Qualitative Research Methods for Psychologists || Diagnostic Discourse in Patient-Staff Interactions

5

Diagnostic Discourse

in Patient–Staff

Interactions:

A Conversation

Analysis Clarified

by Participant

Interviews

Jessie Goicoechea

Editor’s Introduction

Background

A Phenomenological, Hermeneutic, and Discourse

Analytical Approach

The Researcher’s Preconceptions

Method

Site of Data Collection and Illustration of the Context

Data Collection: Treatment Team Meetings andInterviews

Interpretation of the Data

Results: Diagnostic Discourse in Patient–Staff Interactions

Discussion

References

Biographical Background

Qualitative Research111

Copyright � 2006 by Elsevier.Methods for Psychologists All rights reserved.

EDITOR’S INTRODUCTION

Dr. Goicoechea was aware of the usefulness of psychiatric diagnosis

for such purposes as shorthand communication among mental healthprofessionals and for clarity of diagnostic criteria for research on treatmenteffectiveness. However, she was also aware of the typically unacknowledged

impact of this system when used by professionals in their discussions(‘‘discourse’’) among themselves and with patients. In this study, which took

place in a psychiatric hospital, she goes beyond published social andpolitical critiques to look at how actual conversations utilizing diagnosticlanguage shape roles, expectations, understandings, and identities. The

critiques come alive, no longer being just philosophical and conceptual. Wealso see that both staff and patients take up diagnostic talk in diverse waysnot noticed in the literature, and we are encouraged to think critically about

how ‘‘insight into illness’’ is negotiated.Goicoechea, like many of our researchers, adapted an established method,

conversation analysis, to suit her subject matter best. She added phenom-enologically analyzed interviews of all parties to clarify and extend herunderstandings of how staff and patients participated in diagnostic practice.Earlier, as a doctoral practicum student, she had, in effect, conducted anethnographical familiarization with the hospital culture. This carefullytailored methodological combination culminated in findings that invite us toreflect on the powerful systemic impact of psychodiagnostic language on itsparticipants.

The chapter’s Background section provides a useful feel for some ofthe philosophical assumptions of phenomenological, hermeneutic, anddiscourse analysis researchers. Then the chapter provides us with a vividdescription of the hospital setting, an illustrated account of the method, anda report of the findings and their implications.

BACKGROUND

The establishment and use of an official diagnostic language have beenextremely influential in shaping the mental health field. As Kirk and

Kutchins (1992) noted in regard to the Diagnostic and Statistical Manual ofMental Disorders, fourth edition (DSM-IV):

It immediately shaped almost all discussion of diagnosis not only in the United

States, but throughout the world. References to it are ubiquitous in the mental

health journals, where by 1990 over 2,300 scientific articles explicitly referred to it in

the title or abstract. Most clinical discourse and psychiatric research are conducted

within its confines. (p. 11)

Although many have argued for the clinical necessity and scientificvalidity of such a system (e.g., Kendell, 1975; Klerman, 1984; Maxmen,

112 Qualitative Research Methods for Psychologists

1985; Wolman, 1978), others have voiced concerns regarding the waysin which mental illness has been socially constructed through the establish-ment and application of this psychiatric vocabulary (e.g., Caplan, 1995;Kirk and Kutchins, 1992; Szasz, 1974, 1993). Although these debateshave attended to the ways in which diagnostic language permeates clinicaland scientific discourse about mental illness, relatively little has beensaid regarding how diagnostic language enters directly into conversationsbetween clinicians and patients. Hence, for my doctoral dissertation, Iconducted a qualitative study of the ways in which diagnostic language,a language that makes reference to one’s status as mentally ill, organizespatient–staff interactions within treatment team meetings on an adult,inpatient unit of a state psychiatric hospital. My research included thefollowing questions: How is diagnostic discourse used to inscribe someidentities as therapeutic experts and others as mentally ill patients? Howdoes this discourse shape the patient–staff relationship? How does thisdiscourse promote (or impede) a shared understanding of the patient’sdifficulties, an understanding that holds compelling meaning for both staffand patients?

In this chapter, I present the study as a whole, but focus mostly on howI used a conversation analysis (Levinson, 1983; Nofsinger, 1991) modifiedand informed by the following research approaches: discourse analytic(Potter, 2003), phenomenological (Giorgi, 1970, 1985; Wertz, 1985), andhermeneutic (Packer and Addison, 1989; Walsh, 1995). I supplementeda conversation analysis of transcribed treatment team meetings with athematic analysis of my own interviews with treatment staff and patients.Drawing on these approaches and methods, which value language as con-stitutive of social reality and are rooted in a philosophical anthropology thatallows access to intersubjective meanings, my analysis focused on patient–staff interactions as those actions occurred, and on the ways in which theparticipants experienced those actions. By integrating three different sourcesof data, I gained access to places of convergence and divergence within theparticipants’ experiences.

My results are a structural description that weaves together the findingsfrom the conversation analysis of the team meetings and the thematicanalysis of the interviews. This description shows how diagnostic discoursewas used by the staff to teach patients to interpret their experience andbehavior as being symptomatic of mental illness. Diagnostic discourse wasused to promote insight, which is constituted by staff as the patient’sacceptance of him or herself as mentally ill. The development of insight washeld as one of the main goals of treatment, for it was viewed as ultimatelyenabling the patient to manage his or her symptoms and to reach stabi-lization. However, although the patients in this study could name theirdiagnoses in ways that closely matched their charts and even accepted theirdiagnoses as accurately representing certain aspects of themselves, they did

Diagnostic Discourse in Patient–Staff Interactions 113

not necessarily feel understood by the staff. These patients asserted theirown understanding of themselves as a way of resisting being categorized,within a struggle over identity and understanding. Whether these patientsaccepted or rejected the staff ’s view of them, their identity was at stake.Ultimately, the research results illustrate that diagnostic meaning is locallyforged within a context of identity construction and within a struggle formutual understanding.

In the final section of this chapter I discuss my findings in light of theexisting literature on diagnostic terminology in patient–staff interactions.This discussion is not exhaustive, but situates the results of this studytheoretically by attending to claims made by labeling theorists and moretraditional approaches to psychiatric diagnosis.

A PHENOMENOLOGICAL, HERMENEUTIC,

AND DISCOURSE ANALYTICAL APPROACH

A human scientific approach to psychological research developsmethods that do justice to its subject matter—namely, human beings andtheir experiences. Recognizing the importance of allowing the subjectmatter to speak on its own terms, researchers return to the phenomena ofeveryday life as they are actually lived, experienced, and enacted. Con-cretely this means that rather than forcing the subject matter to conform toa preexisting method, the researcher allows the phenomenon of interest toguide her to an appropriate method.

With the introduction of hermeneutics, social constructivist approaches,and postmodern perspectives, the inescapability of interpretation hasdemanded that qualitative researchers think critically about how theirapproach prefigures not only their methods, but also their findings. Myunderstanding of a researcher–researched dialectic draws from theHeideggarian notion of the hermeneutic circle: ‘‘Whenever something isinterpreted as something, the interpretation will be founded essentiallyupon fore-having, fore-sight, and fore-grasp. An interpretation is never apresuppositionless apprehending of something presented to us’’ (Heidegger,1962, pp. 191–192). Within this hermeneutic tradition, unlike perhapsa more Husserlian phenomenological approach, the issue becomes not somuch putting aside or out of mind one’s assumptions to reach clarity,but being aware of and articulating the way one’s assumptions radicallyinform one’s reading of the text.

