A Study Of Formulation In Psychiatrist-Patient Talk-in-Interaction

Formulation,proposed by the enthnomethodologists Garfinkel and Sacks in the 1970s,is a common conversational practice in institutional settings.It is considered a communicative strategy that has a positive role in facilitating conversational interactions,overcoming communicative obstacles and in achieving a smooth communication.However,little if any work has been done in the use of formulation in psychiatrist-patient talk-in-interaction.In particular,not much is known about how formulation is employed to achieve institutional goals in the medical activities such as medical data gathering,diagnosis making and treatment recommending in psychiatrist-patient talk-in-interaction.Taking the naturally occurring psychiatrist-patient conversation at outpatient department as the data,the present research,using Conversation Analysis(CA)as the method of analysis,investigated the employment of formulation in Chinese psychiatrist-patient interaction from the interactional linguistic perspective.It aims to examine the use of formulation from the following aspects:types,sequential features and distribution of formulation in the medical activities;the actions performed through these types of formulation in medical data gathering,diagnosis making and treatment recommending;their implications for psychiatrist-patient relationship and how these types of formulation are constructed to achieve these actions and fulfill the institutional goals.Data of this research were 55 cases of audio-recorded psychiatrist-patient talk-in-interaction at the outpatient department.Data analysis focused on 461 instances of formulation sequences identified from the 55 cases of interaction.Collected by way of field work and audio-taped under the permission of all the participants involved,the data were transcribed,coded and analyzed according to the rules and principles of CA.The present research is principally based on the qualitative analysis of the data,with some basic quantitative analysis as supplement.While quantitative analysis mainly focused on the statistics of formulation distribution in the activities of medical data gathering,diagnosis making and treatment recommending;qualitative analysis was conducted to provide a detailed and in-depth investigation of the formulation sequences and the actions performed,aiming to explore how these instances of formulation are constructed so as to achieve the institutional goals in the medical activities.The major findings of the present research include the types of formulation in psychiatrist-patient interaction and their distribution in the medical activities;the actions these types of formulation performed and their corresponding sequential features and linguistic designs that contribute to the construction of these actions in the activities of medical data gathering,diagnosis making and treatment recommending respectively;the overall interpretation of formulation and the implications for doctor-patient relationship from the perspective of identity construction.In respect of types of formulation,the present study found that in psychiatrist-patient interaction,formulating is not necessarily tied to the institutional identity,i.e.both the professionals and the laypersons can do formulating.They can either formulate the previous words of their own or what the other speaker is saying or has said.Thus,according to the formulation division of labor,four types of formulation were identified,they are,psychiatrist-other-formulation,psychiatrist-self-formulation,patient-other-formulation and patient-self-formulation.With regard to the distribution of formulation,the findings suggested that formulation obviously existed in the medical activities such as medical data gathering,diagnosis making and treatment recommending,but with different frequencies.Generally,psychiatrist-other-formulation was the most frequent type while patient-self-formulation was the least employed type of formulation.Psychiatrist-self-formulation ranked the second among the four types of formulation and patient-other-formulation ranked the third.More specifically,in the activity of medical data gathering,psychiatrist-other-formulation had the highest frequency that was much higher than the rest types of formulation.In the activity of diagnosis making,psychiatrist-other-formulation still ranked the first while the situation would be different in the activity of treatment recommending where patient-other-formulation ranked the first,psychiatrist-self-formulation ranked the second and psychiatrist-other-formulation ranked the third.It did not find any patient-self-formulation in this activity.In terms of the overall features of formulation,the present study found that a basic formulation sequence consisted of three moves:source of formulation,formulation move and the responses to it.Formulation was sequentially implicative and had sequential power to project confirmation,agreement or acknowledgement from the addressee.By other-formulation,we meant that the formulators,as news recipients,formulated the previous speakers’ words by deleting,expanding,transforming,explaining or furnishing a gist or making an implication.Other-formulation made relevant the addressees’ confirmation or disconfirmation,with confirmation as the preferred response.By self-formulation,we meant that the formulators,as news deliverers,formulated the previous utterances of their own.The responses to self-formulation were complicated depending on the actions conveyed by the formulation;including