Strengths and weaknesses of the data

The data explored here provides an opportunity to explore interaction as it takes place in situ. The aim of a study of naturally occurring talk is to gain insights that can, to a greater or lesser extent, be generalised to talk in the same or similar settings outside of the research. However, caution should be taken in interpreting these findings as somehow ‘standard’ of psychiatric consultations. There are several reasons why the size, scope and other characteristics of this data do not necessarily lend themselves to representativeness or replicability in other psychiatric encounters. The weaknesses discussed below are not uncommon for studies of discourse (Heritage and Maynard, 2006) and it is important that claims made on the basis of discourse analysis are appropriate to this methodology. This data may be very different from other consultations and has some limitations in providing wider insights. This study is not, for example, an attempt to characterise the typical consultation, nor to provide a template for conducting a psychiatric consultation.

Recruitment bias

These 92 consultations involve a total of nine psychiatrists who may be atypical in a number of ways. The psychiatrists were identified initially because they had taken part in a study in which they gave their views on decision-making in consultations. In this previous study, the

psychiatrists involved described themselves as patient-centred. Although self-describing in this way is no guarantee that these psychiatrists in fact behave any differently from other

psychiatrists, it implies a commitment at some level to principles of patient-centred care. On top of this, the psychiatrists were all willing to have their practice recorded and scrutinised by external researchers. It is very likely, on this basis, that the psychiatrists included in this study represent an approach to psychiatric practice that may not be reflected across the whole profession.

Similarly, the patients recorded in this study are only those who gave their consent to take part. There are various reasons why patients may choose not to take part in such a study, including concerns about the quality of relationship or trust with their psychiatrist, and the extent to which they were intending to discuss distressing or sensitive matters in the

consultation. As a result, it may be that this study has excluded consultations in which specific types of interaction or behaviour are displayed by participants. Notably, there are few

examples in this data of complaints (see 4.2.3) which may indicate the quality of relationships between these psychiatrists and their patients, or may reflect the challenging nature of such interaction and an unwillingness on the part of participants to open this up to external

scrutiny, or to add what may be perceived as an extra pressure on themselves by participating in the study.

While the sample may not be representative, the extent to which this is a weakness of the study should be assessed in relation to its aims and its conclusions. Unlike in quantitative studies, representativeness is not necessarily the most important characteristic of a qualitative

study’s sample. Indeed, due to the in-depth nature of discourse analysis, it is unusual for samples to be large enough to satisfy the criteria of statistically generalisable claims. The aim of this study is to explore the various ways in which performances and roles may be

constructed in one specific setting, a psychiatric consultation. As such, it follows other qualitative researchers in arguing that:

“the criteria, then, for selecting a sample is not that it be representative of some larger population, but that it be relevant or interesting to developing theory (Glaser &

Strauss, 1967) or that it service as a good ‘take-off point’ for ‘finding one’s way into the phenomenon’ (Schwartz and Jacobs, 1979:293).” (Davis, 1988: 25)

In drawing conclusions, then, it is not possible to extrapolate from the frequency of

occurrences in this data to the frequency of the same occurrences in psychiatric practice more generally. However, the presence of phenomena here, where they provide insight into patterns of behaviour across my data, does reflect something significant about psychiatric discourse that allows us to draw interesting and valuable conclusions.

Audio recordings

Recorded interaction allows a detailed record of what was said, and how it was said with a high degree of accuracy. This is, however, only one part of an interaction. The absence of visual data limits the extent to which I can observe what is going on. Visual data can provide a wealth of additional information about body language, expression and reaction, as well as the ways in which participants relate to the physical setting of the consultation room. There are various points in the data here which suggest this ‘missing data’ may be significant. Long pauses may suggest that a participant is undertaking some activity – for example writing out a prescription or reviewing medical notes – but it is not possible to verify this.