The research results are not evaluated according to a correspondencetheory of truth, but as a new text and an interpretation that is open tomore interpretation. As von Eckartsberg states, ‘‘It is a process of contextu-alization and amplification rather than of structural essentialization.Hermeneutic work is open-ended and suggestive, concerned with relational


fertility’’ (1986, p. 134). The research becomes a text that answers thequestions for which the study was conducted. When evaluating validity,criteria of coherence, comprehensiveness, consistency, and plausibilityare used (Packer and Addison, 1989).

This study also drew from the approaches of discourse analysis anddiscursive psychology, as the study of how talk is used to perform socialactions and the application of these ideas respectively (Potter, 2003). AsPotter (2003) discusses, discursive psychology focuses on talk and texts withinspecific social practices. Its basic theoretical principles include (1) thatdiscourse is the primary medium of human action and that actions areembedded in broader practices; (2) that discourse is locally, institutionally,and rhetorically situated; and (3) that discourse is constructed and con-structive, the latter meaning that versions of the world and people’sexperiential worlds are created and maintained through talk. Given theseprinciples, discourse analytic studies, including those that utilize conversationanalysis, typically ask ‘‘how’’ questions. Examples of research topicsinclude the ways psychological terms and notions are used in practicalsettings, such as what resources are used to construct and identify‘‘delusional’’ speech in psychiatric practice (Georgaca, 2000), and how thepsychoanalytical notion of repression can be understood in conversationalterms (Billig, 1999).

As ‘‘an approach or a stance rather than a method’’ (McLeod, 2001),discourse analysis allowed me to develop a method unique to this study—one that utilized a conversation analysis clarified by a thematic analysisof participant interviews. As McLeod (2001) ‘‘In terms of specifyingor recommending procedures for conducting research studies, discourseanalysts place most weight on the capacity of the researcher to understandthe idea of discourse analysis, rather than on his or her willingness to masterparticular research techniques’’ (p. 100).

THE RESEARCHER’S PRECONCEPTIONS

The design, method, and results of a study imply the researcher’sparticular approach to that study. The insight that consciousness is alwaysperspectival has been one of the great contributions of phenomenology topsychology. It is always from a certain perspective that we gain access tothings, others, and ourselves. What certain things come to mean for usdepends on our personal, existential projects. In that acknowledgmentand explication of one’s perspective situates and facilitates evaluation ofthe research, I attempted to document explicitly the thoughts, feelings, andexpectations I held prior to this study. Following Walsh’s (1995) recom-mendation, I also provided a reflective account of my assumptions andpreconceptions as they evolved during the course of collecting andinterpreting the data. I share some of these reflections here, and some of


them have been woven into the method section. A fuller account can befound in the dissertation.

My research interest emerged from a number of personal experiences.While I worked as a practicum student on the admission unit of a statepsychiatric unit, I witnessed several events that evoked an interest indiagnostic language. During an initial assessment, I asked a woman why shehad tried to kill herself. She looked sad and answered, ‘‘I’m tired of beinga schizoaffective disorder.’’ Ah, despite that the DSM-IV states that thediagnosis refers to the syndrome and not the person who exhibits it(American Psychiatric Associations 1994, p. xxii), some people must feel likethey are the diagnosis. Weeks later, I attended a grief and loss group duringwhich a man became upset that he wasn’t home to cut the grass. He pleadedwith the psychologist, ‘‘Can’t you take these charges off my back, Doc?What did I do to deserve them? What does that word even mean—schizophrenia?’’ Another time during rounds, a psychiatric nurse saidabout one patient, ‘‘And this one is still pretty delusional.’’ The psychologistturned toward the man and said, ‘‘In order to get out of here, you’regoing to have to start speaking our language.’’ The patient responded,‘‘What do you want of me? A sissy? A god, a dazzling god? Or maybe justa man with a six foot tie?’’ No one answered his questions. The looks onsome of the staff ’s faces said that his questions were further evidence of his‘‘delusional’’ state.

As I reflected on these experiences, I thought of Gadamer (1994): ‘‘. . . thehermeneutic phenomenon . . . implies the primacy of dialogue and thestructure of question and answer. That a historical text is made the objectof interpretation means that it puts a question to the interpreter . . . .To understand a text means to understand this question’’ (pp. 369–370).I wondered if patients feel confused, evaluated, or even condemned bytheir diagnoses. Szasz’s (1974) questions sprang to mind: ‘‘What is thedifference between a person complaining of pain and calling himself sick?What is the difference between a physician complaining of a person’smisbehavior and calling him a mentally sick person?’’ (p. viii). I also foundmyself thinking of Foucault’s (1965) words: ‘‘We have seen by whatmeans—and by what mystification—eighteenth century therapeutics triedto persuade the madman of his madness in order to release him from it’’(p. 264), and wondering if something similar goes on today.

METHOD

SITE OF DATA COLLECTION AND ILLUSTRATION

OF THE CONTEXT

This study took place on an adult admission unit of a local statemental hospital, where a summer before conducting the study I had worked


as a doctoral practicum student for 12 weeks. The hospital has beenopen since 1892. At its height, the patient population was around 3500.Today, 16 units large, the patient population is 450 to 500, illustratingthe deinstitutionalization that has been occurring since the 1980s.

The hospital grounds, consisting of beautiful, but dilapidated and emptybrick buildings and newer, metal buildings, stretch across a landscape oftrees and gently rolling hills. Weathered farmhouses where superintendentsand their families once resided also sit on the grounds, not far from themedical buildings. Visitors can see patients walking, visiting a snack shop,and working in greenhouses.

I collected data on one of two admission units, both of which are lockedand have approximately 40 beds each. Primarily, patients on these unitshave been court committed for not more than 90 days. Should a patientrequire longer treatment, he or she is relocated to another unit within thehospital, usually one with fewer restrictions. This is not an infrequentoccurrence, as three of the four patients I interviewed in November hadbeen moved to chronic units and were still there when I returned in March.

Entering the locked admission unit, the heavy door shuts quickly. Abouttwo yards beyond the door, a painted red line stretches across the floor andpart way up the wall on both sides. At waist level, the line ends in signsprinted, STOP. NO PATIENTS BEYOND THIS POINT WITHOUT STAFF ESCORT. Inthat this warning had not been there when I did my practicum, it served as arather startling introduction to the study on which I was embarking.

The three days I spent gathering data, along with the earlier 12 weeks ofpracticum, allowed me only to begin to imagine what life away from homewas like for the patients behind those walls. Upon arriving, patients con-front a profound restriction of everyday personal freedoms, like decidingwhen to wake up, shower, and eat. Ground cards, which allow patients toleave the unit in the morning, and/or afternoon, along with home visits,are contingent on police clearance and the person’s improved functioning.

As I tried to imagine what living in the hospital was like for patients,I also tried to imagine what the treatment staff ’s experience was like. Witha ratio of approximately 40 patients to one psychologist, one psychiatrist,and one social worker, along with several nurses, I realized how busy theclinicians on this unit were. This ratio of patients to staff seemed to limit thetime spent in individual interaction with patients. I also was struck byhow difficult it can be to work in an involuntary treatment setting, parti-cularly with the challenges such a setting creates for building rapport anda working alliance with patients.

From the perspective of a nondualistic ontology or understanding ofhuman life, things and personhood come to be what they are within acertain social and historical context. In my analysis of the data, I triedto appreciate and make explicit how these contextual elements of thesetting provided a ground for and organized patient–staff interactions.


