How student healthcare providers in a communication skills course respond to standardized patient resistance.

Encountering and responding to patient resistance can be especially challenging for student healthcare providers. Navigating who ultimately holds the authority to know and understand a health concern, make recommendations for a course of action, and accept or resist these recommendations are all part of how epistemic authority is negotiated in medical settings. The purpose of this paper is to systematically examine how student providers enrolled in a communication skills course at an American university responded to standardized patient resistance. The data for this study were 121 video-recorded and transcribed final objective structured clinical examinations from the fall 2019 course. We used discourse analysis informed by principles of conversation analysis to identify several discursive strategies used by the students, including: 1) asking for clarification; 2) expressing uncertainty and offering to gather additional resources; 3) aligning with and offering an account for the resistance; 4) recommending a new course of action; and 5) confronting the resistance. Our findings point to the value of including instruction for both student healthcare providers and standardized patients on how to respond to resistance they encounter in ways that may help improve healthcare outcomes.

Strategic use of observer-perspective questions in couples therapy.

Questions are one of the most frequently used strategies in therapy. There is a body of theoretical work on the kinds of questions that are preferred in specific treatment approaches. However, research on the use of questions in general, how they are formed and what specific therapeutic work they do, is relatively scarce in the literature. In this study, we use the conceptual framework and methods of conversation analysis (CA) to examine how systemic questions soliciting clients' perspective on the partners' thoughts and intents (Observer-Perspective Questions; OPQs) are realized interactively in actual clinical practice and the range of therapeutic work they perform in couples therapy. We identified 78 OPQs from archival data of videotaped time-limited couples therapies, a clinical population working with a professional therapist. From this set of 78 OPQs, five excerpts representing diverse use of OPQs were selected. These excerpts were transcribed in detail capturing not only the textual content but also the prosodic, gestural, and non-verbal aspects of these episodes. Using CA methodology, we identified four specific kinds of changes these questions can promote: progress toward relational optimism, support of positive aspects of the couple's relationship, promoting the concept that the couples' experiences and emotions are interlinked, and introducing new creative relational options. Detailed CA analyses of these clinical excerpts allowed us to identify how the OPQ sequences were built to realize these therapeutically useful moves using various conversational resources progressively and interactively. The conversational analysis of these sequences facilitated the exploration of relationships between the ways the questions are formed, timed, and delivered and the specific functions they perform to move the therapy forward. In conclusion, we make the general argument that examining important therapy events through a CA perspective provides a significant complementary vector to quantitative research on the therapy process.

Peer support for accepting distressing reality: Expertise and experience-sharing in psychiatric peer-to-peer group discussions.

Peer-based interventions are increasingly used for delivering mental health services to help people with an illness re-examine their situation and accept their illness as part of their life story. The role of the peer supporter in these interventions, known as experts-by-experience (EbE), is situated between mutual peer support and semi-professional service delivery, and they face the challenge of balancing an asymmetric, professional relationship with a reciprocal, mutuality-based, equal relationship. This article investigates how EbEs tackle this challenge when responding to clients' stories about their personal, distressing experiences in peer-based groups in psychiatric services. The results show how the EbEs responded to their clients' experience-sharing with two types of turns of talk. In the first response type, the EbEs highlighted reciprocal experience-sharing, nudging the clients toward accepting their illness. This invoked mutual affiliation and more problem-talk from the clients. In the second response type, the EbEs compromised reciprocal experience-sharing and advised clients on how to accept their illness in their everyday lives. This was considered less affiliative in relation to the client's problem description, and the sequence was brought to a close. Both response types involved epistemic asymmetries that needed to be managed in the interaction. Based on our analysis, semi-professional, experience-based expertise involves constant epistemic tensions, as the participants struggle to retain the mutual orientation toward peer-based experience-sharing and affiliation.

Authority in therapeutic interaction: A conversation analytic study.

A paradigmatic shift toward postmodern, collaborative practice in family therapy raises questions about how therapists can use professional authority to facilitate change and how clients can assert their knowledge and agency. We used conversation analysis to investigate how the authority to know and to determine here-and-now action (i.e., who does what, and how, in therapy) was negotiated and accomplished in 10 sessions of emotion-focused therapy involving chair work. Therapists were observed to rely on a particular interactional sequence structure: stepwise entry into a directive, in which directives were preceded by a question-answer sequence. We show how instances where clients' views were elicited prior to the delivery of a directive resulted in different interactional consequences from instances where therapists straightforwardly directed clients to perform some action. The study offers evidence concerning how therapists can facilitate chair work collaboratively and responsively.

