Text Analysis: Constructing Social Relations and 'the Self'
Sample 1: 'Standard' Medical Interview
My first sample is an extract from an interview between a male doctor and a female patient, which I have taken from a study of medical interviews recorded in the USA by Mishler (1984).
Silences are marked by sequences of full stops, each representing one tenth of a second; colons mark prolongation of a syllable;
interruptions and overlaps are marked by square brackets; mate-rial in round brackets is unclear speech. The roman numerals divide the sample into 'cycles', corresponding roughly to 'ex-changes' in the Sinclair and Coulthard system (see p. 13 above),
Text Analysis: Constructing Social Relations 139
l
It li- I think- I think it Ifyou take a needle and stick [ya right [ .... there's a pain right here[..Hmhm Hmhm Hmhm
and and then it goes from here on this side to this side.
Hm hm Does it [go into the back?
III [ It's a:ll up here. No. It's all right [UPhere in the front.
Yeah And when do you get that?
· Wehl when I eat something wrong.
.
How-How V soon afteryou eat it?
V' Wel:l
I ....probably an hour maybe [less.
- About an hour?
Vn Maybe less I'vecheated and I've been
i
drinking which I shouldn't have done.[D oes drinking make it worse?
VI [ ( ) Ho ha uh ooh Yes...
· Especially the carbonation and the alcohol.
· Hm hm How much do you drink?
VII I don't know Enough to me
VII'
L
go tosleep at night. and that's quite a bit.One or two drinks aday?
r
O:hno no nohumph... How long have you heen drinking that heavily?
p: IX Since I'vebeen married.
D: IX'
L
... How long is that?
(giggle.. ) Four years. (giggle) 30
I shall begin by focusing upon range of what I shall c.all 'interactional control features', which broadly have to do With ensuring that the interaction works smoothly an
level: that turns at talking are smoothly distributed, that topics are selected and changed, questions are answered, and so forth.
hm...Now do you mean by a sour stomach?
...•.... What's a sour stomach? A heartburn like a heartburn or someth[ing.
Doesitbum over here?
nr
Text Analysis: Constructing Social Relations
DOCTOR:
I
0:
5 P:
I shall focus upon the following analytical properties of te interactional control (including turn-taking, exchange strucn]
topic control, control of agendas, formulation), modality, polir ness, and ethos. In terms of the analytical categories of
above, interactional control is a dimension of text structure, ality a dimension of grammar (though a conception of which is very much oriented to meaning, such as that of 1985), and politeness an aspect of what I called 'force'.
transcends the categories, as I shall explain below, and is vated by the focus on the self. The selection of these topics for attention is not an arbitrary one: each of them is a basis for insight into socially and culturally significant aspects change in the relational and identity functions of discourse.
As in chapter 4, I begin with a discussion of particular course samples. Two of the samples are taken from the broad discourse type, medical interviews, because they show con-trasting ways in which doctor-patient relations and the social identity of the doctor, 'the medical self', are constructed in con-temporary society. The third sample is from informal
sation, and it has been included to underline another contrasr between the first two which takes us back to the last chapter:
differences in modes of intertextuality.
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Analysis: Constructing Social Relations 141
selective way in which the doctor takes up the responses of patient to previous questions is another aspect of his topic Clntrol. For example, in the sequence at11. 21-4 to which I have ust referred, the patient acknowledges having done wrong by rinking, but the doctor does not pursue this admission. He concerned only with the effect of alcohol on the patient's condition. Similarly, the patient's responses in 11. 29-30 d 42 signal problems on the patient's part which the doctor ores in favour of the narrowly medical detail. One has the of the doctor shifting and constraining topic in accordance
·th a pre-set agenda, which the patient is not being allowed to isturb.
Another aspect of the doctor's control is the nature of the he asks. They are not open questions, giving the patient the floor (as 'Tell me how you've been' would be), but more or less closed questions which set relatively tight limits on the con-of the patient's answers. Some are 'yes/no' questions, which a 'yes' or 'no' answer confirming or disconfirming some proposition (e.g, 'Does it burn over here?'). Others are so-called beginning with 'what', 'when', 'how', which elicit details of time, and quantity and type of alcohol.
Itis also instructive to closely at the relationship between doctor's questions and the patient's answers. In I. 4, the doctor begins his question before patient has finished speak-iiig, and there is an overlap. Similarly in11. 20 and34, though in those cases there is a in the patient's turn which the doctor perhaps takes as indicating completion. In other cases, the doc-tor's turn follows immediately on from the patient's without a pause, either with an assessment followed at once by a question (11. 10, 13) or with just a question (I.16).The pattern is different
iI11.
23 for reasons suggested below. This reinforces the impres-sion that the doctor is working through a pre-set agenda or routine, shifting from one stage of it to another as soon as he has he regards as enough information, even if that means cutting the patient'S turn. Looked at from the patient's point of view, this routine can come across as a series of disconnected and unpredictable questions, which is perhaps why the patient's answers, in contrast to the doctor's questions in the first part of the extract, are preceded by hesitations (11. 15, 18, 29, and 42).The overall picture, then, with respect to interactional control Analysis: Constructing Social Relations
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An obvious starting point is the way in which the organized around questions from the doctor, which are by the patient. The transcription incorporates Mishler's of the data into nine cycles, each of which is initiated by question from the doctor. The division of cycles V, VII and (the last of which I have curtailed) into sub-cycles
they also involve 'follow-up' questions from the doctor solicit e1aborations of the patient's answers. In some cases 10, 13, and27), the doctor's question is preceeded by an elerne which overtly acknowledges or accepts the patient's
answer. I shall call it an 'acceptance'. Even when this is absen the fact that the doctor proceeds to a next question, rather asking a follow-up question, may be taken as implicitly acceptiIl the patient'S previous answer. That is why the doctor's questioIls are shown as between the cycles: they terminate one cycle implicitly accepting the patient's answer, as well as initiating next. We may say, therefore, following Mishler, that these have a basic three-part structure: a question from the doctor, a response from the patient, and an implicit or explicit acceptance of that response by the doctor.