This contextual reflexivity also led to a local analysis of the research projectitself (see Walsh, 2003). By attending to the milieu in which the research wasconducted and my place as researcher within that context, distinctionsemerged that informed my results. For example, during the stage ofcollecting data, when it seemed that the patients had a difficult time makingsense of who I was, I had the impression that within these walls, thereare only two groups of people: staff and patients; those who wear badgesand those who don’t; those who are free to leave and those who arenot. This recognition probably foreshadowed the parts of the results thatillustrate how diagnostic discourse can emerge from and constitute aninherent difference between normal and abnormal, and an ‘‘us’’ versus‘‘them’’ way of viewing the world. These contextual elements and my ownassumptions and perspective inform the validity and broader applicabilityof this study’s results.

DATA COLLECTION: TREATMENT TEAM MEETINGS

AND INTERVIEWS

Data for this study were comprised of three sorts: (1) observation (andaudiotaping) of two days of treatment team meetings, (2) individual inter-views with four patients (whose treatment team meetings I attended), and(3) individual interviews with four treatment staff members (the psychol-ogist, the psychiatrist, the clinical nurse specialist, and the social worker).

I chose the treatment team meetings as the main context for my studybecause they were a structured time and place for the treatment staff andpatients to discuss together the patient’s ‘‘mental status,’’ his or her progressin treatment, and discharge planning. It is here that the staff formally givespatients a picture of how they are seen in the staff ’s eyes. The task of themeetings lent itself to my focus on how staff and patients talk to each other,how diagnostic language enters that talk, and ultimately how a mentalillness narrative is constructed during the talk.

Collecting information from three sources—team meetings, patientinterviews, and staff interviews—provided different access points to thephenomenon, thereby rendering a fuller interpretation of the lived events.With this triangulation of data collection (see Maxwell, 1996), I reduced therisk that my results merely reflect the limitations that gathering informationfrom only one of these areas would pose.

Finally, interviewing as the sole method of data collection would not makesense because the nature of languaged interactions between patients and staffis not something that participants would reflect upon during an interview.

Interview Format

Both staff and patient interviews occurred after the treatment teammeetings and on the unit. With both sets of interviews, I attempted to


ground my questions in the concrete events of the meetings. I startedeach interview with some variation of, ‘‘What would you say happenedin that meeting?’’ Guided by Kvale’s (1983) discussion of qualitativeresearch interviews, I wanted to ask questions that would elicit responsesabout specific events, times, and actions, to keep the interviews frombecoming too abstract, theoretical, or intellectualized. However, manyof the staff ’s responses still seemed as if I was asking about what theyintend to accomplish or the purpose of treatment team meetings.Perhaps this was because I was asking what happened during an eventat which I myself was present, which in our everyday world may not becustomary.

After this first question, I asked about specific interactions that Ihad witnessed during the meetings. For example, I asked the clinicalnurse specialist what it was like to converse with a patient she had describedas particularly resistant and as lacking in insight. With the staff, theremaining portion of the interviews focused on how they understood orconceptualized certain patients’ difficulties, and their sense of a patient’sunderstanding of him- or herself. As the staff members brought up varioustreatment issues like compliance and insight, I inquired deeper into theirunderstanding of these concepts and the value they assign to them. Finally,I asked each staff person what role diagnosis plays in their work withpatients.

The interviews with the patients followed a similar format. After askingspecifics about the treatment team meeting, I inquired into their ownunderstanding of their difficulties and the need for psychiatric treatment,including medication. I also attempted to get a sense of how they under-stood the staff ’s views of them. Finally, I asked them about theirdiagnoses—if they knew what they were, how they were told about them,and their own definitions or understanding of their diagnoses.

Participants

To select patient participants, I obtained a list from the psychologist ofthe 11 patients who would be attending a treatment team meeting during thenext two days. This method of selecting patient participants ensured thatgender, age, diagnosis, and number of previous hospitalizations were notfactors in choosing participants. In that I could not physically identify thelisted patients myself, the psychologist either pointed them out to me froma distance, or in a few cases accompanied me to make introductions.These introductions, a seemingly simple aspect of the process, highlightedthe question of my identity for the participants. That is, at one point,the psychologist introduced me as ‘‘a friend,’’ thus possibly aligning mewith staff in that patient’s eyes. I was also required to wear an identificationbadge much like the staff wear. Some patients had difficulty differentiatingme from staff. For example, as I explained the nature of my research,


one patient asked if he was up for a ground card and another referred tome as ‘‘nurse.’’

Following the treatment team meetings, I chose four patients to interviewbased on their availability (i.e., without having to pull them from grouptherapy or a ground pass), and to a lesser degree the diagnostic content oftheir team meetings. For example, the first patient I interviewed haddiscussed with the psychologist the nature of her depression, a discussionI thought might prove fruitful to explore further. I chose another patientbecause during his meeting, he had objected to the staff ’s implicationthat he was a ‘‘psychopath,’’ another interaction particularly relevant tothis study.

Patients

The patient participants consisted of four adults, all with a history ofmultiple hospitalizations and psychiatric medication. I have given allpatients pseudonyms. Irvin was an 18-year-old, single, unemployed African-American man who was diagnosed with major depression, recurrent andborderline personality disorder. Katie was a 36-year-old, single, unemployedwhite woman who was diagnosed with chronic paranoid schizophrenia.Delmo was a 47-year-old, single, unemployed white man diagnosed withchronic schizophrenia, undifferentiated, and cannabis and alcohol abuse.Sheri was a 53-year-old, married, unemployed white woman diagnosed withbipolar disorder, mixed and personality disorder NOS, with dependenttraits.

The Treatment Staff

The psychiatrist had worked at this hospital for 2.5 years followingthe completion of her residency at a local psychiatric hospital. She alsoworked night shifts at a local emergency room and did some outpatientwork at another local hospital. The social worker had worked at thishospital since 1980, previously as a recreational therapist. The clinical nursespecialist had a master’s of science degree in adult, psychiatric nursing. Shehad worked for 14 years in this hospital and previously worked for five yearsin a local community hospital. The psychologist had also worked for manyyears at this hospital and had previously worked at another state hospitalbefore it was shut down.

INTERPRETATION OF THE DATA

The method of interpreting the data that is described in the follow-ing sections evolved during the course of the research. Most likely, thefollowing description appears too clean and straightforward, and belies thefumbling I experienced with what at times seemed like an overwhelmingstack of data. I have attempted to document some of my wanderings.


Fixing the Object of Inquiry

The first step of interpretation involved ‘‘fixing’’ the interviews and thetreatment team meetings. I did this by transcribing the audiotapes intowritten form. As the hermeneutic philosopher Ricoeur (1979) points out,fixing the data is a fundamental step of interpretation, for social action andspeech are fleeting and hence resist systematic inquiry. Although the fixedtext preserves ‘‘what happened,’’ the action is dislodged from its originalspatial and temporal situatedness, and can become a meaningful record forparticipants who were not originally present. As Ricoeur (1979) states,fixing the discourse ‘‘prepares the detachment of the meaning of the actionfrom the event of the action’’ (p. 81).

The fixed text now holds meaning that no longer coincides with theagents’ intentions at the time of the event. This does not mean that one stopsinquiring into a participant’s experience of the event, but that one neednot confine one’s reading of the text to that which was meant by its partic-ipants. One is now free to read the text for social meaning. As Ricoeur(1991) states in his essay, ‘‘The Hermeneutical Function of Distanciation’’:

If we can no longer define hermeneutics in terms of the search for the psychological

intentions of another person which are concealed behind the text, and if we do not

want to reduce interpretation to the dismantling of structures, then what remains to

be interpreted? I shall say: to interpret is to explicate the type of being-in-the-world

unfolded in front of the text. (p. 86).

As each reader approaches the text from his or her own situatedness, thetext is always open to new interpretation. Human action as text is ‘‘an openwork, the meaning of which is ‘in suspense’ ’’ (p. 86).

