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Interactional problems of addressing ‘dreaded issues’ in HIV-counselling a
A. Peräkylä & R. Bor
b
a
Glaxo Research Fellow, University of London Goldsmiths College, Department of Sociology , London, SE14 6NW b
Principal Clinical Psychologist, District AIDS Counselling Unit , Royal Free Hospital and School of Medicine , London, UK Published online: 25 Sep 2007.
To cite this article: A. Peräkylä & R. Bor (1990) Interactional problems of addressing ‘dreaded issues’ in HIV-counselling, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 2:4, 325-338, DOI: 10.1080/09540129008257748 To link to this article: http://dx.doi.org/10.1080/09540129008257748
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AIDS CARE, VOL. 2, NO. 4,1990
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Interactional problems of addressing ‘dreaded issues’ in HIV-counselling A. PERAKYLA’81 R. B O R ~ Downloaded by [Simon Fraser University] at 21:30 13 November 2014
’
GIaxo Research Fellow, University of London Goldsmiths College, Department of Sociology, London SE14 6NW, Principal Clinical Psychologist, Disnict AIDS Counselling Unit, Royal Free Hospital and School of Medicine, London, UK
Abstract Addressing the patient’s fears about the future is an essential task in HIV counselling. The paper examines with conversation armytical methods the interactional dynamics of such discussions in video- and audio-taped counselling sessions with patients coming for an HIV test and others diagnosed as HIV antibody positive. Two communication fonnou were found to be used in the sessions, one based on information delivery made by the counsellor and the other on interviewing the patient. The interactional tasks in the use of the intemiew f m a t include p&ing the patient to produce hisfier own views of thehture and moon’ngfrom mere expression of troubles towards their management.
Introduction Working with patients coming for an HIV antibody test or having been diagnosed as HIVantibody positive requires medical and paramedical professionals to deal with the patients’ fears of what may happen to them in the future. This is not restricted to counselling sessions only, but it usually is most explicit there. In pretest interviews, this means talking about the implications of the possibly positive test result (McCreaner, 1989; Miller & Bor, 1988). In counselling people already diagnosed as HIV antibody positive, talking about the future entails addressing issues like deterioration in health, disfigurement, pain, loss, and death (George, 1989; Bor & Miller, 1988). Bor & Miller (rbtd) have outlined an argument in favour of addressing some of these ‘dreaded issues’ a long time before the patient might otherwise confront them. The counsellor should first find out what the specific fears of the patient are, and then encourage him or her to speak further about them. By so doing, they argue, counsellors can help people to plan ahead and perhaps reduce the possibility of complications should the issue actually occur. Patients prepared beforehand may be less likely to cut off their relations with their support network (including the counsellors) or to develop psychiatric disorders. Also practical issues-such as decisions about future care and difficulties in doing wills-can be attended to, if the difficult situation has been addressed whilst the patient was in good
Address for correspondence: A. Per&ylP, G l v o Research Fellow, University of London Goldsmiths College, Department of Sociology, London SE14 6 N W , UK.
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326 A. PER&-
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health. In sum, addressing the ‘dreaded issues’ in advance can help the patient to think positively and to maintain hope. Talking about fears of death, dying, illness and its consequences, however, is not an easy task to accomplish. Our culture has been described as one which avoids such topics (Aries, 1982; Elias, 1985). The counsellors and the clients have to engage in particular ways of talking in order to be able to deal with them. In this paper, we will present findings from a detailed study on counselling sessions where such discussion took place. We will not be looking at the efficacy of counselling, but rather the minute details of interaction between patients and counsellors when difficult topics are discussed. Fifty three tape-recorded excerpts from counselling sessions with people coming for an HIV antibody test and patients diagnosed as HIV-antibody positive were analyzed. Most of the sessions took place in the Haemophilia Centre or the AIDS Counselling Unit of the Royal Free Hospital, London; and some in other clinics around UK. (Allthe excerpts presented in t h i s paper, except no. 2, are from Royal Free Hospital.) The sociological study on which this paper is based applies conversation analytical methods (Atkinson & Heritage, 1984; Heritage, 1989). Conversation analysis is a qualitative sociological approach developed for the detailed analysis of verbal interaction. However, the reader will need no special knowledge of this approach to follow the argument. Moreover, for the purposes of this paper, the strictly conversation analytical approach has been liberalized and broadened, to give more room for considerations relevant for the profession of counselling. Nevertheless, the concepts applied in this paper are sociological rather than, e.g. psychological. We restrict our examination to the public, interactional features of a counselling session and leave aside the private sphere of the participants’ intentions, motivations and feelings. The findmgs will be formulated as four interactional tasks facing counsellors wishing to address ‘dreaded issues’ with their patients.
First task managing delicacy Sickness and death are not a part of the everyday vernacular of people today. Thus the Counsellor (C) wishing to raise them as a topic of a counselling session has to cope with cultural prohibitions about such talk. Our data reveals an elegant way of doing this: Producing turbulent talk in the issues related to death and illness. Recurrently, when Cs are about to introduce ‘dreaded issues’ in their conversation with the Patients (Ps), their talk reveals several puuses, self-repairs and hesitations. A typical example is Excerpt 1. The C is asking a HIV-poisitive P, how he thinks that his wife would cope if he became ill. (The transcription symbols are presented in the Appendix.)
Excerpt 1 (E4.001) 1 Dr: ( . . . ) but it holds back the: ( S ) 2 multiplication time 3 P: right 4 5 C: 6 7 8 C: 9 10
(1 -4)
If (.6) and we’re just ta:lking very hypothetically (1.2)
if you sh- (.6) yo::ur (.) em (.) T-cells &d drop and your im=:ne system
(.7)
INTERNATIONAL PROBLEMS OF ADDRESSING ‘DREADED ISSUES’IN HIV-COUNSELLING
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11 12 13 14 15 16 17 18 19 20
c:
began not to work so well:.an:d
C:
you b e y e unwell, (.) how do you see
C:
Doreen as coping?
P:
Em
327
(1.5) (2.0) (1.2) (1.1)
P:
She’ll r:- (.4) she’ll respond to the (..*>
In lines 4,5,7,8,10,12, and 14 in the C’s turn we can see a number of pauks. Such pauses, as well as the repairs (like ‘if you sh- (.6) yo::ur (.) em (.) T-cells’ in line 8) and the hesitations (like ‘If (.6) and we’re just talking very hypothetically’ in lines 5-6) are a commonplace in all the excerpts we have examined, when Cs are initiating talk about dreaded issues. The overall working hypothesis in all conversation analytical work is that even the smallest particulars of talk are orderly produced, and orienting to the relevant moral and social structures as well as to the speakers’ individual goals (Sacks, 1984; Sharrock and Anderson 1987). This applies to the perturbations of talk as well. For example, Jefferson (1974) argues that self-repairs are often used in correcting ‘interactional errors’, e.g. as means of saying something ‘inappropriate’. West (1983) observed that the producers of socially dispreffered actions (in her case, patients asking questions from busy doctors) regularly mark these with several kinds of perturbations. Following these lines of thought, we are inclined to see the perturbations of talk occurring in the ‘dreaded issues’ sequences, not as indications of communication difficulties, but of communication skilZs. Our hypothesis is that they perform an essential task by marking the topic of ‘dreaded issues’ as a delicate one: a topic that would not be approached in an ordinary conversation and one that requires a special attention from both C and the client. (Onmarking delicate issues, see further Schegloff, 1980; Bergman, 1989.) In linguistic terms, the perturbations add a certain degree of indirectness on the assertions about the Ps’ potentially gloomy future. According to Leech (1983), the indirectness is a fundamental aspect of tact. The further empirical evidence to support the argument about the functionality of the perturbations concentrates on the colluburation between the C and the P in marking the delicate issues. For reasons of space, it cannot be examined in detail here (see, however, Silverman & Periikyll, 1990) the following points, however, can be listed: (1) The perturbations are attended to by Ps with a ‘frozen orientation’: the Ps direct their gaze towards the C and fix their body posture during the production of the perturbations. (2) The Ps replicate the pauses in their answers in those cases that they produce talk on the topic proposed by C, and they do not do that in those cases that they reject the topic introduced by the C. (3) When Cs do not produce perturbations in their invitations to talk about dreaded issues, Ps may withhold their answer so long that C has to produce another invitation.