This limitation is particularly significant in relation to third party interactions because of the lack of data about participant gaze. Though it is possible to infer who is addressed from the

words spoken and the response of others in the room, this is a weakness and important data may be missing as a result of not having visual data.

Although this is a limitation, it is not fatal to the interests of this study. The richness of the audio data provides a wealth of resources from which to draw insights. Though conclusions drawn without access to visual data must be treated with caution, they are nevertheless built on a robust source of data capable of supporting my claims. In the future, video recordings may allow further development or refinement of the insights offered here.

Re-analysing discourse

This study is a re-analysis of pre-existing data, collected for a separate study using different methods of analysis and answering different questions. Reusing data throws up a number of conceptual and practical challenges which it is useful to discuss, both in understanding my approach to the data and in providing a perspective on a broader debate about the usefulness of reanalysing qualitative data.

Since the late 1990s, there has been a conscious effort to facilitate the reuse of qualitative data (Corti, 2000). In doing so, many researchers have highlighted concerns about re-analysis including issues of ownership, ethical concerns, potential challenge to previous findings, and the validity of new findings.

In this study, the re-analysed data is not part of a national archive, but remains under the control of the research team who collected and owns the data. This has made it possible to conduct a re-analysis since concerns of data ownership have not been a barrier. This has been possible due to two key factors. First, the researcher and their institution are supportive of the re-use of their data and recognise a value in providing further analysis of this rich and sizeable dataset than was possible in the original study. Second, the aims of this study fit well within the stated aims for which the data was collected, i.e. to understand the process of decision-

making through studying naturally-occurring talk. This re-analysis offers a different method and underlying theory, but it continues to address the questions for which participants agreed to take part in the study.

Re-analysis potentially raises considerable ethical concerns, and these have been well-

rehearsed in the literature previously (Parry and Mauthner, 2004, Bishop, 2005). For the most part, these concerns are based around the concept of data archiving, in which reanalysis is conducted independently from the original researcher. In this study, by working under the supervision of the original researcher, it was possible to ensure that this research abided by the commitments given to the participants. Data was provided to me in an already

anonymised form. Transcripts had names and places removed. Although I had access to the original recordings, these also did not contain any information that could have been used to identify individual participants. The recorded data did not indicate which of the two sites they originated from and full names were not used in the consultations, though first names were. Due to the anonymity of the data and by ensuring that the use of the data in this study was in line with the purpose stated to participants at the time of data collection, and under the control of the researcher to whom consent was given, I did not attempt to re-seek consent from the participants themselves for this reanalysis. In part, this is in recognition that it is common in qualitative research for research teams to return to data to seek further insights, beyond those found in the first analysis, and nothing in the initial set up of the study precluded this. In addition, seeking consent again was not practical since the length of time (up to 7 years) between collection and reanalysis for this study, which would have made finding and contacting the participants impossible. The approach I used here was reviewed and approved by the University of Sussex’s ethics review panel.

As long as all precautions are taken to protect participants’ anonymity and to ensure that data is only used in the ways that they have permitted, it is worth considering the arguments in

favour of data re-analysis. Access to settings such as medical consultations is extremely difficult to obtain, limiting the amount of research that is possible regarding important practices. When access is achieved, it is important that data is used as fully as possible to provide the maximum return, both on the time invested by the researcher and for the commitment given by those who chose to participate. By reanalysing in different ways, as much as possible can be learned from data without requiring additional demands on patients or consultants. In general, qualitative data is analysed only in limited ways, leaving

considerable scope to gain more understanding, and to challenge or confirm conclusions by examining the data from a different angle.