Framing dementia experiences in a positive light: Conversational practices in one couple living with dementia.

The general approach to a life with dementia is negatively charged, and alternative views are rarely found in research or in media coverage. This case-study explores conversational practices for framing dementia in a more positive light, employed by a husband of a wife with dementia. Framing regards the structured experiences of dementia, drawing on Goffman's 'Frame Analysis'. Benefitting from conversation analysis, this article presents principal results of four conversational practices used by the spouse without dementia: mitigating trouble, normalising trouble, justifying trouble, and praising. The conclusions drawn are that the practices contribute to the challenging of the dominant negative framework of the dementia experience, as they facilitate talk which emphasises the wife with dementia's positive progression and skills in managing the household chores. Despite a positive framing of dementia, this couple still embed their talk in the overall negative framework of loss and decreased cognitive competence. The visualisation of a positive framing could add to a broadened view of dementia, which in turn could contribute to greater well-being for those affected. However, the results may also imply a risk of one spouse's conversational practices of normalising and mitigating trouble being dominant in interaction and thereby neglecting the other spouse's experience of the situation.

On Epistemics in Expected Free Energy for Linear Gaussian State Space Models.

Active Inference (AIF) is a framework that can be used both to describe information processing in naturally intelligent systems, such as the human brain, and to design synthetic intelligent systems (agents). In this paper we show that Expected Free Energy (EFE) minimisation, a core feature of the framework, does not lead to purposeful explorative behaviour in linear Gaussian dynamical systems. We provide a simple proof that, due to the specific construction used for the EFE, the terms responsible for the exploratory (epistemic) drive become constant in the case of linear Gaussian systems. This renders AIF equivalent to KL control. From a theoretical point of view this is an interesting result since it is generally assumed that EFE minimisation will always introduce an exploratory drive in AIF agents. While the full EFE objective does not lead to exploration in linear Gaussian dynamical systems, the principles of its construction can still be used to design objectives that include an epistemic drive. We provide an in-depth analysis of the mechanics behind the epistemic drive of AIF agents and show how to design objectives for linear Gaussian dynamical systems that do include an epistemic drive. Concretely, we show that focusing solely on epistemics and dispensing with goal-directed terms leads to a form of maximum entropy exploration that is heavily dependent on the type of control signals driving the system. Additive controls do not permit such exploration. From a practical point of view this is an important result since linear Gaussian dynamical systems with additive controls are an extensively used model class, encompassing for instance Linear Quadratic Gaussian controllers. On the other hand, linear Gaussian dynamical systems driven by multiplicative controls such as switching transition matrices do permit an exploratory drive.

Reconciling scientific and commonsense values to improve reasoning.

Scientific reasoning is characterized by commitments to evidence and objectivity. New research suggests that under some conditions, people are prone to reject these commitments, and instead sanction motivated reasoning and bias. Moreover, people's tendency to devalue scientific reasoning likely explains the emergence and persistence of many biased beliefs. However, recent work in epistemology has identified ways in which bias might be legitimately incorporated into belief formation. Researchers can leverage these insights to evaluate when commonsense affirmation of bias is justified and when it is unjustified and therefore a good target for intervention. Making reasoning more scientific may require more than merely teaching people what constitutes scientific reasoning; it may require affirming the value of such reasoning in the first place.

Interactional practices in person-centred care: Conversation analysis of nurse-patient disagreement during self-management support.

BACKGROUND: Person-centred care implies a change in interaction between care professionals and patients where patients are not passive recipients but co-producers of care. The interactional practices of person-centred care remain largely unexplored. OBJECTIVE: This study focuses on the analysis of disagreements, which are described as an important part in the co-production of knowledge in interaction. DESIGN: A qualitative exploratory study using conversation analysis. SETTING AND PARTICIPANTS: Data were collected from a nurse-led person-centred intervention in a hospital outpatient setting. Interactions between adult patients with irritable bowel syndrome (n = 17) and a registered nurse were audio-recorded. COREQ guidelines were applied. RESULTS: Disagreements were found after demonstration of the nurse's or patients' respective professional or personal knowledge. Disagreements were also evident when deciding on strategies for self-management. Although negotiations between opposing views of the nurse and patient were seen as important, the patient generally claimed final authority both in knowing how IBS is perceived and in the right to choose self-management strategies. The nurse generally oriented towards patient authority, but instances of demonstration of nurse authority despite patient resistance were also found. DISCUSSION AND CONCLUSIONS: This study provides information on how co-production of knowledge and decisions occur in the context of a person-centred care intervention. Negotiations between nurse and patient views require a flexible approach to communication, adapting interaction to each context while bearing in mind the patients having the final authority. To facilitate co-production, the patient's role and responsibilities in interaction should be explicitly stated.