A final cautionary note on the step of transcribing the audiotapes is inorder: One can lose sight of the temporal unfolding and open endedness ofthe events as they were lived. Once one ‘‘knows the ending,’’ one can forgetthe fundamental ambiguity that belongs to the horizonal character of livedtime (Packer, 1989).

Conversation Analysis of the Treatment Team Meetings

After transcribing the audiotapes, I began a conversation analysis ofthe treatment team meetings guided primarily by Nofsinger’s (1991) text.Conversation analysis draws from speech act theory, the Americansociological movement of the 1950s and ’60s associated with ErvingGoffman, and Harold Garfinkel’s ethnomethodology. As conversationanalysis holds as its basic premise that speech is not merely the vehicle forknowledge or information, but that social actions and institutions areaccomplished in speech, this method provided a useful hermeneutic to guidemy reading of the text. As Nofsinger (1991) states, ‘‘Conversation is aprimary method through which interpersonal relationships are formed,maintained, and dissolved’’ (p. 3). And as Gale (2000) says, ‘‘Utterances


are viewed as practical activities that both create and maintain our socialselves’’ (p. 2).

Conversation analysis holds that the meaning of a given utterance‘‘depends overwhelmingly on where it is located in a sequence of actions’’(Nofsinger, 1991, p. 50). This view highlights conversation as locally andinteractionally managed. As Nofsinger (1991) says, ‘‘The participantsthemselves, during the course of their interaction, determine which peopleget to speak, in what order they speak, and for how long. The things peopleare expected to talk about, what they actually say, and how they say it arealso worked out among the participants as the conversation progresses’’(p. 4). Viewing conversation as locally managed allowed me to turn myattention to the participant concerns that guided the emerging organiza-tion and design of the team meetings.

Conversation analysis researchers have developed a wide variety of toolsor ‘‘sensitizing constructs’’ (McLeod, 2001, p. 93) by which to make senseof how social realities are constituted through language. These constructsattune the researcher to the process of conversation, in addition to thecontent. Heritage (1997) discusses a number of such principles or questionsthat I found useful in my own analysis: the organization and ‘‘rules’’ ofturntaking and how these rules reflect the values and goals of the institution,the patterns within conversation sequences, conversational asymmetrieswithin institutional discourses or relationships, and lexical choice, or howspeakers use descriptive terms according to institutional context. Althoughexplicitly interested in the latter—that is, how the speakers used diagnosticterms—I also began to make note of the general format of the treatmentteam meetings. For example, after inviting the patient into the room andreviewing the treatment goals, a series of question/answer sequencesfollowed in which the staff person generally reserved longer turns andasked questions seeking the patient’s agreement.

I also made use of the way Nofsinger (1991) characterizes utterancesin terms of three dimensions: action sequences, conversational actions, andextended structures, such as arguments and narratives. I documented thisstep of my analysis in the left column of the transcripts (see examples laterin the chapter). The following gives a brief description of these threedimensions and various types of each:

1. Action sequences: an utterance’s position within a sequence ofutterances. An utterance’s relationship to the surrounding talk, notonly in terms of what is said, but in terms of its location, is influentialin how it will be interpreted by the speakers. Types of actionsequences include the following:

� Adjacency pairs: A sequence of two communicative actions amongwhich the first pair part is typically matched with or calls for one


of a relatively few types of second pair parts. For example, thereare question–answer adjacency pairs, summons–answer pairs,invite–acceptance/refusal pairs, assessment–agreement/disagree-ment pairs, and blame–denial/admission pairs. Adjacency pairsequences include presequences (Pre), which serve as a way ofchecking out a situation before performing some action; first pairpart (FPP); second pair part (SPP); and insertion sequences(insert), which consist of an action inserted between the FPP andthe SPP. Gale (2000) suggests that adjacency pairs be looked atin terms of the assumptions embedded within a question orresponse, the method of question construction, and the implicationof the question/response situation to the relationship betweenparticipants.

2. Conversational actions: The performative function of an utterance;

what the speech act does or is meant to accomplish. Types of

conversational actions include the following:

� Commissives: speech acts whose function is to commit the speakerto some course of action

� Directives: speech acts whose purpose is to get the recipient to dosomething

� Assertives: speech acts that serve to display the speaker’s beliefin the propositional content of the utterance. The talk attempts todescribe an object as it appears to the speaker.

� Expressives: how the speaker feels about what he/she is saying� Alignment: utterances that keep the conversation ‘‘on track’’ and

that potentially demonstrate a move toward convergence between

two (or more) participants’ interpretations. Some forms of align-

ment are as simple as news marks (e.g., ‘‘Oh’’) or continuers

(e.g., ‘‘Mhm’’). More complex forms of alignment include collabo-

rative completions, when one participant completes another

person’s statement for him or her, and formulations, which are

summaries of another participant’s previous talk. Gale (2000)

points out that formulations

are not necessarily neutral or comprehensive summaries, but can provide

an upshot or re-presentation of what was said with changes added. Thus,

a formulation displays its speaker’s alignment as it exhibits not only what

he/she understands of a prior turn, but what is proposed as important to

focus on for further talk. (p. 8)

� Repairs: utterances that fix a breakdown in the conversation.

Repairs can be initiated by the speaker or the recipient, and

generally assist alignment.


3. Extended structures: a series of utterances that constitute a certainpattern of discourse. Types of extended structures include thefollowing:

� Narrative: a series of utterances that tell a story. Speakers orientother participants to the time and place of what is narrated. Theyalso tell the story from a particular perspective, one that is oftenimplicit in the storytelling, but says much about their view of self,world, and others. Narratives often consist of accounts, whichare defined by Gale (2000) as ‘‘ways that people explain actions . . . .Accounts can be used as an excuse . . . or as a justificationclaim . . . , as apologies, requests, and disclaimers’’ (p. 9).

� Argument: extended structures of utterances that constituteand manage disagreement. Participants can make an argumentfor some belief, action, etc.; they can also have an argument over agiven event, interpretation, etc. The basic elements of argumentinclude the following:

Claims: utterances that state one’s position and invite others toagree or disagree

Grounds: utterances that give the underlying foundation forthe claim to be agreed upon

Warrants: utterances that give the connections between the groundsand claims, or that illustrate what is at stake in the argument

Rebuttals: utterances that give the circumstances in which anargument may be unreliable

Backing: utterances that back up the claim or warrant

Analyzing the team meetings in these ways was an initial step and notan end in itself, but provided the foundation for a fuller, narrative accountof the patient–staff conversations. For it is the microactions within con-versation ‘‘that coordinate (either through binding or unraveling) thebroader moves of discourse, which lead to the construction of socialnarratives’’(Gale, 2000, p. 1). As Gale (2000) says

This [method] contradicts the Parsonian view that individuals are the product of a

society which dictates activities and functions (and that the ordinary judgments of

individuals are irrelevant). Instead, our social institutions are constructed through

the managed practices of the participants themselves. (p. 3)

The Delineation of Meaning Units

After identifying the previous conversational moves within the treatmentteam meetings, I printed out the excerpts of the meetings for each of the fourpatients I had individually interviewed. Taking one segment at a time,I divided each into meaning units (MUs). I did this by attending to shifts inwhat the participants were doing in their talk, and with regard to the


emergence of diagnostic terminology and its meaning within the conversa-tion. My earlier step of marking the conversational moves in the left marginof the transcripts facilitated this delineation of the text, as it was already aprocess that focused on the cohesion among the utterances, and on the shiftsin conversational actions.