The doctor, then, is closely controlling the basic organiza-tion of the interacorganiza-tion by opening and closing each cycle and accepting/acknowledging the patient's responses. One corollary of this is that the doctor is controlling the turn-taking system, way turns are distributed between participants in interaction (on turn-taking Sacks, Schegloff and Jefferson 1973; Schenkein1978).The patient only turns when offered them by the doctor, which means when the doctor directs a question at her. The doctor, on the other hand, is not
turns but takes them when the patient has finished her
or when he decides the patient has said enough for his purposes (see below).
A further corollary of this basic organization is to do with 'topic control'. It is mainly the doctor who introduces new topics through his questions, for example when he shifts in lines 1-13 from what is meant by 'sour stomach', to where 'it bums', to whether the pain 'goes into the back', to when the patient gets the pain. Notice, however, that the patient does introduce a topic in 11.21-22 drinking which the doctor takes up inI.024. I to this exception below.
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1978) for orientation and sensitivity to the 'face' of partici-their self-esteem, partici-their privacy and autonomy.
absence of politeness can be linked to the more general of ethos - how the total comportment of a participant, of hich her verbal (spoken or written) style and tone are a part,
press the sort of person she is, and signal her identity d subjectivity (Maingueneau 1987: 31-5). Doctors standard practice manifest what one might call a scientific ethos itself 'medical science') which variously realized the ways which they touch and look at when they examine them, the way in which they filter atients' contributions in terms of topic, and the absence of iceties of interpersonal meaning such as politeness, which would suggest an orientation to the patient as a person rather than a orientation to the patient as a case. (See Emerson 1970 a study of gynaecological examinations along these lines, and Fairclough 1989a: 59-62 for a discussion of it).
The account of sample 1 so far has been very one-sided in its upon control over the interaction by the doctor. Mishler points out that there are ways of analysing the interview which more oriented to the perspective of the patient. They also turn out to be more interesting in terms of intertextuality. I have already pointed to evidence of a mismatch between the medical perspective and the perspective of ordinary in the in which the doctor filters out parts of the patient s turns which, for him, are off topic. Whereas the doctor consistently manifests the 'voice' of medicine, the patient's contributions mix the voice of medicine with the voice of 'the lifeworld', or ordinary experience (these terms are Mishler's, following Habermas). The alternative analysis suggested by Mishler focuses upon the dialectic, conflict and struggle within the interaction between these two voices. This suggests a way of extending what I have said so far about inrertextuality, to allow for the possibility, in explicit dialogue, of an intertextual relation between different voices brought to the interaction by different participants.
Seen in these terms, the interaction appears to be rather more fragmented and rather less well ordered than if one views it as a manifestation of doctor control. The voices of medicine (M) and the lifeworld (L) interrupt one another repeatedly: L interrupts M in I. 21 (from 'I've cheated'), M interrupts L in I. 24 ('Does Text Analysis: Constructing Social Relations
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features, is that through the question-response-assessment cycles the doctor pursues a pre-set agenda, in accordance with which controls the taking, content and length of patient turns, introduction and shift of topics. Let me now add some comments on three other aspects of the sample which are more fully later in the chapter: modality, politeness, and ethos.
Modality concerns the extent to which producers commit selves to, or conversely distance themselves from,
their degree of 'affinity' with the proposition, as Hodge Kress (1988) call it. As Hodge and Kress point out, however, affinity a producer shows with a representation of the worldi inseparable from the relationship (and 'affinity') between the ducer and other participants in the discourse. In 11. 2-3, for pie, the patient defines a 'sour stomach' as 'a heartburn heartburn or something'. The patient first glosses it with a 'folk medicine' term, then distances herself from the gloss by
it into a simile ('like' a heartburn), and then further herself from it by hedging' it (Brown and Levinson 1978)with something'. This is low affinity modality. But it is difficult disentangle factors of propositional truth and social relations in the patient's motivation for it: does she select low modality because she is not sure how accurate the gloss is, or because she is reluctant to claim anything resembling medical knowledge in an interaction with a legitimized medical expert? Propositional and social relations, knowledge and power, seem to be intricately linked in such cases.
Let me turn to politeness. The patient introduces the presum-ably difficult and potentially embarrassing issue of her drinking
in
11. 21-2, as an addition tagged on to the answer to one of the doctor's questions. According to Mishler (1984: 86), she speaks at this point in a 'teasing', 'flirtatious' or 'childish' tone, which may be interpreted as a way of mitigating the threat to her self-esteem, her 'face' (see Brown and Levinson 1978, and the section on politeness later in this chapter), of her admission. By contrast, the doctor's questions about the patient's drinking are unmitigated, bald, and even rather brutal (I.41): he formulates the patient's situation as 'heavy drinking' without diplomacy or mitigation (on formulation, see pp. 157-8 below). The doctor's questions are low in politeness, using the term in the broad way it is used in the pragmatics literature (for instance, Leech 1983; Brown and