Identity and action: Help-seeking requests in calls to a victim support service.

The nature of the link between identity and action is a fundamental question for social science. One focus in psychology is how actions like seeking help are implicated in matters of identity. This paper presents a discursive psychology study of identity and help in social interaction. Drawing on a corpus of nearly 400 recorded calls to a victim support helpline, I analysed how participants oriented to the link between identity and help. With attention to epistemic, deontic, and affective relations between participants, I analysed how identity was demonstrably relevant and procedurally consequential for building and interpreting help-seeking requests. Participants displayed an understanding that seeking help from Victim Support necessarily implicates identity. Callers' identities as victims or clients rendered their help-seeking accountable and invoked identities for call-takers as representatives of a support service. The findings show that identity and help are mutually constitutive. Seeking help constituted callers' identities as victims; and their identities as victims constituted their requests for help. I suggest that analysing identity and help in social interaction provides evidence for the mutually constitutive link between identity and action.

Morality justifies motivated reasoning in the folk ethics of belief.

When faced with a dilemma between believing what is supported by an impartial assessment of the evidence (e.g., that one's friend is guilty of a crime) and believing what would better fulfill a moral obligation (e.g., that the friend is innocent), people often believe in line with the latter. But is this how people think beliefs ought to be formed? We addressed this question across three studies and found that, across a diverse set of everyday situations, people treat moral considerations as legitimate grounds for believing propositions that are unsupported by objective, evidence-based reasoning. We further document two ways in which moral considerations affect how people evaluate others' beliefs. First, the moral value of a belief affects the evidential threshold required to believe, such that morally beneficial beliefs demand less evidence than morally risky beliefs. Second, people sometimes treat the moral value of a belief as an independent justification for belief, and on that basis, sometimes prescribe evidentially poor beliefs to others. Together these results show that, in the folk ethics of belief, morality can justify and demand motivated reasoning.

Epistemic Responsibility - Labored, Loosened, and Lost: Staging Alzheimer's Disease.

Interlocutors hold one another accountable for knowing certain information about themselves (their roles, activities, and memories) and for keeping track of information in the current conversational exchange. When speakers have trouble with this expectation, they themselves work to repair the breach, often doing a memory search, or when unsuccessful they provide an account (e.g. "I don't remember"). Memory searches (like word searches) are observable, interactional accomplishments. Speakers disengage with their interlocutors (look away), produce hesitation markers, take repeated pauses, engage in pre-positioned and post-positioned repairs, make epistemic assessments, and on finding an answer, re-engage with their interlocutors (look back). For their part, interlocutors comply with the search by not interrupting and continuing to yield the floor. At progressively severe stages of Alzheimer's disease, individuals exhibit increasingly labored memory searches that often trail off into non-answers, until at the latest stages, they eschew the search and (almost smoothly) provide either grammatically appropriate but wrong and improbable answers or give answers to previous questions on now closed topics. With data from the clinical administration of a disease staging instrument (Clinical Dementia Rating) this article examines the inexorable loss of epistemic responsibility as a key discursive dynamic in the progression of the disease.

Caller resistance to perform cardio-pulmonary resuscitation in emergency calls for cardiac arrest.

A key objective of an emergency call for cardiac arrest is to recruit a bystander to perform cardio-pulmonary resuscitation (CPR) until the ambulance arrives. Emergency medical services worldwide work towards increasing the rate of bystander-CPR, and existing research has identified a number of physical barriers to the provision of bystander-CPR. Yet, little is known about the specific ways in which emergency callers resist recruitment to perform basic first-aid, sometimes in the absence of any physical obstacle. This study investigated 65 emergency calls for cardiac arrest received in Australia in 2014 and 2015, in which the callers initially resisted CPR. We used conversation analysis to examine callers' practices to resist recruitment and call-takers' practices to counter this resistance. We found that callers who resisted CPR typically provided an account. When callers accounted for their resistance on deontic grounds, they expressed that CPR was not a possible course of action (e.g. "I can't do it"). When callers provided an epistemic account, their justification was based on their knowledge or opinion (e.g. "I think it's too late"). Our findings suggest that epistemic resistance can be a barrier to bystander-CPR. We identified two practices used by call-takers to address caller resistance based on epistemics. Providing more context on the purpose of CPR (e.g. "this is to help him in the meantime") seemed effective in persuading callers to perform CPR. By contrast, aligning with the caller's epistemic and deontic rights (e.g. "it's up to you") did not seem effective in persuading callers.