Delineating MUs is an important step in phenomenological research withprotocol analysis (Giorgi, 1985; Wertz, 1985) in that it makes the text moremanageable while it invites the researcher to begin to shift his or herattention to the meaning the events have for the participants.

A Narrative Interpretation of Each Unit

The next step involved articulating what the participants were doingduring their talk. To aid this process, first I put it in boldface type anypart of the conversation that included diagnostic terms. Attempting to stayclose to the participants’ own words, I wrote out how they answeredeach other’s concerns and what that implied about their relationship.I also attended to the rhetorical structure of their discourse, to the waysin which diagnostic terminology encourages patients to believe certainthings about themselves. This narrative interpretation took its lead fromall the previous steps, particularly the identification of the conversationalmoves.

After a lot of rereading and trimming, I underlined (italicized below)those sections of my own narrative description of their talk that seemedparticularly salient to this study. These sections were the ground for amore abstract level of description, as well as for providing concreteexamples with which to illustrate the results. By comparing commonalitiesfrom across all four analyzed portions of the treatment team meetings, Ideveloped a structural description of how diagnostic discourse constitutesthe patient–staff relationship in general.

The following examples utilize the following transcript notationsstandard to most conversation analysis (see Atkinson and Heritage, 1984):

Symbol Meaning

[] At the end and beginning of lines indicate overlapping talk

(1) Numbers in parentheses represent silence measured to the nearest

tenth of a second

end of line¼ Latching symbols indicate that there was no hesitation or

¼start of line pause between the utterances

Under Underlining indicates words that were uttered with vocal emphasis

CAPITAL Words in uppercase are louder than the surrounding talk

( ) Empty parentheses indicate talk that was inaudible or

impossible to interpret

((laughing)) Double parentheses enclose transcriber comments

Wait a min- A hyphen indicates a sudden cutoff of speech


The following segments are two examples of these procedures:

Repair/First Pair Part/ Social Worker: Okay, you’re all set. ’Kay, Irvin, you

Question came in- Can you tell us why you came into the hospital?

Second Pair Part/ Irvin: Anger, depression, irritation, and flippin’ out

Answer ((staff laughs)) and suicidal thoughts^

Agreement/Request Social Worker: Alright, well those are some of the things that we found

from your records and those are the things we wanna work on while

you’re here.

Assertive Irvin: My records suck.

Informative Social Worker: ’Em ’kay, well I’m gonna tell you what your discharge

criteria is, what you have to accomplish in order to be considered

for discharge . . .

After greeting Irvin, the social worker begins to inform him of his admittingcircumstances, but interrupts herself to ask him why he feels he’s beenadmitted. (She seems to be checking to see if he holds the same view as theydo, a view she earlier asserted during her case presentation to the staff: ‘‘Hestates he’s very depressed and afraid to be alone due to suicidal feelings.Reports command hallucinations to harm self . . . . Mental health, he can beimpulsive and angry . . ..’’) Irvin answers with a quick list: ‘‘Anger, depression,irritation, and flippin’ out and suicidal thoughts.’’ After the staff brieflychuckles at his term flippin’ out, the social worker confirms that his owncharacterization is in line with what his records say and frames his responseas the problems needing ‘‘work.’’ In accepting his response, she confirms acorrespondence between what he has said about himself and what she pre-viously presented to staff. Furthermore, the social worker locates their view ofhim in his ‘‘records,’’ creating anonymity to their view, along with backing itup with a sense of evidence and authority. Without giving much attentionto Irvin’s response that his ‘‘records suck,’’ she continues to hold the floorby informing him of the conditions of his discharge.

Request Psychologist: We want you to continue to go to groups that help you^

Overlap/ Delmo: ^I’M NOT A PSYCHOPATH!

Argument; Claim

Rebuttal Psychologist: No one even mentioned the word ‘‘psychopath.’’

Preface Delmo: Well[

Overlap/Assertive Psychologist: ]No one mentioned—you didn’t hear me say that. But we

want you to go to the groups, the different groups that we have for

you, okay? One of which is for you to go to the anger management

group, which you’ll come, although I have to invite you many times,

but you know that we have a group every Wednesday, and we’d like

you to come to that group.

The psychologist informs Delmo that the staff wants him to attendgroups and he begins to offer justification for this request. Delmo interruptsto assert loudly and adamantly, ‘‘I’m not a psychopath.’’ Delmo interprets thepsychologist’s statement as implying something offensive and inaccurateabout his identity. He interprets the psychologist as implying that he is a


psychopath, a diagnosis he finds insulting and inaccurate. The psychologistresponds to this outburst by attempting to correct Delmo’s perception of theconversation, informing him that ‘‘no one even mentioned the word‘psychopath’.’’ When Delmo tries to take a turn, the psychologist interrupts,reiterating that Delmo misperceived him. The psychologist continues torequest Delmo’s attendance at groups, particularly the anger managementgroup.

Thematic Analysis

Interviews

To interpret the interviews, I used a modified version of the phenom-enological method generally used for protocol analysis as described byGiorgi (1970, 1985). Because my interviews were not descriptions of an eventor situation per se, I did not delineate them into MUs. Instead, I usedthis method to guide me in an analysis of the themes implied by theparticipants’ understanding of how diagnosis enters into the therapeuticrelationship.

Step 1: With each of the eight interviews, starting first with the four staffinterviews, I read through each to gain a sense of the whole. Next,I highlighted diagnostic terms and discussions about diagnoses, notingin the margin key words or phrases. This involved jotting down myimpressions of how a patient’s diagnosis guides the staff person’sperspective and clinical work. I also attended to the terms the staff usedto describe mental illness. For the patients, I focused not only on howthey understand their diagnoses, but also on their own vocabulary andunderstanding of why they’ve been psychiatrically hospitalized. I triedto articulate what place the patients give diagnostic terminology in theirown understanding of themselves.

Step 2: Next, I grouped the marginal notations into themes for each ofthe individual interviews. I did not view every marginal notation asrevealing a new theme, but often listed many of the notations as con-stituents of already existing themes. This step also involved articulatingwhat was prethematic or implicit within the participants’ descriptions.

Example of a Theme from My Interview with the Clinical Nurse Specialist

Treatment is constituted as an educational process.

� Patients who ‘‘need to be educated about their diagnosis andsymptoms . . .’’ attend symptom management group.

� Treatment consists of ‘‘repeated sharing of their symptoms . . . . Thenthey become more receptive to it if you repeat it enough.’’

� Therapeutic groups are understood as primarily educational.


� Patients are taught how to interpret their behavior as beingsymptomatic.

Step 3: I read each of the individual interviews again, with the individualthemes at hand, looking for disconfirming information that then ledme either to new themes or to a revision. At times, an ambiguity arosethat did not necessarily find its way neatly into the themes, and I simplynoted it as such.

Step 4: This step involved moving from individual themes to two sets ofgeneral themes, one for staff and one for patients. I illustrated eachtheme with examples from all participants.

Example of a Theme from the Staff Interviews

Patients are understood as having impaired insight.

� When a patient says, ‘‘I don’t need to be here’’ (clinical nurse)� When disagreeing with the diagnosis—e.g., ‘‘No, I don’t have

schizophrenia. I’m not paranoid.’’ (clinical nurse)� When patients blame others (e.g., the police) for their admission to the

hospital (clinical nurse)� The clinical nurse specialist describes one patient as ‘‘pretty resistant

. . . I knew that there would be a lot of denial there. And that’s whyI wanted to go with a meeting with kind of clear-cut goals for her. Oneof them was to increase your level of insight into why you’re here.’’

