The consultation as a genre (1)

Paul ten Have©

This paper is concerned with the in situ ordering of consultations in General Practice. Extracts from transcribed recordings of GP consultations, made in the Netherlands, will he used to develop the idea that doctors and patients use a variety of interactional formats to structure their encounters. Specifically, I will suggest that participants and observers of consultations use a general cultural 'ideal sequence' for the consultation as a genre as a device for constituting instances of consultations as such.

Furthermore, I will use some notions adapted from an analysis by Gail Jefferson and John Lee (1981) to describe episodes of seeming 'disorder' as either 'interactional asynchronies' within the format of the consultation, or as 'activity contamination' produced by the simultaneous relevance of different interactional formats. Two kinds of such 'convergences' will be considered in detail, one in which the consultation converges with Troubles Telling, and the other in which this is the case with Therapy Talk. In other words, while participants in consultations structure their interactions most of the time by using the social forms that are 'typical' for their settings, i.e. the Ideal Sequence for the consultation, they sometimes 'borrow forms that have their 'natural' place elsewhere, in ordinary conversation or in other institutional settings, respectively. This paper builds on and contributes to the general ethnomethodological notion that as regards institutional interaction: "it is within these local sequences of talk, and only there, that these institutions are ultimately and accountably talked into being" (Heritage, 1984:290). And it underscores the idea that, although participants use a similar cultural repertoire to structure their situations together, the actual interactional constitution of the occasion is locally negotiated through and through, each time again.

Interactional formats and institutional settings

Since the conceptual apparatus for this paper is in large part derived from Jefferson and Lee (1981), it makes sense to discuss some of their arguments first. Their report is part of a larger collection of studies focussed on various properties of everyday conversations in which parties talk about 'troubles'. The authors state that a thorough examination of their materials revealed a recognisable 'shape' to those conversations. This shape appeared to be well-formed in some cases, but was distorted and incomplete in many others. Certain utterance-types seemed to belong to specific positions within that overall order, but the authors found that in no case was it perfectly realised. As detailed analysis revealed: "in case after case a potentially strict sequence is encountering problems, and is thus becoming disordered" (Jefferson and Lee, 1981:401). These problems did not seem to be purely local or incidental, but instances of specific problem-types. The potential order that could result from the fact that participants join in a certain type of interaction is liable to a disordering when other types become relevant, or - as Jefferson and Lee call it - when several formats 'converge'. In their article they focus on one specific type of convergence, that of a Troubles Telling and a Service Encounter. Specifically, they argue that advice is liable to be rejected when it is given early in a projected Troubles Telling.

Jefferson and Lee appear to be somewhat ambivalent about their conceptualisation, especially as concerns the idea of an interactional format or 'template'. They concede that their formulation is reminiscent of Max Weber's conception of Ideal Types, but they add:

However, while akin to Weber's 'ideal type', our 'template' was not preformulated, but was grounded in and constructed from the data under inspection, in contrast to Weber's methodological program, we did not set out to find/construct a non-actual but representative model. Indeed, such a procedure is at variance with our own program which insists upon the description and analysis of actually occurring events in the very details of their occurrence. The notion of a 'model' in this case is tentative and problematic; we are far more committed to its analytic sequelae.
Jefferson and Lee, 1981:401
Thus, Jefferson and Lee are rather defensive about their 'candidate Troubles Telling sequence'; in fact, the sequence is never spelled out in their paper.

In my own work on doctor-patient interaction, I am much less hesitant about the Ideal Sequence that I have formulated for the consultation (cf. ten Have, 1987:103-41). I am convinced that consultations are much more clearly ordered in terms of an 'overall structural organisation' (Schegloff and Sacks, 1973:289) than are informal conversations. But additionally, I consider the programmatic gulf between Max Weber and Harvey Sacks, who is the acknowledged source of Jefferson and Lee's program and to whom they refer as a student and critic of Max Weber's methodology, to be less wide than they seem to do. I think one may consider Sacks as, in a certain fashion, a continuer of the Weberian tradition, at least as it took shape in the works of Alfred Schutz and Harold Garfinkel.