Thus the professional quality of Cs’ activity is not due to their ability to appear as unembarrassed while talking about Ps’ menacing future. Rather, it lies in their ability to combine the unequivocality in references to P’sfuture, with the use of the publicly available
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ways of displaying embarrassment (i.e. perturbation of talk) in the management of a delicate topic.
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Second task eliciting P’s talk
In our corpus, there appears two opposing interactional formats in which the talk about dreaded issues was accomplished: what we call the Information Delivery format and the Interview format. The difference is very simple. In the former, the C does almost all the talking, whereas in the latter, the C asks questions and the P answers to them. An example of Information Delivery format in talking about dreaded issues is the following. The excerpt is from a pre-test interview; the P is told here about the implications of a positive test result.
Excerpt 2 (E4.2.003) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34
c: P:
c: P:
c: P: C:
When someone (.4) h:as this test. (5) UhU? (-7) I mean obviously: everybody hopes it nega-sative test result: (.) I mean end of it= =u m h .hh (.) we have to make sure you understand (.) what happens when someone(.3) gets a positive result .h[hh (.) I’m= [ uhu? =not saying (lets) assume you? (-8)
C
that I think for one minute: (.4) ) that would be the case ( uhu? (-3) but people (.2) you know have to be aware:
P:
UhU?
c:
.hhhhWhen someone’s getting a positive result (.2) they ( 1 (4 they (-3) go into sho:ck (.2) [ ( ) how well
P:
[ umh:?
C:
P:
(-3)
C:
=prepared they are: .hh and (that can) 1a:st up to three months: (.4) befo:re they come (.3) to terms with h : s
P:
UhU?
C:
But be&? HIV-positive:: (.6)means (.3) that that person is ca:rrying a vi:rus. (.6) We don’t know for sure (.) whether or no:t, (.4) they’ll develop aids (.) later e give is: (.) on? .hhh but the a d ~ c we
INTERNATIONAL PROBLEMS OF ADDRESSING ‘DREADED ISSUES’ IN HIV-COUNSELLING
35 36 P: 37 38 C: 39 40 41
329
common sense if you think abo:ut i:t = =uhu? (-6) for the only way: its passed (.2) is through: (.) blood? (.3) or through sex flu:& (.4) or from mother to baby ((continues))
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The Interview format is exemplified by the next excerpt. This is also a pre-test counselling session, but now the implications of a positive result are elicited from the P.
Excerpt 3 (E4.26) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
c: P: P:
c: P: P: C:
P:
c C:
P: P: C:
..
( . ) what for you the wo:rst thing would(.) be: ( S ) knowing your result (.) one
way or the other (1 .a>
Em::
(1 *a well I mean obviously (.) (if it wasn’t Aids er-) ( 1-81
um that would be p;reat (.) or: (-6) but if it was was p i t i v e I (really) don’t kno:w ho:w (-3) um: (-2) ((sniff, cough)) I would be able to deal with this er:: uhm: what do you thin:k (.2) the problems would be: immediately on hearing it (-2) just (.a) out of &gsity; (3.8) I don’t knnw ( 1 (1.0) [how its gonna- (.8) affect my life (.) or [hum
(-3)
C:
P: P:
Ho- how do you ima:gine that does affect people’s: live:s from what you know (4.0) I s u p ~ s it e (might) just make you (3.0) just be a little bit mo:re (*4)
330 A P E m m & R BOR 37 38 39
P:
aware of
P:
.hh dyiing an:d
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40 41 42 43 44 45 46 47 48
P: P:
(a
( 1-01 the way of dying you know I mean
(*a> how you die (-3)
c:
Wh- what it is a b u t ho:w one dies that(.6) that might be a problem,
P:
Just becoming:: dependent on somebody:: ((continues))
(-7)
The difference between the two excerpts, although both from an pre-test session, is evident. Whereas in one the C offers the P her own version of the implications of a positive result, in the latter the C actually withdraws from the expression of his own views in favour of eliciting the P’s talk about his views on the implications of a positive result. The difference between these two excerpts (and more generally, between the Information Delivery and Interview formats) is not in the content: they both deal mostly with the psycho-social implications of the positive result. The difference is in the format, and more specifically, in the different conversational roles adopted by the P and the C.We shall call the set of roles alignment. A single counselhg interview usually consists of several phases applying different forms of alignment, the most recurring and important of which are Information Delivery and Interview. So those Cs who apply Information Delivery in talking about ‘dreaded issues’ may very well apply Interview format while talking about something else. The tendency is, however, that getting ill and dying are topics that seem to sharpen the contrast between two different approaches to HIV-counselling. W e addressing many other topics, Information Delivery and Interview formats are more or less mixed; but when it comes to talking about ‘dreaded issues’ (especially initiating such talk), the sessions are clearly divided into two groups: those where Cs ask questions and Ps answer and those where Cs talk and Ps are recipients. A series of questions asked by the C of the P cannot, however, continue endlessly. In our material, the Cs using the Interview format do quite often also offer Ps their own views about the P’s situation. But that happens only after a long sequence of questions and answers, and as a way out from the talk on dreaded issues rather than as its upshot. The Information Delivery format is far less complicated in comparison with the Interview. A counsellor applying it is less dependent on the P’s contribution to the conversation: only recipiency and no talk is required from the P. As a result of this, a similar range of issues can be covered within a shorter amount of time. This is not an irrelevant consideration within a hospital setting, where time available may be very limited. Moreover, the greater dependency of the Interview format upon the P’s contribution makes it more liable to interactional hfficulties. Our data, the corpus of transcriptions from counselling interviews, does not in itself validate any claims about the therapeutic effects of these two models. Obviously, there are as many ways of doing counselling as there are theories of it, or even as many as there are individual counsellors. We cannot claim that one way is better than another. Our own
INTERNATIONAL PROBLEMS OF ADDRESSING ‘DREADED ISSUES’IN HIV-COUNSEUING
33 1
clinical experience, however, makes us particularly interested in the Interview format, because in it the P is given a possibility to reflect upon his or her own beliefs and fears. In any case, it is important to emphasize that in addressing dreaded issues, paying attention to the form of the talk is at least as important as paying attention to its content. But as said above, the Interview-format entails interactional difficulties. In the rest of this paper, we are going to examine some of them.
