, gestures, the personal meaning individuals attach to the word(s), their culture, education and literacy level, feelings at the time, health status and culture affect the way language is interpreted.
Listener characteristics: all of the speaker characteristics as well as hearing acuity, interest in the topic, concentration span, listening skills and learning style.
Environment: noise, privacy and other distractions.
Written
Written words can be inert, ambiguous or very clear, depending on how the sentences are constructed and the ‘signposts’ the writer uses to help the reader find meaning in the text. Passive language and weasel words are more likely to be ambiguous than active, clear writing. Examples of passive language abound in many government documents, just watch any episode of Yes Minister or listen to parliamentarians being interviewed on the news. Weasel words can be useful if the intention is to create fog and confuse, or reduce tension and slow the pace in fiction writing, but they usually do not belong in diabetes education information.
‘Signpost’ in the context of writing refers to punctuation, headings, subheadings, design and layout, which help the reader navigate the text. Grammar and words can have a profound effect on how people see the world (Boroditsky 2003) and by extension, their diabetes. Significantly, people who speak different languages think differently.
Thus, words come alive in the minds of the individual, or they are discarded if the word is not understood or the individual is not interested in the topic. Words can be the starting point in a conversation, or a conversation stopper. They can help people assemble information they already know, or trigger new learning, which has important implications for both spoken and written diabetes education information.
Learning a language
Learning any language is not easy, except for children! Consider the word ‘diabetes’. Most diabetes educators know it is derived from the Greek word for ‘siphon’. However, most people diagnosed with diabetes have to learn a lot of words related to diabetes, such that it could be considered a ‘language or dialect’ in its own right. Diabetes is a very complex language, and like all languages, it constantly evolves as new words are added and old ones are discarded.
Diabetes educators have to learn ‘diabetes’ initially and then keep up-to-date with the evolving language. But do diabetes educators and people with diabetes speak the same diabetes language/dialect?
Can you understand the following Old English verse from Beowulf?
Alegdon tha middes maerne theoden
Haeleth hiofende hlaford leofne
Ongunnon tha on beorge bael-fyra maest
Wigend weccan wudu-rec astah
Sweart ofer swiothhole swogende leg
Wope bewunden
Perhaps modern English is easier:
The sorrowing soldiers then laid the glorious prince, their dear lord, in the middle. Then on the hill the war-men began to light the greatest of funeral fires. The wood-smoke rose black above the flames, the noisy fire, mixed with sorrowful cries.
Chickman and Howett (2006)
Did you try to understand the Old English or give up because it is not relevant to you and you are not interested in it anyway? Did you ‘cheat’ and read the modern English version? If you could read it, it tells you quite a lot about how the soldiers regarded their dead Prince and their funeral rites. Likewise, written diabetes information generally contains a lot of information about diabetes, but unless the individual can read and understand it easily, is interested in it and it is relevant to their needs at the time, they are likely to ignore it.
A great deal of ‘diabetes’ reflects the biomedical language of health professionals (HPs) rather than the psychosocially oriented language people with diabetes use. When relating to people with diabetes, HPs often only hear the former. When that happens, there is a mismatch between what the individual wants to know or discuss and what HPs want to know and discuss (Scheeres et al. 2008).
The power of language
Language is so powerful that the major cause of health-related critical incidents and complaints about HPs are the result of ineffective communication on the part of HPs. Not recognising the importance of language and culture can result in health-related problems, inhibit a person’s ability to provide informed consent and understand and accept a diagnosis and treatment, dissatisfaction with care, and preventable morbidity and mortality (Flores et al. 2002).
Language in the broadest context influences the way people:
- Perceive and remember events
- Make decisions about causality
- Understand written and spoken materials and numbers
- Perceive and experience emotion
- Choose to take risks
- Think about other people (Boroditsky 2003).
When people learn a new language they also learn new ways of thinking. Thus, the language(s) people speak has a profound effect on the way they think, view the world and live their lives, and can affect the people around them.
The book The Uncommon Reader (Bennett 2007) is a fictitious account of the profound effect a chance encounter with a mobile library had on Queen Elizabeth II. The Queen became obsessed with books. The story traces the consequences of her obsession on her family, her advisers, who, among other things, had to warn the public: ‘Her Majesty will probably ask you what you are reading’. The obsession even threatens her position as Queen. Over 20 books are mentioned in the novella.
The title is a play on the word ‘common’, which has several meanings in English: vulgar, ordinary and anybody who is not royal or of noble birth. But how does Queen Elizabeth’s reading habits relate to diabetes? Consider the Diabetes Australia (DA) (2011) Position Statement: A New Language for Diabetes. The Statement highlights the effect language and words can have on an individual’s health, self-identity and self-efficacy, and suggests some ways people with diabetes could interpret words like ‘disease’, ‘failed’, ‘blood tests’ and ‘compliance’ and recommends some alternatives.
Readers will note I was deliberately non-compliant with the Position Statement recommendations in Chapter 11: I choose to use the words ‘compliant’ and ‘non-complaint’ with respect to medicine use. These words embody far more complex behaviours/issues than is apparent on first reading the words. Compliance and non-compliance were more appropriate in Chapter 11 than many of the current euphemisms. HPs are not immune to non-compliance!
Hitler’s Private Library: The Books That Shaped His Life (Ryback 2009) is an account of the books that shaped Hitler’s thoughts and deeds—fascinating, considering Hitler is renowned for burning books. Hitler’s book choices are interesting, and his handwritten notes, comments in the margins and underlined passages of text tell the reader a lot about how the words affected him and shaped the dictator he became. A lot of the text Hitler highlighted, and his margin notes, are evident in his speeches.
Hitler is quoted as saying ‘… I take what I want from books’ (Ryback 2009, p. xi). Hitler ranked the Collected Works of Shakespeare, Don Quixote, and Uncle Tom’s Cabin among the greatest works of world literature. In addition, he owned many works by German writers and other world philosophers including von Goethe.
Anybody reading my writing can see books have a powerful influence on my thinking and philosophy, including my philosophy of diabetes education (Chapter 3). I am a voracious reader, and love good writing. I get enormous pleasure from creative and academic writing. Like Hitler, I write notes in book margins and underline or highlight text, I too ‘take what I want from books’, but there the comparison ends!
People with diabetes also ‘take what they want’ from written and spoken information diabetes educators provide, they highlight and use what is interesting and relevant to them and discard the rest. Thus, the individual with diabetes has control over whether and how they use information. However, not all language is verbal or written: body language plays a major role in communication.
Body language
Body language is a sophisticated language that emerged before spoken language (Eggert 2010). Complicated messages can be communicated via body language, just think of mimes and charades. Likewise, babies have different cries to signify hunger or discomfort. Some body language is universal, but most people develop their own body language style, which is influenced by their culture, upbringing, role models, manners and etiquette, experience and social environment. Thus, the more time a diabetes educator spends with an individual, the better they will understand them.
Body language acts as a catalyst between the words people say and the full meaning they wish to convey. Thus, body language helps give colour, drama and meaning to spoken language. Some experts believe humans are programmed to use and understand basic body language (Ekman 1982), which helps people respond to the situation, for example when it is another person’s turn to speak, or when the individual does not understand what was said. However, it is essential to listen, check assumptions and consider cultural differences, rather than jumping to conclusions or speaking at cross-purposes.
Body language refers to the unconscious movements people make while thinking, speaking and listening. Often the individual is unaware of their body language; at other times they use it deliberately. Mehrabian (1971) said there are three main components of face-to-face communication and indicated the percent contribution of each component to the communication:
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