In his critique of Weber, Schutz (1972) developed the notion that the use of types is not restricted to the work of social scientists trying to analyse social life. It is also basic to the constitution of social life in and through the actions of ordinary members. He observed that the use of every knowledge of the social world is basic to action in that world. Typifications of courses-of-action, in conjunction with typifications of motives and persons, are used as both 'schemes of orientation', for producing action, and 'schemes of interpretation', for understanding the actions of others. He also pointed out that these typifications tend to be more anonymous, abstract, and standarised when one deals with more strongly institutionalised patterns of conduct (cf. Schutz, 1962:19-26).

Schutz's conceptions were, of course, of founding significance for Harold Garfinkel's work, which itself has been the major starting point for Harvey Sacks. In his discussion of 'the documentary method of interpretation', Garfinkel (1967:76-103) stresses that the correspondence between the commonsense knowledge of social structures - which will include typifications of courses-of-action - and what actually happens in situations of social life, is an 'achieved' correspondence. As he puts is, the 'patterns' that people know, and the 'documents' that they take to 'stand for' those patterns', are 'each used to elaborate the other' (1967:78).

A similar conception seems to underlie one of the most famous notions developed by Emanuel Schegloff and Harvey Sacks, that of 'adjacency pairs' (1973:295-8). This notion provides for the unity of sequences which consist of connected types of utterances, such as 'questions' and 'answers'. As they write:

The component utterances of those sequences have an achieved relatedness beyond that which may otherwise obtain between adjacent utterances. That relatedness is partially the product of the operation of a typology in the speakers' production of the sequences.
Schegloff and Sacks, 1973:295
In other words, the in situ production of social order in conversations is ultimately based on the recognisable application of a similar, typified knowledge of social structures. That knowledge is available to both participants and analysts, because they are members of society. Analysts can go beyond the situated use of ordinary members: they can analyse the use and formulate the knowledge involved. What separates Harvey Sacks from Max Weber is his admonition that one should base one's formulations of types, as knowledge-in-use, firmly on the detailed observation of what is actually done by members in interaction (cf. Sacks, 1984). I fully adhere to that.

In short, I think that students of institutional action can and should formulate the typified knowledge used by members to produce those actions, and thus, the institutions as well. These formulations, however, should be developed in close connection with a devoted study of the details of the actions that are seen to be so produced.

The format of the consultation

In my experience, the most concise way to describe the basic format of the medical consultation is to cite its usual sequential structure, or, as I call it, its Ideal Sequence, in the following way:

1. opening
2. complaint
3. examination or test
4. diagnosis
5. treatment or advice
6. closing

The sequence is called 'ideal' because one observes many deviations from it that seem to be quite acceptable to the participants. It often happens, for instance, that during a later phase people return to an earlier one, especially when problems arise later on. It should be noted that phases 2 to 5, which are the ones specific for the occasion, usually include some sort of 'discussion' of what is proposed or done. The physician, in most cases, is the one in charge of the proceedings, the one who initiates the various steps, with the patient following him. Similar schemes have been formulated in the literature (for instance, Byrne and Long, 1976:21).

I have based my proposal on three kinds of argument: firstly, the empirical argument that the Ideal Sequence corresponds approximately with what goes on during most consultations; secondly, the analytic argument that the Sequence can be analysed in terms of the 'logic' implied in the consultations as a specific kind of service provision established in society; and finally, the empirical argument that participants display an orientation to a Sequence such as this one in the details of their interaction (ten Have, 1987:103-141). It is to the study of such details that I now turn.

Sequential activities and sequential problems

I find, in my transcripts, many episodes in which participants in one way or another tell or show each other what they are doing or what they want the other to do. Tellings or showings which advance the sequence are mostly done by the physician, but. sometimes by the patient, as in Extract 1 (2):

Extract 1 ((GP1, after lengthy introductions))

   27 P (.7) well (1.2) yes there we are again huh there we are
   28     again yes
* 29 P I have two more things that uh you have to take a look at
   30 A and that is
* 31 P (first uh) at my throat and then at this knee
   32 A okay (.) and how are you doing besides that?

The physician lets the patient formulate the purpose of the visit in terms of a proposal for the examination, but he insists on having a general discussion of the latter's health first.