� Patients ‘‘forget the symptoms they had,’’ leading to noncompliance(clinical nurse specialist)

� Team meeting as time to ‘‘help reestablish the awareness’’ (socialworker)

� Patients may ‘‘know’’ what mental illness they ‘‘have’’ and yet still lackinsight regarding the course of illness and their need for medication(psychiatrist)

� The psychologist constitutes many of the patients as not beingable to understand their diagnoses. For example, he says that Sheri‘‘might have some recollection . . . some awareness of that diagnosis . . .but I don’t think so . . . and I don’t know if that means anythingto her.’’

Example of a Theme from the Patient Interviews

The patients accept certain aspects of their psychiatric diagnoses as accurate

descriptions of themselves.

� Sheri: ‘‘I think the closest one was the first one [recurrent majordepression with suicidal ideation] . . . .’’ When asked what that


diagnosis meant to her, she stated, ‘‘That I’ve been in the hospital withdepression a whole bunch of times.’’ Sheri was able to state two morerecent diagnoses with technical accuracy, but she didn’t agree witheither of them: ‘‘They changed it . . . to um, um manic depression,although I’ve never had a manic episode in my life that I remember . . . .And then the third one I got was um, um schizoaffective disorder . . .I didn’t agree with that either.’’

� Katie: ‘‘I’m paranoid schizophrenic.’’ When asked what that diagnosismeant to her, she gave a descriptive definition: ‘‘Paranoid, you’rescared, you think someone’s after you. You’re scared to go out. Andschizophrenia is hearing voices and seeing things.’’ She acknowledgedthat she had experienced such things.

� Irvin: ‘‘I was diagnosed with depression and dyslexia . . . . Hey, that’swhat I do . . . That’s what I do. I get depressed all the time.’’

� Delmo: ‘‘Catatonic schizophrenia . . . . That’s like the, uh, Rolls Royceof the mental illnesses. It’s really good quality . . . . Confident,confident that I really had it . . . . Oh, there’s no doubt in my mind.’’

Step 5: Finally, I looked at similarities and points of tension acrossthe two sets of general themes from the interviews and all the placesduring the treatment team meetings where diagnostic terminologyemerged. This step is documented in Table 5-1. The grouping of themesin this manner facilitated articulating a structural description thatincorporates all the findings.

Table 5-1

General

Themes, Staff

General Themes,

Patients

Treatment Team

Meetings

Treatment as

an educative

process

Patients have been taught

a language within which

to view themselves as

mentally ill.

Patients accept their diagnoses

as accurately describing some

aspects of themselves.

Patients monitor themselves in

line with the staff ’s interests.

Diagnostic terms emerge in conversation

with patients during a process

of sharing with the patients their view of

the problems. A correspondence between

the staff ’s view and patient’s view is

sought. Patients are required and taught

to interpret aspects of their experience

as being symptomatic of mental illness.


A Structural Description

This final step involved weaving together the two sets of general themesfrom the interviews, along with the insights gained from the conversationanalysis of the treatment team meetings. While writing this structuraldescription, I frequently returned to the raw data, including the areas inthe treatment team meetings beyond the four patient visits, to confirm ordisconfirm my interpretations and to include any overlooked data.Following convention within conversation analysis research reports,quotes from the transcripts of the team meetings and the participantinterviews are included in the results.

RESULTS: DIAGNOSTIC DISCOURSE IN

PATIENT–STAFF INTERACTIONS

The staff use diagnostic terms in conversation with each other to presenta clinical portrait of a given patient. This portrait or case presentation is notwithout a perspective; it is reflective of and configured by what this staffview as ‘‘psychiatric.’’ Certain aspects of the person’s life world are focusedon while others are left out. The description of the person, along with thestated treatment goals, is grounded in an understanding of him or her as‘‘mentally ill.’’ The description is given not only to acquaint the other staffwith the patient, but also to provide implicitly a case for why that personwarranted involuntary treatment. To facilitate building this case, the termpatient is peppered throughout the presentation, often in lieu of the person’sname. Furthermore, the patient is often identified as being in denial and asrefusing to acknowledge the need for treatment. When presenting a patient,the authority and anonymity of the record are invoked; the staff builds theirargument within a rhetoric of ‘‘evidence.’’

It is usually only immediately prior to the patient’s attendance at theteam meeting that formal or specific diagnoses are discussed. Within thecontext of paperwork and administrative concerns, the diagnosis andexplicit goals can sometimes eclipse interest in the patient’s recovery andwell-being. For example, the psychologist explains that the substance abusegroup cannot be listed as one patient’s goal because his diagnosis issubstance abuse in remission: ‘‘It’s not a goal because it’s in remission . . . .Now we can invite him to come . . . , that’s different. But as far as the goalsare concerned, umm.’’ The staff ’s operating conceptualization of pathologyas located within the individual can also undermine therapeutic concerns.This is illustrated in the community liaison’s frustration about the difficultyof including Sheri’s husband in treatment. She rhetorically asks the rest ofstaff, ‘‘. . . can we make him go? We can’t do that. ( ) I mean, who is thepatient here?’’


Once a patient arrives at the meeting, diagnostic terms emerge withinthe purpose of the treatment team meeting—to share with the patient howhe or she is seen in the staff ’s eyes and to inform the patient of his or hergoals. Diagnostic terms emerge within the staff ’s project to teach patientsto interpret certain aspects of their experience and behavior as beingsymptomatic of mental illness. The staff view this project as promotinginsight and maintain that it fosters treatment compliance and, ultimately,symptom management and stabilization. For example, the clinical nursespecialist summarizes one patient’s goals: ‘‘. . . that she’ll demonstrate lessdenial of her illness and more a willingness to listen to the explanations ofprofessionals as to why she’s here; that she’ll comply with recommendedtreatment and state benefits of doing so.’’ That the patients become subjectto the implicit conversational format of these meetings, also serves toestablish the staff ’s authority—the staff make assertions, ask questions,redirect the conversation, and, only at the end, give patients some time tovoice their own concerns.

Within their attempt to persuade patients to hold an understanding ofthemselves that corresponds with the staff ’s view, the staff use bothdiagnostic terminology and descriptive terminology. At times, the stafftranslate their clinical and technical terminology into a language that maybe more easily understood and meaningful to patients. For example, whenthe psychologist is reviewing Katie’s progress, he asks her if he is correctin maintaining that she is still ‘‘hyperverbal.’’ Assuming that Katie maynot understand this specialized term, the recreational therapist clarifiesthe question by explaining that it means to ‘‘talk, talk, talk, talk, talk.’’Offering further assistance, another recreational therapist gives an exampleof when she noticed this behavior. Katie begins to disagree, but changesher mind: ‘‘It wasn’t- oh yeah, I was.’’ This dialogue illustrates howdiagnostic meaning is locally forged.

Another example of the shift from diagnostic terminology to every-day language occurs when the psychologist is speaking to the staff aboutDelmo. He asserts, ‘‘Many times when he talks, it’s irrelevant, kind of flightof ideas to be exact.’’ Later, in conversation with Delmo, the psychologistbegins to inform him of their concern: ‘‘. . . sometimes when we talk withyou¼’’. However, before the psychologist can complete his turn, Delmofinishes his sentence for him: ‘‘¼I don’t make sense.’’ The psychologistconfirms Delmo’s perception: ‘‘You don’t make sense.’’ To which Delmoeventually responds, ‘‘Am I rambling like a brook sometimes?’’ With somecorrection, the psychologist again confirms Delmo’s perception: ‘‘Yeah,sometimes you do babble like a brook.’’ This conversation illustrates theinterface of two vocabularies, along with demonstrating Delmo’s alignmentwith staff. He communicates that he is aware of how they see him.