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Third task overcoming the P’s reluctance Patients are not always immediately willing to reveal their concerns about the future. We will now leave aside the ethical question of how far a C should encourage P talk in cases where the P does not show immediate signs of willingness to talk. Instead of that, let us analyze the interactional dynamics of how patients are encouraged to talk about ‘dreaded issues’. Nelson-Jones (1988) says that the hstinguishing feature of ‘facilitative skills’, i.e. skills to make it easier for the client to disclose herlhunself, is the C’s ability to stay within the client’s frame of reference. In other words, if a C empathetically perceives the lived private meanings of the client, it is easier for the client to talk about her/his concerns. We would like to propose that there are also some other essential features which facilitate P talk. These are simple public and interactional phenomena that may precede the displays of empathy (or the lack of them). Two of those are visible in Excerpt 4. Excerpt 4 (E4.00S) 1 2 3
c:
4 P: 5 6 C: 7 P:
a 9 10 11 12 13 14 15 16 17 ia
19
I’m wondering what it is particularly ) about that is frightening ( (1.6) umh its (0.6) illness: the (1 -0) Okay so what about the ill[ness [ hhhhh (4.0)
P: P:
c: P: P:
making (if a bit) hard hhh gh You E::h[hh ’ [heh .hh what about the illness (-9) Thought that (we’d) gone through that (.a) but .hhhh (1.9) ImthethoughtofbeingillanIm like being ill (-6) I really don’t at all .hh
The simplest public interactional device used by Cs to encourage P talk about dreaded issues is u repccued quenion. In the line 6, C asks the first question ‘what about the illness’. As no reply is supplied by the P, the question is repeated in line 1l-and now the answer is supplied by the P. A question, especially a question made by a person acting as a professional, is an extremely powerful vehicle. A question always creates a moral obligation for the recipient to
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332 h PERhKYLh & R BOR
provide an answer (Schegloff & Sacks, 1973). If he fails to do so, then the situation is accountable: either the recipient or the questioner has to provide an explanation for the lack of an answer. In excerpt 4, the explanation is provided by C in line 9: ‘making (it a bit) hard’. Accounting for the lack of the answer to the original question does not make the renewed question less obligating. So Cs eliciting P talk inevitably draw upon the basic social rule obligating people to answer when asked a question. The other public and interactional device used by the C here in encouraging P talk is contained in her explanation for not succeeding in getting an answer from the P (‘making (it a bit) hard’). That comment namely also accomplishes what we will call a fmularion of the ongoing talk. Formulations are a persistent feature in any’conversation (Garfinkel & Sacks, 1970, Heritage & Watson, 1980), and especially numerous in certain types of institutional encounters (Heritage, 1985). A formulation can be a summary of a part of the conversation or of the whole conversation, or it can describe the conversation in otherwise, e.g. the mood of the conversation or the reasons why the participants do what they do in the conversation. Through making formulations, the participants achieve a public interpretation of what is going on in the conversation. Now formulations are regularly made by the Cs in the cases when Ps display a reluctance to talk about the dreaded issues. They seem to be a part of the standard procedure of persuading the P to talk. The formulation may, as in the case above, do the work of accounting for a failure to have an answer to a question, or they may stand independently. Moreover, the formulations are regularly coupled with a repeution or rephrazing of the original question. In Excerpt 5, a formulation follows an account given by a patients wife (W) for not answering to C’s question related to dreaded issues.
Excerpt 5 (E4.008.) 1 2 3 4 5 6 7 8
9 10 11 12 13 14 15 16
w: c:
w: c: w:
) aids just another thing (2.9) I’m at a S e where I feel if (.9) it would just be another dung okay having heard what your husband said (.) that even if he was negative (1.5) it wouldn’t make him conduct his Me any different (1.2) what (.8) affect would that ha:ve if (.8) I mean what are the things it would affect if he was positive? hhhhhhh Umh? I just don’t know (.a) I’m afraid (2.8) I’m in a frame of the mind a (.) mind at the moment (2.8) that I’m not a lot of use: (.) to hypothetical things ((continues)) (
As we can see, not even the formulation coupled with the renewed question is successful here in the work of persuasion. In her next turn (lines 12-15) W still offers an account for not answering the questions instead of producing an answer. (In this particular case, the C’s special insistence in persuading the patient’s wife to talk is due to the fact that the P-a haemophiliac-has been d r e d y diagnosed as positive, but the couple ‘denies’ it.) What is achieved the Cs through offering formulations as a part of the encouragement
INTERNATIONAL PROBLEMS OF ADDRESSING ‘DREADED ISSUES’ IN HIV-COUNSELLJNG
333
to talk? Obviously a formulation displays C’s attention to the difficulties that the P has in disclosing more of his or her concerns (cf Nelson-Jones, 1982). But we would suggest that in doing this, the formulation also gives an extra backing to the initial question. A formulation is a means of achieving a publicly available and recognized interpretation of what is happening in the conversation. Through establishing an interpretation of what was happening in the previous talk, the C makes the question appear as a logical outcome of it. That function of the formulation is quite obvious in Excerpt 6. The P is just about to finish an utterance where he says that at the moment it is impossible for him to think about arrangements if he were to become demented. Not now, but only later on would it be the right time to think about such things. Downloaded by [Simon Fraser University] at 21:30 13 November 2014
Excerpt 6 (E4.12) 1 2
P:
3 4. 5
P:
15 16 17 18 19 20 21
. . . ) and I think
bethetime(
(.6) it [would umh ) to make that kind [ of
r
c:
6 P: 7 c: 8 P: 9 c: 10 P: 11 c: 12 13 14
(
c
[umh ( S ) .hh a provisionumh= =erh (.) in any case. But we are n[ot I think what I heard Dr A = [ erh: =saying that answers her question partly .hhhbut it doesn’t- (1.2) a:nswer the question that (1.6) you raised and I hadn’t (.7) WASN’T thinking about it and it made me thinking in terms of all of us in this room that if any of us should .hh ( S ) have some b i n d of impairment who would we (1.2) want to make those E.nd of decisions would it be one’s parents or would it be ( S ) the closest person to one?
As a response to P’s expressed reluctance to talk about the dreaded issues, in line 9 onwards the C formulates the preceding conversation. She establishes an interpretation of the foregoing events, according to which P has not answered more than partly to a question raised by Dr A (a co-counsellor), and not at all to the question that has been implied by the P himself. After the formulation, the C makes her original question anew. The C here may not be pursuing an answer as such, but rather trying to make the P consider seriously the hypothetical future circumstances depicted in the question. But the public indication of such consideration is answering the question. That’s why the exchange overtly takes the form of pursuing an answer. We need not go further into the d e t d s of formulations and repeated questions. What is essential here, is that talk about dreaded issues (in an Interview format) in counselling entails a great deal of pmuasion. That persuasion is not (only) based on empathetic understanding, but on the use of the publicly available conversational devices, like repeated questions and formulations. The message for the counsellors here is perhaps an unfashionable one: If you want your
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clients to talk about dreaded issues, you can and must use your professional authority through consistently asking questions and making formulations. Fourth task moving towards problem-solving
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There is a further possible obstacle for a successful sequence of talk about ‘dreaded issues’. It is very much related to the difficulties considered above, but also has an additional characteristic. Namely, even when the dreaded future possibilities have been introduced as a topic for the conversation, the P may be reluctant to view the hypothetical future situation as a problem to be solved. That is the case in Excerpt 7. The P’s wife (W) has just a moment ago disclosed her concerns about the possibility of the P developing AIDS. Excerpt 7 (E4.16)
w:
1 2 3 w: 4 c: 5 6 7 8 C:
w:
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
an::d (1.6)
what would happen to me:?
d and the children (2.1)
w:
if he did deEl[op
w:
something?
c: C:
C:
W:
[d
(4 mmh What’s your greatest f
e about that?
(1.8) ( [ 1 (-2) ( [ There isg’t anything (.2) speGfic (.) I mean it’s just a general absua:ct:
1
C:
I mean would you: have any: E r e womes than you’ve got now?
c:
when he’s anti:wy: Esitive?
C:
(Is he) what would you know about .hh (.2) looking after people with Aids, (Well) I donJ? (Well) what (.3) do you kno[:w ( 1 [I haven’t even, I haven’t even thou:p;ht that fa:r Um: Because I feel that (.2) .hhhhhh
W: C:
W:
C:
W:
c: w:
(.4)
(1 *o>
Would you see [ (there) [
(
(
1 ) ENOUGH
TO WORRY ABOUT (I’m) cairn enough to worry abo[ut that
INTERNATIONAL PROBLEMS OF ADDRESSING ‘DREADED ISSUES IN HIV-COUNSELLING
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37 c: 38 3: 39 w:
40
c:
41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59
C:
335
[ BUT I THINK AS YOU’VE RAI(SED-
[oo:h something ( @uld happen ( Liza As you’ve raised it (.) I mean: .would there’re any more- ( S ) attached (.) for you and the children than there are now (3.0)
C:
w:
I’m not talking about well-
c:
future risks and (.) and
(a41
(-4) life (
W:
[
1
W
[What you mean risks? You mean (in an-)= = (well) (.4) yes: Infection [ and that sort of [ thing, [ Es: [ Yes Em::
W:
Not (.3) that I’m aware of
c: w c:
(2.6)
c:
=
=Yes. Would you confirm that? (.2) Dr A?