Extract 2 ((GP2, after a discussion of the condition of a child brought by her mother))

* 34 A 'hh well we will take a look 'tcan uh (.) simply (.) be
   35 A that she has a little blood shortage she is [nine years
   36 M                                                             [°yes that's
   37 M what I also°)
   38 A 'hhh the ages
*  45 A I don't know if it's something but we can just prick

Here we can see how the physician announces what I call a 'test', first at 34 in terms of 'taking a look', and second, more specifically at 45, with 'we can just prick'. In the first instance the hypothesis that guides the testing is given immediately with it, thus anticipating the diagnosis. The moment the doctor has given this first formulation of his views on the problem, the mother softly acknowledges that this corresponds to her own thinking. But she stops in mid-sentence and the physician ignores her action, collaborating, so to speak, in the 'ritual' preservation of the established distribution of knowledge, and the Ideal-Sequence in which this distribution is expressed (cf. ten Have, 1986).

Extract 3 ((GP3, after a diagnosis))

* 138 A 'h and well what I would like to propose to you is to
   139 A take a sedative to counter the pain
   140 P hmhm

Here the doctor follows his diagnosis with a proposed treatment advice. He just starts the next phase in the sequence while he tells his patient that this is what he does.

In all three examples we observe that the participant who initiates a new step in the sequence does so in a manner that incorporates some of the most general conversational devices for such moves, such as making a pause (in Extract l), producing audible in-breath (in Extracts 2 and 3), or using 'starters' like 'well' (in Extracts 2 and 3). Often, such devices are used in combination, as they are here. It is suggestive of an acknowledgment of the established division of conversational labour that the initiative of the patient in Extract I seems to be somewhat more elaborate and dependent on collaboration by the physician. But in all three cases the initiatives seem to be accepted by the other party, at least in part. I will now consider some examples in which utterances which clearly belong to a later step in the sequence are followed by one that seems to get back to an earlier phase, in this way producing the kind of sequential trouble which Jefferson and Lee (1981:402) call interactional 'asynchrony'.

Extract 4 ((GP2, an earlier moment in the encounter from which Example 2 was also extracted; after the mother has given a concise description of her child's condition, the doctor has asked the latter to show him her tongue))

   23 A (.) yes (.) very well (.) yes put it inside again girl=
* 24 M =and that tired she is already a long time complaining
* 25 M about that and she does sleep

The mother's description of symptoms and circumstances has been followed by the physician's request to the child to cooperate in an examination. He has started a next phase. But still, the moment he completes a recognisable part of the examination, the mother adds more information to her earlier description, in a way going back to the earlier phase, the complaint. We can say that she is out-of-phase with what the doctor is doing, but we have to concede that this kind of asynchrony is very common. Many patients use free moments during various phases, even the writing of the prescription, as an occasion to add information to their original complaints, or to give an other version of those. Here is another example.

Extract 5 ((GP3, a few moments after Extract 3))

   148 A and the moment you (.) are still not satisfied 'hh [( )
* 149 P                                                                         [ it is
* 150 P u:h during the night it is at its worst huh?

The explanation by the physician is interrupted by the patient before it is completed for another description of his complaints. It might be that this expressive utterance is 'triggered' (cf. Jefferson, 1978) by the doctor's reference to his feelings in 'satisfied'. A few moments later the physician has to remind the patient that he is still waiting for an acceptance of his proposal (not quoted), thus indicating retrospectively that the sequence was interrupted by the patient.

The convergence with Troubles Telling

Episodes like the foregoing can be analysed as merely interactional organisation going momentarily wrong and being remedied again, as cases of interactional 'asynchrony. But it is also possible to consider these cases as the result of a deeper disturbance, as what Jefferson and Lee (1981:402) call an activity 'contamination' or a 'convergence' of one interactional format with another. Talking about a troublesome condition can he part of several different interactional formats. In a 'service encounter', such as a consultation, it can figure as a request for service, that is as a first step in an Ideal Sequence for such an encounter. In informal conversation, however, it can be a part of several different types of activity, such as Building a Case, Negotiating a Plan, Dispute, or Troubles Telling (Jefferson and Lee, 1981:402). The specific type that will be enacted is often open to negotiation and 'problematic convergences' are quite frequent.