Beyond the ethical concerns, several researchers have discussed the challenges to validity and usefulness of re-analysing qualitative data. In his discussion of challenges to qualitative reanalysis, Van den Berg identifies a perspective from some researchers that:

“an intense personal involvement in the fieldwork constitutes a necessary prerequisite in order to grasp the relevant context and to interpret interview transcripts. From this viewpoint, secondary analysis of qualitative interviews amounts to doing the

impossible.” (Van den Berg, 2005)

This perspective, which is at the heart of much criticism of reanalysis, focuses particularly on qualitative research interviews. There are a number of strands to this criticism. On the one hand, it recognises that interviews are co-constructed accounts involving the interviewer themselves (Silverman, 1993). They are theoretically-driven and as such the interviewer influences the scope of the data – what is included and excluded, where more detail is sought and how participants are asked to consider the topic – and the way the participant’s account is constructed – for example use of language and terminology and the extent to which rapport facilitates more or less open narratives. Equally, this viewpoint highlights the extent to which researchers draw not only on the transcripts and recordings but also on having been present at the interview itself. This allows the interviewer to draw on privileged knowledge about the

setting, the chat before and after the recorder is on, the memories of gesture and facial expression not captured by the recording, and the general feel of the interaction. In this sense, the qualitative interviewer also acts as ethnographer in observing the interaction first-hand. These criticisms may be more or less justified, depending on the study. It is worth noting that it is not at all uncommon for at least some of the people analysing an interview not to have been present at the time, due to collaboration between more than one researcher and turnover of research staff. More importantly however, these perspectives, while relevant, do not apply so directly to the recording and analysis of naturally-occurring talk. In the case of the data analysed here, the researcher was not present during the recorded interaction. Rather than being part of the co-construction of the talk, the researcher does as much as possible to reduce their influence on the interaction and to preserve the natural course of interaction in this setting. This is not to say that the researcher does not impact on the data. It is important to acknowledge the ways in which the data has been influenced, including through the pre- consultation questionnaire, and the presence of a recording device. This is discussed further in Chapter Four. However, in this type of analysis the aim is to minimise and to acknowledge the researcher influence on data, rather than to use it to inform the analysis.

4. Framing in psychiatric consultations

This chapter describes how frames are constructed and negotiated in psychiatric consultations. I identify and describe eleven frames which occur within the psychiatric consultation. These are loosely grouped as Information sharing frames, Influencing frames, and Other frames. As Information sharing frames I identify ‘Interviewing’ (where the interaction is predominantly managed by the questioner); ‘Narrative’ (where the narrator provides an account of an occurrence situated in a time and space); ‘Troubles-telling’ (where the troubles-teller provides an account oriented to explaining an ongoing difficulty); and disclosure (where personal information, rather than accounts, are provided). Influencing frames include ‘Negotiation’ (in which preferences are indicated and argued for); ‘Directing’ (in which one party offers instruction or indicates that a decision has been made); ‘Advice-giving’ (in which participants provide suggestions, generally oriented to a Troubles-telling) and ‘Lecture’ (in which the ‘lecturer’ makes de-personalised knowledge claims). Finally, in other frames I describe

‘Complaints’ (in which talk is oriented to a concern for which responsibility is laid on one of the participants); ‘Stage direction’ (in which talk is aimed at managing the immediate interaction) and ‘Informal’ (in which participants step outside institutional roles).

These frames are not necessarily equivalent in their status or analytical focus. Goffman argued that “any event can be described in terms of a focus that includes a wide swath or a narrow one and – as a related but not identical matter – in terms of a focus that is close up or distant. And no one has a theory as to what particular span and level will come to be the ones

employed” (Goffman, 1974: 8). It could be argued that the frame of significance in this data is simply that of ‘psychiatric consultation’. This frame category is consistent with the criteria outlined in the previous chapter: the setting for the frame is boundaried (usually physically, as

well as by the social construction of the activity) in a way that distinguishes it from other social interaction; it has its own set of rules for appropriate behaviour and talk; it assigns specific roles for the people taking part; and it is oriented to a particular goal or goals. There is value, however, in focusing on the use of more narrow framing. By applying Goffman’s concept of frames systematically, it is possible to provide a fine-grained analysis of discourse and how it changes within the confines of a single setting.