The wife of the P in this excerpt is reluctant to consider her worry as something that can be divided into smaller pieces (‘T:here isn’t anythmg (.2) speccfic (.) I mean it’s just a general abstra:ct:’). When challenged to examine her knowledge about looking after people with Aids, she responds by saying that she has not thought that far, and appeals to the fact that she has got now enough to worry about. This type of response to Cs’ questions are quite frequent in our corpus. Again, psychological explanations are available: the Ps may have different sorts of inhibitions towards examining in detail their fears. But in addition to psychological phenomena, there are also social and interactional ones involved here. Following our sociological approach, we will concentrate on them. Jefferson & Lee (1981; see also Jefferson, 1980) have suggested that there is a specific kind of talk, called rroubles telling. In troubles telling, one participant reveals hidher troubles to another, who in turn offers affiliation and sympathy. The conversational category of a ‘troubles teller’ is a favourable one: he/she is the one who speaks, and the ‘troubles recipient’ largely only listens and responds. As Jefferson & Lee have pointed out, the troubles tellers sometimes definitively reject advice from their recipients, because (as Jefferson & Lee argue) accepting the advice would imply giving up the favourable conversational role of a troubles teller. Now addressing dreaded issues seems to entail a similar type of tension. The moment of revealing his or her concerns to the C may give the P a role quite close to that of a troubles teller. But in the course of the session, that role has to be abandoned. The concern has to treated as a manageable problem rather than as a misfortune or as a misery. A troubles teller becomes a problem solver, which may be much less rewarding a conversational role. Hence the resistance. The means of dealing with the P’s resistance available for the Cs are here much the
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same as in the case of reluctance to talk about dreaded issues at all. The questions can be repeated and the foregoing conversation formulated. That is what the C does in Excerpt 7. In line 26 she is repeating her questions concerning the P’s wife’s knowledge about taking care of people with AIDS, and in lines 37 and 41, she formulates the foregoing conversation: You have raised this issue. The renewed questions and the formulation turn out to be successful, as the Wife and the C end up by examining risks involved in living in the same household with a person suffering from AIDS. As a conclusion, we would like to emphasize that addressing dreaded issues-like any serious counselling-entails not only talk that Ps immediately consider as pleasant and rewarding. The P has to give up the rewarding role of a troubles teller, in favour of engaging in problem management. It is the task of the C to conduct this shift, using hidher interactional skills and professional role. Our intention, however, has not been to give an impression that Cs dominate the sessions and clients merely respond to them. Addressing dreaded issues is a joint accomplishment: whatever is done in such talk, is done collaboratively. The Cs do take the initiative in many instances, e.g. when the P is displaying reluctance to address the issues. But the initiation of Cs does not lead to a full sequence unless the Ps give their contribution. Each answer that the P gives to the C‘s questions is equally a display of P’s contribution and alignment in talking about the difficult topics.
Conclusion In this paper, we have examined the dynamics of addressing ‘dreaded issues’ in HIV counsehg. It has turned out that ‘dreaded issues’ is a topic requiring special attention from the counsellors, who have to overcome the dispreferred nature of t h i s topic. It is done through the application of conversational devices like perturbations of talk (renewed) questions and formulations. Conversation analytical studies have previously found these devices and techniques working in ordinary conversation and in other institutional spheres. What makes the counsellors’ way of using them a particular professional activity, is the consistent and systematic application of those techniques in order to reach specific goals related to counselling. One of such goals is the encouragement of patients’ talk about ‘dreaded issues’. In methodological terms, this paper has explored the possibilities of conversation analysis in research on HJV counselling. Detailed qualitative analysis of a relatively small set of cases can reveal some of the problems that the counsellors have to deal with in their practice. Hopefully this type of analysis can suggest new areas of interest for quantitative research, as well as for the further development of counselhg practice.
Acknowledgements We are grateful to Professor David Silverman (University of London) for the invaluable support and help in analysing the data. We wish to thank Dr P. B. A. Kernoff for the access to the video archives of the Haemophilia Centre of the Royal Free Hospital, and Mrs R. f i l l e r and Ms H. Salt for the access to those in the AIDS counselling unit of the Royal Free Hospital. We are particularly grateful to M r s R. Miller and Dr E. Goldman (Royal Free Hospital Haemophilia Centre) whose counselling practice and theoretical work has provided us with a frame of reference for studying the discussions about hypothetical future situations in HIV counselling. The first author gratefully acknowledges the generous financial support provided by Glaxo Holdings plc.
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References
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ARIES, P. (1982) The Hour of Our Death (New York, Vintage Books). ATKINSON, J M . & HERITAGE, J. (Eds) (1984) Structlrres of Social Actioc Studies in Comenation Anahsir (Cambridge, Cambridge University Pms). BERGMAN, J.R. (1989) Veiled morality: notes on discretion in psychiatry, in: P.-A. F o ~ s r (Ed.) o ~ ~hcourse in Rofesrimal and Eueryday Culrutr, University of Linkoping, Studies in Communication: SIC 28. BOR,R. & M u . q R. (1988) Addressing ‘dreaded issues’: a description of a unique counselling intervention with patients with AIDS/HIV, Counselling Psychology Quanerly, 1, pp. 397-405. GARPINKEL,H. & SACKS,H. (1970) On formal structures of practical actions, in: J. C. MCWNNEY& E. A. TIRYAR~AN (Eds) Theorerid Sociology, pp. 338-366. (New York, Appleton Century Crofts). GEORGE, H. (1989) Counselling people with AIDS, their lovers, friends and relations, in: J. GREEN & A. MCCRJMNER (Eds) Counselling rpith HIV-infection and AIDS, pp. 69-87 (Oxford, Blackwell Scientific Publications). E w , N. (1985) The Laclimss of I c Qymg (Oxford, Basil Blackwell). HERITAGE, J. (1985) Analyzing news interviews: aspects of the production of talk for an overhearing audience, in: T. A. VAN DIJK (Ed.) Handbook o f k o v n e Analysis Vol3 (London, Academic Press). HERITAGE, J. (1989) Recent developments in conversation analysis, in. D. ROGER& P. BULL(Eds) Conwenatin An Inmdisciplimny Perspectior (Clevedon, MultrlinguPl Matters). HERITAGE, J. & WATSON,D.R. (1980) Aspects of the properties of formulations in natural conversations: some instances analyzed, SnnWtica, 30, pp. 245-262. JEFTERSON, G. (1974) Error correction as an interactional resource, Language and Society, 2, pp. 181-199. J E F F E R S G. O N(1980) , Final Rtpa w the SSRC on the Analyru of CaomartOnr in which ‘Troubles’ and ‘Anrieties’ arc Expnsrrd (no. HR 4805). JEFFERSO G.N&, LBB,J.R.E. (1981) The rejection of advice: managing the problematic convergence of a ‘troubles t e w and a ‘service encounter’, jovlnal of Ragmafiu,5, pp. 339-422. L m x , G.N. (1983) Principies of Rqgm4tics (London and New York, Longman). M~REANER, A. (1989) Pretest counselling, in: J. GREEN& A. MCCRPANER (Us) Counselling wirh HIV-Infecrion and AIDS, pp. 21-27 (Oxford, Blackwell Scientific Publications). M w , R. & B ~ R R , (1988) AIDS A Guide w Clinical Counselling (London, Science Press). NELSON-JONES, R (1982) The Theory and Practice of Counselling Psychology (London, Cassel). R (1988) RacriCal Counselling and Helping Skills, Second Edition (London, Cassel). NELSON-JONES SACKS,H. (1984) Notes on methodology, in: P. ATKINSON & J. HERITAGE(Eds)Smcrtlrres ofsocial Action: Studies in Conomation Analysis (Cambridge, Cambridge University Press). SCHEGLOFF, E. A. (1980) Preliminaries to preliminaries: ‘can I ask you a question’, Sociological Inquiry, 50,pp. 104152. SCHEGLOFF, E.A. & SACKS, H.(1973) Opening up closings, Snnbtica, 7, pp. 289-327. SHARROCR, W.& ANDERSON, B. (1987) Work flow in a pediatric clinic, in G. B ~ & J. N R E. LH! (Eds) Talk and social organization (Clevedon: M u l M Matters). SILVERMAN, D. & Pmkm A. (1990) AIDS counselling: the interactional organization of talk about delicate issues, Sociology of Heawl and Illness, 12, p. 3. WEST, C. (1 983) ‘Ask me no questions . . . I. An analysis of queries and replies in physician-patient dialogues, in: S. FISHER& A.D. TODD(Eds) The Social Organization of Docwr-Patient Communicarion (Washington DC, Centre for Applied Linguistics).