My thesis is that episodes like Extract 5 above can be seen as examples of a convergence, specifically a convergence of a Troubles Telling and a Service Encounter. Troubles Telling consists in a telling of some trouble, a reception of that telling, and possibly a discussion, in such a way that it can be considered as a moment of 'phatic communion', as a building of 'emotional reciprocity' concerning the troublesome experience involved. Physicians, of course, massively treat the description of symptoms as a request for a service, i.e. as a request for a diagnosis and/or treatment or advice. This is by far the dominant scheme for consultations and it seems to be accepted as obvious by most patients on most occasions. But underneath, as it were, another scheme is of potential relevance, and there can be moments in which the two activity types alternate, or in which one party seems to use one t)W, and the other the other one. Those are instances of a problematic convergence. We sec that the 'subordinate' scheme of a Troubles Telling is sometimes honoured marginally by physicians, especially when the trouble is a serious one, but patients seem to slip into it much more easily, more frequently, and more totally.

Examining the interactional environment in which these 'contaminations' arise, the following features have been found. Often the elaboration of the trouble beyond the amount 'technically necessary' for a service encounter, is done in 'empty spaces', that is, in moments when the physician is not talking, when he bas finished a certain recognisable 'unit' and has not requested the patient to do anything specific. Extract 4 above can be seen as an example of this. A different mechanism has been observed in Extract 5. Here the 'elaboration' erupted, so to speak, before a unit was finished, possibly 'triggered' by a reference to future feelings of the patient. Such a 'trigger'-phenomenon has been observed in other cases, such as Extract 6 below.

Extract 6 ((GP4, a female patient with stomach- and headaches has been invited by the physician (see Extract 7) to describe her current family problems, which she has done extensively; the doctor has expressed his understanding of her feelings about these problems and suggested that these feelings might be the cause of her aches))

   146 A seems to me quite probable 'hh well (.) thus with this
   147 A medication I will not solve that problem (.) but I think
   148 A that you do very well u::h see how how it is really (.)
   148 A how powerless you
* 149 P yess::
   150 A are fee[ling don't you
* 151 P            [yes: that's just it I have told him do bring your
   152 P clothes home so I can wash them

Here the 'trigger' seems to be the word 'powerless', that sets off the patient on a new round of expressive narration. In both cases, Extracts 5 and 6, the trigger-words were part of contributions by the physician that summarised what had been said so far during the encounter. Such summaries carry the implication that their speaker works to close off the encounter. The expressive utterances that 'erupt' at such moments can therefore also be considered as counter-moves to such a closing. They re-open the interaction, so to speak, at least for some time. Jefferson and Lee (1981) have shown that when, in informal interaction, one party starts a Troubles Telling, that party is likely to 'reject' advice coming from the other party directly following that Telling. They explain this rejection as a refusal of the interactional format of a Service Encounter. Such a format implies a local identity of the first speaker as Advice-Seeker which is mis-fitted with the identity of Troubles Teller, projected by that speaker. Advice-Giving works to shift the focus of the interaction from the person of the Teller to the Trouble itself, as a 'technical' matter, they suggest. Similarly, one can say that the fact that physicians tend to give only low-keyed kinds of contributions to projected Troubles Tellings works to keep the major focus of the encounter on the problem, and away from the person of the patient. There are, however, some occasions on which it is the physician, rather than the patient, who works to put the patient's person into focus. I will argue that these occasions represent a different kind of convergence.

The convergence with Therapy Talk

The narrative expressions which take up a large part of the encounter from which Example 6 was extracted, were not started at the initiative of the patient, but at the invitation of the doctor. Here follows an earlier extract from the episode in which that occurs.

Extract 7 ((GP4, the patient bas reported symptoms related to her stomach and these have been discussed technically, then follows:))

* 32 A 'hh (.6) where would that come from do you think?
   33 P welt I thought really perhaps very strange from my head-
   34 P ache tablet (.)
   35 A (hun)
   36 P because I take a lot of those at this moment because I
   37 P have splitting headaches
   38 (.7)
* 39 A a:nd where does that come from?
   40 P u:h (.) well that wilt come again from all hhh (eh) all
   41 P small things toge[ther
   42 A                         [(heheum)
   43 P that is again-uh nicely rolling all together
* 44 A what is that altogether?
   45 P well again with Leo I've been called this week by his landlady