Challenging the interprofessional epistemic boundaries: The practices of informing in nurse-physician interaction.

Interprofessional management of knowledge in health care settings appears to be particularly vital for the ways in which information circulates, medical decisions are taken, and nursing practices are implemented. Drawing on an extensive ethnographic fieldwork in an Italian Intensive Care Unit, this article investigates how the nurses orient to and concurrently challenge the nurse-physician epistemic boundaries by the different ways through which they perform "informing", and make it work as a diagnostic-relevant activity. Adopting an ethnographic-nurtured discursive approach to a dataset of video-recorded morning briefings, we analyze the nurses' informing contributions in terms of sequential position, turn-taking and turn design. We identify five practices of informing and show how they display different degrees of agency and differently impact on the team's "infectious diseases diagnostic reasoning". This article contributes to nurse-physician interaction studies by showing how the epistemic imbalance at play is interactionally accomplished by participants one interaction at a time. Particularly, the analysis demonstrates that the nurses actively contribute to the teamwork by a skillful management of knowledge that precedes the exercise of the physicians' epistemic and deontic rights implied in diagnosing and planning. Our findings illustrate how the nurses: a) exert their interactional agency without crossing the institutionally sanctioned epistemic and deontic boundaries to which they are observably oriented to; b) cautiously challenge the epistemic imbalance at play in nurse-physician interaction and c) actively contribute in setting the premises of the team's collective decisions. Conclusion and practical implications are proposed.

Shaming interrogatives: Admonishments, the social psychology of emotion, and discursive practices of behaviour modification in family mealtimes.

This paper contributes to the study of admonishments, the operation of shaming in family interaction, and more broadly presses the virtue of a discursive psychological reconsideration of the social psychology of emotion. It examines the methodological basis of contemporary research on shame in experimental and qualitative social psychology, illustrated through the Test of Self-Conscious Affect (TOSCA) and qualitative work using shame narratives. Doubts are raised about how these methods can throw light on shaming practices in natural situations. The study uses a collection of video recordings of family mealtimes, focusing on admonishment sequences in which parents address the interrogatives 'what are you doing' or 'what did I say' to a 'misbehaving' child. Despite the interrogative syntax, rather than soliciting information we show that these interrogative forms pursue behaviour change by publicly highlighting both the problem behaviour and the child's active and intentional production of that behaviour. This is the sense in which the practice can be understood as shaming. Although this practice prosecutes shaming, ways in which the children can ignore, push back, or rework parents' actions are highlighted. This study contributes to a broader consideration of how enduring behavioural change can be approached as a parents' project.

When the larger objective matters more: support workers' epistemic and deontic authority over adult service-users.

We report on how support workers sometimes over-ride the wishes of people living with cognitive impairments. This can happen when they are both involved in some project (such as an institutionally-managed game, a physical journey, an educational activity and so on). The support worker might use their deontic authority (to propose, decide or announce future actions) to do things that advance the over-arching project, in spite of proposals for what are cast as diversions from the person with impairments. They might also use their epistemic authority (their greater knowledge or cognitive capacity) to trump their clients' choices and preferences in subordinate projects. Not orienting to suggested courses of actions is generally interactionally dispreferred and troublesome, but, although the providers do sometimes orient to their actions as balking their clients' wishes, they usually do not, and encounter little resistance. We discuss how people with disabilities may resist or palliate such loss of control, and the dilemmas that support staff face in carrying out their duties.

Asking 'What about' questions in chronic illness self-management meetings.

OBJECTIVES: This study investigates 'What about' questions asked by patients in the course of diabetes self-management groups led by nurses, and explores their functions in these empowerment-informed settings. METHODS: Conversation Analysis of 24 video-recorded sessions of a Start Insulin Group Programme for patients with type 2 diabetes, in a diabetes centre in the South of England. The groups included 2-7 patients and were led by 5 nurses, all of whom had received training in the empowerment approach. RESULTS: The analysis revealed a prevalence of single-unit 'Whatabout X' questions and found that they were used to embed requests for information in current or just closed activities. The nurses always provided the information, but could ask patients to specify the content of the question and collaborate to the answer. CONCLUSION: The analysis suggests that the short form of the question may be adapting to the nurses' restraint in giving recommendations or immediate responses to information seeking-questions. PRACTICE IMPLICATIONS: When healthcare communication practices are shaped in observance to a theoretical approach, such as empowerment, it is recommendable that practitioners monitor not only what they do, but also how patients change their habitual forms of speech in response.