acknowledgment,(un)acceptance and answer if the formulation move was a question.The present study has found that the asymmetrical nature of psychiatrist—patient conversation as a typical institutional interaction and its peculiarities that make it a special kind of doctor-patient interaction would contribute to these features of formulation.The peculiarities of psychiatrist-patient interaction mainly lie in the patients(who may have different degrees of deficiency in cognition,ways of thinking and memory due to their mental disorders),their ways of seeing the doctors(mainly at the volition of their dependents rather than their own),experience of stigma and the resistance brought about by these factors.Thus,it argued that formulation was,to some extent,context-shaped and had the nature of context-sensitiveness.When it comes to the actions performed through formulation,this study found that in the activity of medical data gathering,psychiatrist-other-formulation performed the action of checking understanding,psychatrist-self-formulation performed the action of information-seeking and patient-self-formulation was represented as clarification of the problem presentations.They contribute to fulfillment of the institutional goals in this activity,including making the patients’history straight and getting a sense of the patients’ symptoms and problems.It is considered as a preliminary step to diagnosis making and treatment recommending.In the activity of diagnosis making,psychiatrist-other-formulation was employed as a way to arriving at diagnosis and may be taken as a counterbalance between doctors’authority and accountability.Furthermore,psychiatrist-self-formulation of the diagnostic statement would be taken as an opportunity to popularize mental health knowledge to the patients and/or their dependents.In addition,in this activity,patient-other-formulation for candidate self-diagnosis was deployed as an effective way of achieving patients’ self-awareness.It displayed the patients’ active participation and cooperation in the interaction.In the activity of treatment recommending,psychiatrist-self-formulation,through repeated formulation of the treatment recommendations,was employed as a resource to explain and emphasize the recommendations,aiming to improve the patients’ adherence to the recommendations and instructions.In this activity,patient-other-formulation was employed by the patients to check their understanding to the treatment recommendations delivered by the psychiatrists;while through formulating an already agreed upon treatment plans or instructions,the patients indicated their commitment for further actions,i.e.their adherence to the treatment recommendations and instructions.In addition,psychiatrist-other-formulation in this activity could be deployed as a way of psychological treatment by challenging the patients’ distorted conceptions and ridiculous ideas,aiming to dispel their fears and anxieties.This study further found out that formulation had organizational functions at three levels of interaction.At the turn-by-turn level,formulation performed the actions of checking understanding,clarifying,information-seeking and challenging.At topical level,formulation was represented as a transition from one topic or one activity to another.Through curtailing or extending formulation,the psychiatrists bridged the patients’ talk and moved the story along;while through diagnostic formulation,the psychiatrists transited the interaction from medical data gathering to diagnosis making,which would contribute to fulfillment of the institutional goals in such a time-limited task-oriented interaction.At the case level,formulation to treatment recommendations functioned as pre-closure of the whole interaction and when it was confirmed,the interaction would come to a real closure.Besides,patient-formulation of treatment recommendations would display their commitment of future actions(adherence to the recommendations).In addition,it found out that formulation had relational functions and it contributed to constructing different discursive indentifies for both patients and psychiatrists.In the process of formulating,the psychiatrists’ multi identities such as authority,expert,educator and active listener were constructed;while for the patients,their identities as responsible agent and active participator were constructed.Under interactional linguistic perspective,formulation was regarded as not being pre-determined but emergent in the process of interaction.It reflected psychiatrist’s authority as well as the respect for the patients.Thus,it tempered,and to some degree,readdressed the authority and deontic rights between doctors and patients in their interaction.With regard to the implications of formulation for psychiatrist-patient interaction,the study revealed that as a conversational practice,formulation played a role in medical data gathering,diagnosis making and treatment recommending.As an interactional resource,formulation could contribute to removing obstacles of communication and facilitating interaction.As a necessary way to medical data gathering,diagnosis making and treatment recommending,formulation not only had organizational functions but also functioned in constructing the discursive identities for both psychiatrists and patients.Therefore,the study of formulation,part and parcel of psychiatrist-patient interaction,provided a window through which we could have a deeper understanding of how psychiatrist-patient interaction was done and how formulation was employed in the interaction.