Within the Ideal Sequence for consultations, this fragment would he seen as belonging to phase 2, the complaint. Physicians tend te follow their patients' complaint with a selection from a set of quite specific questions. This set includes requests for further description of the symptoms reported; often a sort of checklist is worked through concerning other possible symptoms, and the patient is asked to describe the circumstances surrounding the reported symptoms, as far as these could be useful for the doctor's understanding of what went wrong. But in Extract 7 the physician extends the latter type of questions to include requests for possible explanations. That is, he asks the patient to do what is officially his own job in a next part in the Ideal Sequence: the giving of a diagnosis. A basic presupposition of professional service is that the client is cognitively and/or practically less able to deal with a problem than is the professional. The client is supposed to lack the necessary knowledge, skills, or equipment to solve the problem in an efficient manner. By asking the patient to explain her own symptoms, the physician changes the basic interactional format of the consultation in a way that has important consequences for the ensuing interaction.

By asking the patient to do diagnostic work, the physician confronts her with a puzzle: 'his asking me to do his work can mean either that he thinks I can do that work myself or that I should do it myself'. The first alternative suggests that the problem is simple, that a lay person can do the job, and that it was really unnecessary for the patient to consult the doctor. The second alternative suggests that the patient - as the saying goes - is both a part of the problem and a part of the solution. In Extract 7 the patient shows, in her response to the doctor's questions, that she starts by considering the first alternative, and, as the physician insists, is willing to consider the second one. She first gives a lay explanation in the sense that her symptoms could be an instance of a well-known side-effect of certain types of medicine. When the physician neglects the content of her response and re-phrases his question in an ironic manner she, hesitantly and smiling self-consciously (as can be seen on video), seems to be willing to discuss another type of explanation, a social one, that would probably include the second alternative to the puzzle.

Referring to the earlier discussion concerning identities, one could say that the strategy of the physician works to 'fuse' a focus on the problem and a focus on the person. It is that 'fusion' that seems to be essential to still another interactional format in which reporting troubles is an essential part, what I want to call - following Turner, 1972 - Therapy Talk. My thesis is that it is this format that is 'converging' here with that of the consultation. The physician has brought the patient to the point that she seems to be willing to report on her personal experience of her trouble, as part of the professional treatment, as material for a professional discussion. A convergence such as this one seems rather hard to accept for many patients, and hard to handle for many physicians, for reasons to be spelled out later. Some of these difficulties could already be observed in Extracts 6 and 7. I will now quote some episodes from another encounter which clearly demonstrate these problems. This meeting was one in a series specifically arranged to provide physician and patient with more time to discuss the latter's predicament. This patient had, for some time already, suffered from pains in the heart region but, during extensive hospital examinations, no sign of physical disorder had been found. The patient's father, to whom he had been very much attached, died two years before and the patient was still very emotional about that, although he did not express his feelings on this very often.

Extract 8 ((GP5)) (3)

   1 A no of course it doesn't only concern the time of his
   2 A death of course it also concerns uh (.) the whole situation
   3 P yes (.) yes (.) yes (.) that's right yes (.) also what
   4 P happened before that time (.) right but yes I mean
   5 P (.) can I have those pains from that
   6 A yes that is possible
   7 P that's what I mean but (.) and what can be done about that (.)
* 8 A yes what did you feel when Last time for example you
* 9 A became so emotional what did you feet then in your body do you still know that

In this extract, the patient asks two specific questions. Firstly, a 'diagnostic' question in lines 4 and 5. To this, the physician gives a qualified answer in line 6. Then, secondly, there is a 'treatment' question in line 7. This question is not directly answered by the physician. Instead, he asks a counter-question concerning the feelings the patient has 'in his body' during an emotional episode at their last meeting (lines 8 and 9). This counter-question could he heard as an answer to the foregoing question in several ways, for example as 'the treatment consists in the expression of your feelings', or 'the treatment is to look at the bodily effects of your emotions'. But in the actual conversation it is, locally at least, only treated as a request for information, leading eventually to a discussion of the norm that a man should control the expression of his grief (not quoted here). Extract 9 depicts a later phase in that conversation.