When patients are expected to interpret aspects of their experience andbehavior as being symptomatic of mental illness, the patient’s own


perspective is often constituted as being false. Its own meaning is inval-idated and leveled. When the staff ’s diagnostic perspective is held over andagainst the patient’s, that patient’s behavior is not understood as ameaningful and valid response to his or her world or to the immediateinteraction with staff. For example, when Delmo’s talk is understood asdisordered and as nonsensical, its meaning is not inquired into. Further-more, when ‘‘not making sense’’ is cast as diagnostic of mental illness,making sense becomes the burden of the patient. Rather than attemptingto understand the patient’s speech or behavior, the discourse is focused moreon changing the patient’s views and behavior. This stance is framed by thestaff as a way of assigning responsibility and as empowering their patientstoward recovery.

Whether these patients accept or reject the staff ’s view of them and themental illness narrative offered to them, their identity is at stake. Thesepatients are striving to come to terms with the practices of this community,adopting various attitudes, and attempting to take a stand on the waythe staff have positioned them. For example, Irvin seems eager to alignhimself with the staff ’s view of him and with their recommended treatment.Delmo, on the other hand, expresses frustration. When he is trying toexpress that he doesn’t like how his medication makes him feel, he backs uphis complaint with the assertion that he’s ‘‘a damn good psychiatrist.’’Perhaps Delmo feels that he’s not being listened to or that he’s not beingunderstood as insightful about the way his medication is affecting him.Perhaps he feels that to be taken seriously, his complaint must be groundedin the kind of expert knowledge the staff possess. But instead of respondingto Delmo’s feelings about his medication, the psychologist argues, ‘‘This iswhere you get to be a problem . . . .’’ When resistance to the staff ’s view isunderstood as a function of one’s illness and within a problem discourse,it is not appreciated or explored as part of the patient’s struggle over his orher identity.

When the staff set aside their agenda to address and understand apatient’s concern, the staff and patient together forge a shared under-standing of that patient’s difficulties. For example, the psychologist andSheri reach an understanding of her difficulties that is meaningful to all ofthem when they allow themselves to be engaged in dialogue with her.

The psychologist begins the meeting with Sheri by giving her encouragingfeedback regarding her insight into her difficulties: ‘‘. . . what I mean bythat is, uh, beginning to recognize how you are . . . when your husband, let’ssay, when he gets angry and upset with what happens with you . . . . AndI think you’re just coming to recognize that there has to be some changesthere in order for you to stay out of the hospital.’’ He expands this view ofher when he informs her of her goals. Summarizing from the writtentreatment plan, he states, ‘‘One of them is certainly that we want you toexpress your feelings . . . rather than you kind of turn them over in your


head . . . . I think sometimes you get upset, but you don’t share it with us . . . .So, that’s one of the goals that we want you to do.’’ The staff haveformulated a goal that is grounded in their view of Sheri as ‘‘not the type todeal with confrontation well . . . and [who] retreats and isolates herself,’’ asthe social worker explained to me in her interview.

After the psychologist finishes explaining the treatment plan andbegins to involve the rest of the staff in paperwork, Sheri tentatively assertsherself. Despite the psychologist’s view, as given in his interview with methat Sheri ‘‘doesn’t spontaneously talk [during the meetings],’’ she seekspermission to steer the conversation in a particular direction. Despite howrisky it feels to her to speak up in life, as she described in her interview withme, she requests the staff ’s attention: ‘‘Can I ask you something . . . uhm,when you were talkin’ about my comin’ back here, what did you mean bythat?’’ In asking the psychologist for clarification, Sheri calls the staff awayfrom their immediate agenda.

Making implicit reference to Sheri’s status as mentally ill, the psy-chologist responds by predicting that if she were discharged to home,she would ‘‘decompensate’’ or ‘‘deteriorate’’ and thus return to the hospital.He uses these terms to argue that she should instead be discharged to aresidential treatment setting. He shares his belief that after some timeat home, Sheri and her husband would eventually argue. He states,‘‘He would yell and scream. You would get angry and upset with yourselfand it wouldn’t be very long before you’re talking about hurting yourself . . .what I think happens Sheri, and you correct me, but I think you getangry and you never speak up, you never assert yourself . . . .’’ Agreeing withhim, Sheri completes his sentence and offers her own conceptualization,‘‘Yeah, I go into a ball and stay there.’’ At this point, Sheri and thepsychologist are speaking together about the way she retreats from othersto protect herself.

That this shared understanding has been accomplished not by way ofimposing a diagnostic label, but in a conversation that takes into accountSheri’s own narrative, is consistent with the psychologist’s view that beingdescriptive addresses the patient as an individual. As he says in his interviewwith me, ‘‘Probably if you use the label as a way to communicate to thepatient, you are really dehumanizing that individual. You are intellectualiz-ing that person. You don’t see the person for who they are . . . . Sheri is aperson to me . . . not a diagnosis.’’ Furthermore, helping to ‘‘reestablish[the patient’s] awareness,’’ as the social worker states in her interview, isthe purpose of these meetings, is accomplished not by informing Sheri ofher diagnosis, but by addressing her concerns and engaging in dialogue withher. This last part of their conversation with Sheri holds so much morevitality and concreteness than one of the abstract goals it might fulfill—that she ‘‘discuss two symptoms of [her] illness and its relation to inter-personal kinds of difficulties.’’


DISCUSSION

Research in labeling theory has claimed to look at the ways in which apsychiatric diagnosis, as a tool of social control and through a process ofstigmatization, can launch patients ‘‘on a career of ‘chronic mental illness’ ’’(Scheff, 1975, p. 10; see also Link et al., 1989; Scheff, 1966). However,most of this research has remained quite vague about the actualconversations within which clinicians discuss diagnoses or mental statuswith patients. Although labeling theorists have maintained that a ‘‘built-in‘catch-22’ . . . is that nonacceptance of the feedback is deemed lack ofinsight, which is used as another symptom or evidence of mental illness’’(Wilson and Plumy, 1984, p. 7), they have not clearly spelled out how suchconversations occur. Research into labeling theory has been criticized forhaving ‘‘largely overlooked practices of talk, action, and social interaction.Consequently, even in research arguing most fervently that labelingprofoundly affects the lives of individuals, the acts of giving and acquiringlabels appear as obscure, disembodied events’’ (Gill and Maynard, 1995,p. 11; see also Maynard,1988; Raybeck, 1988).

Gill and Maynard (1995) have pointed out how in focusing on ‘‘whathappens to the targeted individual, rather than on the way in which groupmembers enact practices’’ (p. 12), labeling theory has ignored systematicinquiry into the local and interactional character of diagnostic events.In Gill and Maynard’s (1995) own study, which used conversation analysisto examine how clinicians informed parents and children of developmentaldisabilities, they found that clinicians used ways of engaging the recipientsin the conversation and even in the decision regarding the diagnosis:‘‘By delivering the news as a confirmation of the recipient’s views, theclinician incorporate[d] the recipient’s perspective within the actual delivery,in effect transferring to them some of the ‘authorship’ of the news’’ (p. 16).Gill and Maynard (1995) found that when recipients resisted labels,clinicians used remedial strategies, such as eliciting those aspects of theparents’ views that are most consistent with the diagnosis, in an attemptto obtain some agreement. But clinicians also backed down from ormodified their own judgments in light of parental response. Clinicians werealso found to minimize the positivistic meaning of diagnoses and to depictthe label as less of ‘‘a pristine, objective reflection of the child’s abilities’’(p. 26), and more as a tool that can result in desirable or undesirableoutcomes.