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Appendix The transcription symbols C2: quite a [
[
Mo:
[
while Yea
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W: that I’m aware of = C. =Yes. Would you c o n h that? (.4)
Yes (.2) yeah
(.)
to get (.) treatment
Ok?
WORD
I’ve got ENOUGH TO WORRY ABOUT
.hhhh
I feel that (.2) .hhh
(
future risks and (
)
(
(word) ((
))
) and life
1
Would you see (there) anytlung positive c o b that ((continues))
Left brackets indicate the point at which a current speakers talk is overlapped by another’s talk. Equal signs, one at the end of a line and one at the beginning, indicate no gap between the two lines. Numben in parentheses indicate elapsed time in silence in tenths of a second. A dot in parentheses indicates a tiny gap, probably no more than one-tenth of a second. Undekoring indicates some form of stress, via pitch and/or amplitude. Colons indicate prolongation of the immediately prior sound. The length of the row of colons indicates the length of the prolongation. Capitals, except at the beginnings of h e s , indicate especially loud sounds relative to the surrounding talk. A cow of h’s prefixed by a dot indicates an inbreath, without a dot, an outbreath. The length of the row of h’s indicates the length of the in- or outbreath. Empty parenthem indicate the transcribers inability to hear what was said. Parenthesized words are possible hearings. Double parentheses contain author’s descriptions rather than transcriptions.
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Interactional problems of addressing ‘dreaded issues’ in HIV-counselling a
A. Peräkylä & R. Bor
b
a
Glaxo Research Fellow, University of London Goldsmiths College, Department of Sociology , London, SE14 6NW b
Principal Clinical Psychologist, District AIDS Counselling Unit , Royal Free Hospital and School of Medicine , London, UK Published online: 25 Sep 2007.
To cite this article: A. Peräkylä & R. Bor (1990) Interactional problems of addressing ‘dreaded issues’ in HIV-counselling, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 2:4, 325-338, DOI: 10.1080/09540129008257748 To link to this article: http://dx.doi.org/10.1080/09540129008257748
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AIDS CARE, VOL. 2, NO. 4,1990
325
Interactional problems of addressing ‘dreaded issues’ in HIV-counselling A. PERAKYLA’81 R. B O R ~ Downloaded by [Simon Fraser University] at 21:30 13 November 2014
’
GIaxo Research Fellow, University of London Goldsmiths College, Department of Sociology, London SE14 6NW, Principal Clinical Psychologist, Disnict AIDS Counselling Unit, Royal Free Hospital and School of Medicine, London, UK
Abstract Addressing the patient’s fears about the future is an essential task in HIV counselling. The paper examines with conversation armytical methods the interactional dynamics of such discussions in video- and audio-taped counselling sessions with patients coming for an HIV test and others diagnosed as HIV antibody positive. Two communication fonnou were found to be used in the sessions, one based on information delivery made by the counsellor and the other on interviewing the patient. The interactional tasks in the use of the intemiew f m a t include p&ing the patient to produce hisfier own views of thehture and moon’ngfrom mere expression of troubles towards their management.
Introduction Working with patients coming for an HIV antibody test or having been diagnosed as HIVantibody positive requires medical and paramedical professionals to deal with the patients’ fears of what may happen to them in the future. This is not restricted to counselling sessions only, but it usually is most explicit there. In pretest interviews, this means talking about the implications of the possibly positive test result (McCreaner, 1989; Miller & Bor, 1988). In counselling people already diagnosed as HIV antibody positive, talking about the future entails addressing issues like deterioration in health, disfigurement, pain, loss, and death (George, 1989; Bor & Miller, 1988). Bor & Miller (rbtd) have outlined an argument in favour of addressing some of these ‘dreaded issues’ a long time before the patient might otherwise confront them. The counsellor should first find out what the specific fears of the patient are, and then encourage him or her to speak further about them. By so doing, they argue, counsellors can help people to plan ahead and perhaps reduce the possibility of complications should the issue actually occur. Patients prepared beforehand may be less likely to cut off their relations with their support network (including the counsellors) or to develop psychiatric disorders. Also practical issues-such as decisions about future care and difficulties in doing wills-can be attended to, if the difficult situation has been addressed whilst the patient was in good
Address for correspondence: A. Per&ylP, G l v o Research Fellow, University of London Goldsmiths College, Department of Sociology, London SE14 6 N W , UK.
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326 A. PER&-
61R BOR
health. In sum, addressing the ‘dreaded issues’ in advance can help the patient to think positively and to maintain hope. Talking about fears of death, dying, illness and its consequences, however, is not an easy task to accomplish. Our culture has been described as one which avoids such topics (Aries, 1982; Elias, 1985). The counsellors and the clients have to engage in particular ways of talking in order to be able to deal with them. In this paper, we will present findings from a detailed study on counselling sessions where such discussion took place. We will not be looking at the efficacy of counselling, but rather the minute details of interaction between patients and counsellors when difficult topics are discussed. Fifty three tape-recorded excerpts from counselling sessions with people coming for an HIV antibody test and patients diagnosed as HIV-antibody positive were analyzed. Most of the sessions took place in the Haemophilia Centre or the AIDS Counselling Unit of the Royal Free Hospital, London; and some in other clinics around UK. (Allthe excerpts presented in t h i s paper, except no. 2, are from Royal Free Hospital.) The sociological study on which this paper is based applies conversation analytical methods (Atkinson & Heritage, 1984; Heritage, 1989). Conversation analysis is a qualitative sociological approach developed for the detailed analysis of verbal interaction. However, the reader will need no special knowledge of this approach to follow the argument. Moreover, for the purposes of this paper, the strictly conversation analytical approach has been liberalized and broadened, to give more room for considerations relevant for the profession of counselling. Nevertheless, the concepts applied in this paper are sociological rather than, e.g. psychological. We restrict our examination to the public, interactional features of a counselling session and leave aside the private sphere of the participants’ intentions, motivations and feelings. The findmgs will be formulated as four interactional tasks facing counsellors wishing to address ‘dreaded issues’ with their patients.
First task managing delicacy Sickness and death are not a part of the everyday vernacular of people today. Thus the Counsellor (C) wishing to raise them as a topic of a counselling session has to cope with cultural prohibitions about such talk. Our data reveals an elegant way of doing this: Producing turbulent talk in the issues related to death and illness. Recurrently, when Cs are about to introduce ‘dreaded issues’ in their conversation with the Patients (Ps), their talk reveals several puuses, self-repairs and hesitations. A typical example is Excerpt 1. The C is asking a HIV-poisitive P, how he thinks that his wife would cope if he became ill. (The transcription symbols are presented in the Appendix.)
Excerpt 1 (E4.001) 1 Dr: ( . . . ) but it holds back the: ( S ) 2 multiplication time 3 P: right 4 5 C: 6 7 8 C: 9 10
(1 -4)
If (.6) and we’re just ta:lking very hypothetically (1.2)
if you sh- (.6) yo::ur (.) em (.) T-cells &d drop and your im=:ne system
(.7)
INTERNATIONAL PROBLEMS OF ADDRESSING ‘DREADED ISSUES’IN HIV-COUNSELLING
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11 12 13 14 15 16 17 18 19 20
c:
began not to work so well:.an:d
C:
you b e y e unwell, (.) how do you see
C:
Doreen as coping?
P:
Em
327
(1.5) (2.0) (1.2) (1.1)
P:
She’ll r:- (.4) she’ll respond to the (..*>
In lines 4,5,7,8,10,12, and 14 in the C’s turn we can see a number of pauks. Such pauses, as well as the repairs (like ‘if you sh- (.6) yo::ur (.) em (.) T-cells’ in line 8) and the hesitations (like ‘If (.6) and we’re just talking very hypothetically’ in lines 5-6) are a commonplace in all the excerpts we have examined, when Cs are initiating talk about dreaded issues. The overall working hypothesis in all conversation analytical work is that even the smallest particulars of talk are orderly produced, and orienting to the relevant moral and social structures as well as to the speakers’ individual goals (Sacks, 1984; Sharrock and Anderson 1987). This applies to the perturbations of talk as well. For example, Jefferson (1974) argues that self-repairs are often used in correcting ‘interactional errors’, e.g. as means of saying something ‘inappropriate’. West (1983) observed that the producers of socially dispreffered actions (in her case, patients asking questions from busy doctors) regularly mark these with several kinds of perturbations. Following these lines of thought, we are inclined to see the perturbations of talk occurring in the ‘dreaded issues’ sequences, not as indications of communication difficulties, but of communication skilZs. Our hypothesis is that they perform an essential task by marking the topic of ‘dreaded issues’ as a delicate one: a topic that would not be approached in an ordinary conversation and one that requires a special attention from both C and the client. (Onmarking delicate issues, see further Schegloff, 1980; Bergman, 1989.) In linguistic terms, the perturbations add a certain degree of indirectness on the assertions about the Ps’ potentially gloomy future. According to Leech (1983), the indirectness is a fundamental aspect of tact. The further empirical evidence to support the argument about the functionality of the perturbations concentrates on the colluburation between the C and the P in marking the delicate issues. For reasons of space, it cannot be examined in detail here (see, however, Silverman & Periikyll, 1990) the following points, however, can be listed: (1) The perturbations are attended to by Ps with a ‘frozen orientation’: the Ps direct their gaze towards the C and fix their body posture during the production of the perturbations. (2) The Ps replicate the pauses in their answers in those cases that they produce talk on the topic proposed by C, and they do not do that in those cases that they reject the topic introduced by the C. (3) When Cs do not produce perturbations in their invitations to talk about dreaded issues, Ps may withhold their answer so long that C has to produce another invitation.
Thus the professional quality of Cs’ activity is not due to their ability to appear as unembarrassed while talking about Ps’ menacing future. Rather, it lies in their ability to combine the unequivocality in references to P’sfuture, with the use of the publicly available
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h R BOR
ways of displaying embarrassment (i.e. perturbation of talk) in the management of a delicate topic.
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Second task eliciting P’s talk
In our corpus, there appears two opposing interactional formats in which the talk about dreaded issues was accomplished: what we call the Information Delivery format and the Interview format. The difference is very simple. In the former, the C does almost all the talking, whereas in the latter, the C asks questions and the P answers to them. An example of Information Delivery format in talking about dreaded issues is the following. The excerpt is from a pre-test interview; the P is told here about the implications of a positive test result.
Excerpt 2 (E4.2.003) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34
c: P:
c: P:
c: P: C:
When someone (.4) h:as this test. (5) UhU? (-7) I mean obviously: everybody hopes it nega-sative test result: (.) I mean end of it= =u m h .hh (.) we have to make sure you understand (.) what happens when someone(.3) gets a positive result .h[hh (.) I’m= [ uhu? =not saying (lets) assume you? (-8)
C
that I think for one minute: (.4) ) that would be the case ( uhu? (-3) but people (.2) you know have to be aware:
P:
UhU?
c:
.hhhhWhen someone’s getting a positive result (.2) they ( 1 (4 they (-3) go into sho:ck (.2) [ ( ) how well
P:
[ umh:?
C:
P:
(-3)
C:
=prepared they are: .hh and (that can) 1a:st up to three months: (.4) befo:re they come (.3) to terms with h : s
P:
UhU?
C:
But be&? HIV-positive:: (.6)means (.3) that that person is ca:rrying a vi:rus. (.6) We don’t know for sure (.) whether or no:t, (.4) they’ll develop aids (.) later e give is: (.) on? .hhh but the a d ~ c we
INTERNATIONAL PROBLEMS OF ADDRESSING ‘DREADED ISSUES’ IN HIV-COUNSELLING
35 36 P: 37 38 C: 39 40 41
329
common sense if you think abo:ut i:t = =uhu? (-6) for the only way: its passed (.2) is through: (.) blood? (.3) or through sex flu:& (.4) or from mother to baby ((continues))
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The Interview format is exemplified by the next excerpt. This is also a pre-test counselling session, but now the implications of a positive result are elicited from the P.
Excerpt 3 (E4.26) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
c: P: P:
c: P: P: C:
P:
c C:
P: P: C:
..
( . ) what for you the wo:rst thing would(.) be: ( S ) knowing your result (.) one
way or the other (1 .a>
Em::
(1 *a well I mean obviously (.) (if it wasn’t Aids er-) ( 1-81
um that would be p;reat (.) or: (-6) but if it was was p i t i v e I (really) don’t kno:w ho:w (-3) um: (-2) ((sniff, cough)) I would be able to deal with this er:: uhm: what do you thin:k (.2) the problems would be: immediately on hearing it (-2) just (.a) out of &gsity; (3.8) I don’t knnw ( 1 (1.0) [how its gonna- (.8) affect my life (.) or [hum
(-3)
C:
P: P:
Ho- how do you ima:gine that does affect people’s: live:s from what you know (4.0) I s u p ~ s it e (might) just make you (3.0) just be a little bit mo:re (*4)
330 A P E m m & R BOR 37 38 39
P:
aware of
P:
.hh dyiing an:d
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40 41 42 43 44 45 46 47 48
P: P:
(a
( 1-01 the way of dying you know I mean
(*a> how you die (-3)
c:
Wh- what it is a b u t ho:w one dies that(.6) that might be a problem,
P:
Just becoming:: dependent on somebody:: ((continues))
(-7)
The difference between the two excerpts, although both from an pre-test session, is evident. Whereas in one the C offers the P her own version of the implications of a positive result, in the latter the C actually withdraws from the expression of his own views in favour of eliciting the P’s talk about his views on the implications of a positive result. The difference between these two excerpts (and more generally, between the Information Delivery and Interview formats) is not in the content: they both deal mostly with the psycho-social implications of the positive result. The difference is in the format, and more specifically, in the different conversational roles adopted by the P and the C.We shall call the set of roles alignment. A single counselhg interview usually consists of several phases applying different forms of alignment, the most recurring and important of which are Information Delivery and Interview. So those Cs who apply Information Delivery in talking about ‘dreaded issues’ may very well apply Interview format while talking about something else. The tendency is, however, that getting ill and dying are topics that seem to sharpen the contrast between two different approaches to HIV-counselling. W e addressing many other topics, Information Delivery and Interview formats are more or less mixed; but when it comes to talking about ‘dreaded issues’ (especially initiating such talk), the sessions are clearly divided into two groups: those where Cs ask questions and Ps answer and those where Cs talk and Ps are recipients. A series of questions asked by the C of the P cannot, however, continue endlessly. In our material, the Cs using the Interview format do quite often also offer Ps their own views about the P’s situation. But that happens only after a long sequence of questions and answers, and as a way out from the talk on dreaded issues rather than as its upshot. The Information Delivery format is far less complicated in comparison with the Interview. A counsellor applying it is less dependent on the P’s contribution to the conversation: only recipiency and no talk is required from the P. As a result of this, a similar range of issues can be covered within a shorter amount of time. This is not an irrelevant consideration within a hospital setting, where time available may be very limited. Moreover, the greater dependency of the Interview format upon the P’s contribution makes it more liable to interactional hfficulties. Our data, the corpus of transcriptions from counselling interviews, does not in itself validate any claims about the therapeutic effects of these two models. Obviously, there are as many ways of doing counselling as there are theories of it, or even as many as there are individual counsellors. We cannot claim that one way is better than another. Our own
INTERNATIONAL PROBLEMS OF ADDRESSING ‘DREADED ISSUES’IN HIV-COUNSEUING
33 1
clinical experience, however, makes us particularly interested in the Interview format, because in it the P is given a possibility to reflect upon his or her own beliefs and fears. In any case, it is important to emphasize that in addressing dreaded issues, paying attention to the form of the talk is at least as important as paying attention to its content. But as said above, the Interview-format entails interactional difficulties. In the rest of this paper, we are going to examine some of them.