Gill and Maynard’s (1995) focus on local praxis provided support for myown study and an example of how conversation analysis can be applied tosimilar topics. Similar to Gill and Maynard’s 1995 findings, my studyshowed how diagnostic meaning is locally forged and negotiated, but alsohow this staff invoked a rhetoric of facts, evidence, and authority to obtainthe patients’ agreement with their diagnostic views.


Research in labeling theory also has been critiqued for portraying thosewho receive diagnoses as passive targets (Davis, 1975; Hagan, 1973; Schur,1971), for not adequately addressing those people who voluntarily requestmental health services and seek a diagnostic understanding of their situation(Thoits, 1985; Wilson and Plumy, 1984), and for collapsing subjectiveexperiences of pain and confusion into social deviance (Whitt et al., 1979).In my own study, I have attempted to avoid these assumptions. My methodgave me access to the staff ’s sensitivity to the limitations of imposing adiagnostic discourse, and to how patients descriptively situate their ownsuffering in terms of problematic life events, accept certain aspects of theirexperience as diagnostic of mental illness, but also resist being categorizedwithin a struggle to define themselves. My study showed how both ‘‘patient’’and ‘‘clinician’’ are social positions that are constituted by a community ofpractice and within a diagnostic discourse.

In reaction to labeling theory, researchers have suggested that accept-ing one’s psychiatric label can improve functioning. Schwartz et al. (1997)found that for inpatients diagnosed with schizophrenia, those with goodinsight showed more improvement after long-term inpatient treatment.Similarly, Walker and Rossiter (1989) found that among outpatientsdiagnosed with schizophrenia, those who perceived themselves to be men-tally ill had a shorter duration of the most recent hospitalization, a smallernumber of previous hospitalizations, and greater compliance with treat-ment. Influenced by findings of this sort, Will (1980) and Kemp and David(1997) have argued that the promotion of insight into illness ought to beone of the principal goals of treatment.

My interviews with the staff and the conversation analysis of theteam meetings revealed that such an approach is operant within thistreatment setting. However, rather than studying this approach from afactors-and-outcomes logic, my study investigated how clinicians promoteinsight in actual conversations with patients, and how insight is negotiatedin the talk. That is, rather than asking whether insight as a form of cognitionimpacts a patient’s functioning, my qualitative research approached insightdiscursively. As Potter (2003) states, ‘‘Discourse work is not designed toanswer questions of the kind, ‘What is the influence of X on Y’ . . . [but]typically asks questions of the form, ‘How is X done?’ ’’ (p. 78).

By approaching insight discursively and by utilizing participant inter-views to clarify the conversation analysis of the treatment team meetings,my findings can offer a critique of the previous label–acceptance or‘‘psychotherapeutic model’’ (Warner et al., 1989). In my interviews withpatients, I found that all of them could name their diagnoses in ways thatclosely matched their records, and even accepted and agreed with theirdiagnoses as accurately describing certain aspects of themselves. During thetreatment team meetings, they also demonstrate alignment with the staff ’sdiagnostic view, and yet these patients continue to suffer and return for


multiple hospitalizations. They report losing hope in treatment, not feelingunderstood by staff, and assert their own understanding of themselves.They voice ambivalence toward the staff, which emerges within a conflict ofwills, agency, expertise, and identity. The patients make an appeal for thestaff to appreciate what is at stake for each of them in accepting a mentalillness narrative and in complying with treatment. My study encouragescritical thinking about this model and suggests that ‘‘insight’’ is mostsuccessfully negotiated in dialogue with patients. Indeed, despite its traditionwithin sociology and its emphasis on explicating the discursive structureof social and institutional settings, conversation analysis research canspeak directly to the therapeutic implications of the identified practices(McLeod, 2001).

My findings, then, also give empirical support to many therapists’ viewsthat imposing a diagnostic perspective on the patient can become an

obstacle to the therapeutic relationship. Karon and Van den Bos (1981),psychoanalytically oriented psychologists who have worked with patients

diagnosed with schizophrenia, have suggested that contrary to the ‘‘psycho-therapeutic’’ or label–acceptance model, asking the clients to accept anillness identity impedes the therapeutic relationship, the vehicle for change:

It is true that if you asked him whether he was paranoid or schizophrenic, he would

get very angry at you and not accept such words. Why should he? What benefits

derive from accepting a ‘‘diagnosis?’’ From his standpoint, the primary consequence

of accepting the ‘‘diagnosis’’ would be to legitimize the right of others to make

decisions about his life. On the other hand, when a therapist says to him, ‘‘What’s

your problem?’’ and he says, ‘‘I hurt people even though I don’t want to,’’ and the

therapist offers to deal with that problem, the patient suddenly becomes part of a

working alliance. (1981, p. 154)

Yalom (1990) has also maintained that a reliance on diagnosis to guidetreatment obscures empathy and genuine listening. He warns against letting

diagnostic formulations take precedence in the therapy:

Beyond these relatively crude determinations, which serve the function of initial

triage, further and ‘‘finer’’ diagnostic discriminations not only offer little help to the

therapist but often interfere with the formation of relationship . . . . The standard

diagnostic formulation tells the therapist nothing about the unique person he or she is

encountering; and there is substantial evidence that diagnostic labels impede or

distort listening . . . . Too often diagnostic categorization is a stimulating intellec-

tual exercise whose sole function is to provide the therapist with a sense of order

and mastery. The major task of the maturing therapist is to learn to tolerate

uncertainty. (p. 410)

Finally, current psychotherapy research (e.g., Norcross, 2002; Wampold,2001) clearly identifies the relationship between therapist and client as a

critical component of successful outcome. I believe more now than I did atthe beginning of my research that addressing patients’ lived worlds as thecontext of problematic (diagnosed) behavior strengthens the therapeutic


relationship and maximizes collaborative involvement toward positive

change.At this point, my research into diagnostic discourse in patient–staff

interactions suggests that a fruitful follow-up study would be one addressinghow treatment teams are influenced by and perpetuate a complex allegianceto caring about patients, following hospital mandates, and utilizing a closeddiagnostic system. Such a study would identify points at which all systemscould more flexibly serve patients. Outcome studies based on theseconsiderations would be motivating for staff, legislators, hospital directors,and other policy makers.

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BIOGRAPHICAL BACKGROUND

JESSIE GOICOECHEA, PhD, received a BA in psychology from the Universityof Dallas, where the department’s commitment to a human scienceapproach and her growing interest in phenomenological and existential phi-losophies led her to Duquesne University, where she received her MA andPhD in psychology. She completed her predoctoral internship at Clinton-Eaton-Ingham Community Mental Health Center in Lansing, Michigan,which consisted of rotations in a psychiatric hospital and a rural out-patient clinic. Experiences in both settings contributed to her interest in thesystems and institutions within which mental illness is socially constructed.In 2003, Goicoechea joined the faculty at Duquesne as assistant professorand director of the psychology clinic, the primary training facility for thegraduate students. She enjoys the combination of participating in thestudents’ academic and clinical training, including teaching introductorycourses on psychotherapy and assessment, and overseeing the proceduraland program development aspects of the clinic to ensure that clients areserved well.

Goicoechea also works as a psychotherapist at Persad Center, acommunity mental health agency that serves the gay, lesbian, bisexual,transgender, and HIV communities. An area of special clinical interestand expertise is domestic violence in same-sex couples. She leads a


psychotherapy group for offenders and would like to extend her generalresearch interest in language as constructive of social reality, to look athow the terms perpetrator and victim are used in treatment discourse.She has co-authored an article that articulates themes of a nondualisticontology within the sociocultural perspective on learning and thatproposes a reconciliation between this perspective and constructivisttheories.


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