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Third task overcoming the P’s reluctance Patients are not always immediately willing to reveal their concerns about the future. We will now leave aside the ethical question of how far a C should encourage P talk in cases where the P does not show immediate signs of willingness to talk. Instead of that, let us analyze the interactional dynamics of how patients are encouraged to talk about ‘dreaded issues’. Nelson-Jones (1988) says that the hstinguishing feature of ‘facilitative skills’, i.e. skills to make it easier for the client to disclose herlhunself, is the C’s ability to stay within the client’s frame of reference. In other words, if a C empathetically perceives the lived private meanings of the client, it is easier for the client to talk about her/his concerns. We would like to propose that there are also some other essential features which facilitate P talk. These are simple public and interactional phenomena that may precede the displays of empathy (or the lack of them). Two of those are visible in Excerpt 4. Excerpt 4 (E4.00S) 1 2 3
c:
4 P: 5 6 C: 7 P:
a 9 10 11 12 13 14 15 16 17 ia
19
I’m wondering what it is particularly ) about that is frightening ( (1.6) umh its (0.6) illness: the (1 -0) Okay so what about the ill[ness [ hhhhh (4.0)
P: P:
c: P: P:
making (if a bit) hard hhh gh You E::h[hh ’ [heh .hh what about the illness (-9) Thought that (we’d) gone through that (.a) but .hhhh (1.9) ImthethoughtofbeingillanIm like being ill (-6) I really don’t at all .hh
The simplest public interactional device used by Cs to encourage P talk about dreaded issues is u repccued quenion. In the line 6, C asks the first question ‘what about the illness’. As no reply is supplied by the P, the question is repeated in line 1l-and now the answer is supplied by the P. A question, especially a question made by a person acting as a professional, is an extremely powerful vehicle. A question always creates a moral obligation for the recipient to
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332 h PERhKYLh & R BOR
provide an answer (Schegloff & Sacks, 1973). If he fails to do so, then the situation is accountable: either the recipient or the questioner has to provide an explanation for the lack of an answer. In excerpt 4, the explanation is provided by C in line 9: ‘making (it a bit) hard’. Accounting for the lack of the answer to the original question does not make the renewed question less obligating. So Cs eliciting P talk inevitably draw upon the basic social rule obligating people to answer when asked a question. The other public and interactional device used by the C here in encouraging P talk is contained in her explanation for not succeeding in getting an answer from the P (‘making (it a bit) hard’). That comment namely also accomplishes what we will call a fmularion of the ongoing talk. Formulations are a persistent feature in any’conversation (Garfinkel & Sacks, 1970, Heritage & Watson, 1980), and especially numerous in certain types of institutional encounters (Heritage, 1985). A formulation can be a summary of a part of the conversation or of the whole conversation, or it can describe the conversation in otherwise, e.g. the mood of the conversation or the reasons why the participants do what they do in the conversation. Through making formulations, the participants achieve a public interpretation of what is going on in the conversation. Now formulations are regularly made by the Cs in the cases when Ps display a reluctance to talk about the dreaded issues. They seem to be a part of the standard procedure of persuading the P to talk. The formulation may, as in the case above, do the work of accounting for a failure to have an answer to a question, or they may stand independently. Moreover, the formulations are regularly coupled with a repeution or rephrazing of the original question. In Excerpt 5, a formulation follows an account given by a patients wife (W) for not answering to C’s question related to dreaded issues.
Excerpt 5 (E4.008.) 1 2 3 4 5 6 7 8
9 10 11 12 13 14 15 16
w: c:
w: c: w:
) aids just another thing (2.9) I’m at a S e where I feel if (.9) it would just be another dung okay having heard what your husband said (.) that even if he was negative (1.5) it wouldn’t make him conduct his Me any different (1.2) what (.8) affect would that ha:ve if (.8) I mean what are the things it would affect if he was positive? hhhhhhh Umh? I just don’t know (.a) I’m afraid (2.8) I’m in a frame of the mind a (.) mind at the moment (2.8) that I’m not a lot of use: (.) to hypothetical things ((continues)) (
As we can see, not even the formulation coupled with the renewed question is successful here in the work of persuasion. In her next turn (lines 12-15) W still offers an account for not answering the questions instead of producing an answer. (In this particular case, the C’s special insistence in persuading the patient’s wife to talk is due to the fact that the P-a haemophiliac-has been d r e d y diagnosed as positive, but the couple ‘denies’ it.) What is achieved the Cs through offering formulations as a part of the encouragement
INTERNATIONAL PROBLEMS OF ADDRESSING ‘DREADED ISSUES’ IN HIV-COUNSELLJNG
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to talk? Obviously a formulation displays C’s attention to the difficulties that the P has in disclosing more of his or her concerns (cf Nelson-Jones, 1982). But we would suggest that in doing this, the formulation also gives an extra backing to the initial question. A formulation is a means of achieving a publicly available and recognized interpretation of what is happening in the conversation. Through establishing an interpretation of what was happening in the previous talk, the C makes the question appear as a logical outcome of it. That function of the formulation is quite obvious in Excerpt 6. The P is just about to finish an utterance where he says that at the moment it is impossible for him to think about arrangements if he were to become demented. Not now, but only later on would it be the right time to think about such things. Downloaded by [Simon Fraser University] at 21:30 13 November 2014
Excerpt 6 (E4.12) 1 2
P:
3 4. 5
P:
15 16 17 18 19 20 21
. . . ) and I think
bethetime(
(.6) it [would umh ) to make that kind [ of
r
c:
6 P: 7 c: 8 P: 9 c: 10 P: 11 c: 12 13 14
(
c
[umh ( S ) .hh a provisionumh= =erh (.) in any case. But we are n[ot I think what I heard Dr A = [ erh: =saying that answers her question partly .hhhbut it doesn’t- (1.2) a:nswer the question that (1.6) you raised and I hadn’t (.7) WASN’T thinking about it and it made me thinking in terms of all of us in this room that if any of us should .hh ( S ) have some b i n d of impairment who would we (1.2) want to make those E.nd of decisions would it be one’s parents or would it be ( S ) the closest person to one?
As a response to P’s expressed reluctance to talk about the dreaded issues, in line 9 onwards the C formulates the preceding conversation. She establishes an interpretation of the foregoing events, according to which P has not answered more than partly to a question raised by Dr A (a co-counsellor), and not at all to the question that has been implied by the P himself. After the formulation, the C makes her original question anew. The C here may not be pursuing an answer as such, but rather trying to make the P consider seriously the hypothetical future circumstances depicted in the question. But the public indication of such consideration is answering the question. That’s why the exchange overtly takes the form of pursuing an answer. We need not go further into the d e t d s of formulations and repeated questions. What is essential here, is that talk about dreaded issues (in an Interview format) in counselling entails a great deal of pmuasion. That persuasion is not (only) based on empathetic understanding, but on the use of the publicly available conversational devices, like repeated questions and formulations. The message for the counsellors here is perhaps an unfashionable one: If you want your
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clients to talk about dreaded issues, you can and must use your professional authority through consistently asking questions and making formulations. Fourth task moving towards problem-solving
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There is a further possible obstacle for a successful sequence of talk about ‘dreaded issues’. It is very much related to the difficulties considered above, but also has an additional characteristic. Namely, even when the dreaded future possibilities have been introduced as a topic for the conversation, the P may be reluctant to view the hypothetical future situation as a problem to be solved. That is the case in Excerpt 7. The P’s wife (W) has just a moment ago disclosed her concerns about the possibility of the P developing AIDS. Excerpt 7 (E4.16)
w:
1 2 3 w: 4 c: 5 6 7 8 C:
w:
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
an::d (1.6)
what would happen to me:?
d and the children (2.1)
w:
if he did deEl[op
w:
something?
c: C:
C:
W:
[d
(4 mmh What’s your greatest f
e about that?
(1.8) ( [ 1 (-2) ( [ There isg’t anything (.2) speGfic (.) I mean it’s just a general absua:ct:
1
C:
I mean would you: have any: E r e womes than you’ve got now?
c:
when he’s anti:wy: Esitive?
C:
(Is he) what would you know about .hh (.2) looking after people with Aids, (Well) I donJ? (Well) what (.3) do you kno[:w ( 1 [I haven’t even, I haven’t even thou:p;ht that fa:r Um: Because I feel that (.2) .hhhhhh
W: C:
W:
C:
W:
c: w:
(.4)
(1 *o>
Would you see [ (there) [
(
(
1 ) ENOUGH
TO WORRY ABOUT (I’m) cairn enough to worry abo[ut that
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37 c: 38 3: 39 w:
40
c:
41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59
C:
335
[ BUT I THINK AS YOU’VE RAI(SED-
[oo:h something ( @uld happen ( Liza As you’ve raised it (.) I mean: .would there’re any more- ( S ) attached (.) for you and the children than there are now (3.0)
C:
w:
I’m not talking about well-
c:
future risks and (.) and
(a41
(-4) life (
W:
[
1
W
[What you mean risks? You mean (in an-)= = (well) (.4) yes: Infection [ and that sort of [ thing, [ Es: [ Yes Em::
W:
Not (.3) that I’m aware of
c: w c:
(2.6)
c:
=
=Yes. Would you confirm that? (.2) Dr A?
The wife of the P in this excerpt is reluctant to consider her worry as something that can be divided into smaller pieces (‘T:here isn’t anythmg (.2) speccfic (.) I mean it’s just a general abstra:ct:’). When challenged to examine her knowledge about looking after people with Aids, she responds by saying that she has not thought that far, and appeals to the fact that she has got now enough to worry about. This type of response to Cs’ questions are quite frequent in our corpus. Again, psychological explanations are available: the Ps may have different sorts of inhibitions towards examining in detail their fears. But in addition to psychological phenomena, there are also social and interactional ones involved here. Following our sociological approach, we will concentrate on them. Jefferson & Lee (1981; see also Jefferson, 1980) have suggested that there is a specific kind of talk, called rroubles telling. In troubles telling, one participant reveals hidher troubles to another, who in turn offers affiliation and sympathy. The conversational category of a ‘troubles teller’ is a favourable one: he/she is the one who speaks, and the ‘troubles recipient’ largely only listens and responds. As Jefferson & Lee have pointed out, the troubles tellers sometimes definitively reject advice from their recipients, because (as Jefferson & Lee argue) accepting the advice would imply giving up the favourable conversational role of a troubles teller. Now addressing dreaded issues seems to entail a similar type of tension. The moment of revealing his or her concerns to the C may give the P a role quite close to that of a troubles teller. But in the course of the session, that role has to be abandoned. The concern has to treated as a manageable problem rather than as a misfortune or as a misery. A troubles teller becomes a problem solver, which may be much less rewarding a conversational role. Hence the resistance. The means of dealing with the P’s resistance available for the Cs are here much the
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same as in the case of reluctance to talk about dreaded issues at all. The questions can be repeated and the foregoing conversation formulated. That is what the C does in Excerpt 7. In line 26 she is repeating her questions concerning the P’s wife’s knowledge about taking care of people with AIDS, and in lines 37 and 41, she formulates the foregoing conversation: You have raised this issue. The renewed questions and the formulation turn out to be successful, as the Wife and the C end up by examining risks involved in living in the same household with a person suffering from AIDS. As a conclusion, we would like to emphasize that addressing dreaded issues-like any serious counselling-entails not only talk that Ps immediately consider as pleasant and rewarding. The P has to give up the rewarding role of a troubles teller, in favour of engaging in problem management. It is the task of the C to conduct this shift, using hidher interactional skills and professional role. Our intention, however, has not been to give an impression that Cs dominate the sessions and clients merely respond to them. Addressing dreaded issues is a joint accomplishment: whatever is done in such talk, is done collaboratively. The Cs do take the initiative in many instances, e.g. when the P is displaying reluctance to address the issues. But the initiation of Cs does not lead to a full sequence unless the Ps give their contribution. Each answer that the P gives to the C‘s questions is equally a display of P’s contribution and alignment in talking about the difficult topics.
Conclusion In this paper, we have examined the dynamics of addressing ‘dreaded issues’ in HIV counsehg. It has turned out that ‘dreaded issues’ is a topic requiring special attention from the counsellors, who have to overcome the dispreferred nature of t h i s topic. It is done through the application of conversational devices like perturbations of talk (renewed) questions and formulations. Conversation analytical studies have previously found these devices and techniques working in ordinary conversation and in other institutional spheres. What makes the counsellors’ way of using them a particular professional activity, is the consistent and systematic application of those techniques in order to reach specific goals related to counselling. One of such goals is the encouragement of patients’ talk about ‘dreaded issues’. In methodological terms, this paper has explored the possibilities of conversation analysis in research on HJV counselling. Detailed qualitative analysis of a relatively small set of cases can reveal some of the problems that the counsellors have to deal with in their practice. Hopefully this type of analysis can suggest new areas of interest for quantitative research, as well as for the further development of counselhg practice.
Acknowledgements We are grateful to Professor David Silverman (University of London) for the invaluable support and help in analysing the data. We wish to thank Dr P. B. A. Kernoff for the access to the video archives of the Haemophilia Centre of the Royal Free Hospital, and Mrs R. f i l l e r and Ms H. Salt for the access to those in the AIDS counselling unit of the Royal Free Hospital. We are particularly grateful to M r s R. Miller and Dr E. Goldman (Royal Free Hospital Haemophilia Centre) whose counselling practice and theoretical work has provided us with a frame of reference for studying the discussions about hypothetical future situations in HIV counselling. The first author gratefully acknowledges the generous financial support provided by Glaxo Holdings plc.
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Appendix The transcription symbols C2: quite a [
[
Mo:
[
while Yea
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W: that I’m aware of = C. =Yes. Would you c o n h that? (.4)
Yes (.2) yeah
(.)
to get (.) treatment
Ok?
WORD
I’ve got ENOUGH TO WORRY ABOUT
.hhhh
I feel that (.2) .hhh
(
future risks and (
)
(
(word) ((
))
) and life
1
Would you see (there) anytlung positive c o b that ((continues))
Left brackets indicate the point at which a current speakers talk is overlapped by another’s talk. Equal signs, one at the end of a line and one at the beginning, indicate no gap between the two lines. Numben in parentheses indicate elapsed time in silence in tenths of a second. A dot in parentheses indicates a tiny gap, probably no more than one-tenth of a second. Undekoring indicates some form of stress, via pitch and/or amplitude. Colons indicate prolongation of the immediately prior sound. The length of the row of colons indicates the length of the prolongation. Capitals, except at the beginnings of h e s , indicate especially loud sounds relative to the surrounding talk. A cow of h’s prefixed by a dot indicates an inbreath, without a dot, an outbreath. The length of the row of h’s indicates the length of the in- or outbreath. Empty parenthem indicate the transcribers inability to hear what was said. Parenthesized words are possible hearings. Double parentheses contain author’s descriptions rather than transcriptions.