Extract 9

   1 P yes but then I would tike to know (.) what should you
   2 P start doing about that C.) should you start to change your pattern of behavior
   3 P in your life uh (.) right should you start to follow a certain different way
   4 P so that that so in one way or another can be pressed back can be cured (.)
* 5 A mm what do you think yourself about that because you
* 6 A certainty have an idea about it
   7 P yes (.) uh (.) an idea about (.) I mean trying not to
   8 P excite myself about su' su' (.) things so uh (.) to excite myself less (.)
* 9 A welt that's not what I am thinking really
   10 P huh (.) what?
* 11 A that's just not what I am thinking
   12 P ( ) (.) well what did you think then?
* 13 A no but go ahead for a moment (.) so keeping yourself quiet?
   14 P yes (.) yes (.) I thought may be that that could be a cause that that you should
   15 P keep yourself a bit more quiet may be excite yourself a bit less about
   16 P the whole situation (.) it is hard for me to formulate what I mean (.)
   17 P Look when you are going to talk with me about a certain subject about which
   18 P I know a lot right (.) yes then I can better speak for myself
   19 P as about such situations (.)
* 20 A but you know best who you are yourself don't you?
   21 P yes of course I do know who I myself that I (.) how I have to
   22 P control myself and that that is obvious I mean but (.)
* 23 A no but you know best what's going on in your mind don't
* 24 A you (.) nobody else can do that can one (.) does know that (.)
   25 P yes sure do I know what's going on in my mind
* 26 A so you are the expert as concerns yourself Vou are the only expert (.)
   27 P yes (.) okay (.) but that that that does not have to be
   28 P the cause of that pain in my breast (.)
* 29 A no (.) no but I say I mean (.) as concerns that we are completely equivalent
   30 P course I know (.) of course I know my own pattern of behaviour how I am
   31 P how I live and what stand I take over against my wife and my child
   32 P and what stand I take over against my colleagues that I know very well (.)
* 33 A no but I mean also to say (.) you are uh (.) as concerns
* 34 A your own life you are your own doctor in principle (.)
* 35 A there I am not more of an expert than you are yourself (.)

In this episode, the physician refuses to honour his patient's requests for his expert opinion and advice. He insists, on the contrary, that the patient is 'the only expert' concerning his own mind and that he is 'his own doctor in principle'. These suggestions that the patient should have confidence in himself are preceded, however, by a flat disagreement concerning the patient's crucial thesis (9 and 11), and by an invitation to the patient to provide the physician with further 'displays of self' (line 13), presumably as material for more critical discussion. Therapy Talk, then, seems to involve as a basic strategy a refusal to answer requests for expert diagnosis and advice, and an invitation to express one's feelings and self-interpretations. It seems to encourage the patient to 'treat' himself or herself by a sustained self-expression and self-reflection. But, of course, there is a paradoxical air about all this. In fact, the suggestion that one is able to 'treat' oneself is given by a professional expert to his own client. And this expert does not accept everything his or her client reports as equally valid or relevant. Thus Therapy Talk, while negating officially the difference in expertise between physician and patient, still confirms the expertness of the former and the dependence of the latter on his expert judgement. (4)


In the introduction to this paper, I suggested that encounters may be constituted as instances of a genre by being structured in accordance with known institutional patterns. Such patterns, however, do not exhaustively describe the devices that are used by participants in institutional encounters. In addition to patterns natural to the specific institutional environment the interactants use the general interactional repertoire of their culture, both as a foundation for the institutional patterns and to structure events of a generalised social nature, such as introductions, leave-taking and small-talk. Furthermore, one observes the incidental use of formats that can be used in a variety of settings, such as various types of joking, mentioning the presence of a pretty girl or bureaucratic identification/registration (examples in ten Have, 1987). In this paper, however, I have analysed some instances of what seem to be less incidentally 'borrowed' formats, characterised as 'convergences' of the consultation with Troubles Telling and Therapy Talk, respectively. What is essential to the three formats involved in these convergences is the fact that a report about a self-experienced trouble is basic to each. It may he that this similarity accounts in part for the confusions that were observed in the quoted instances.

It seems to me that what makes for the differences between these three formats is not so much the content of the troubles- reports that they contain, as the manner in which these are produced and taken up. When the trouble is reported in a way that dramatises the suffering and emotionally involves the teller, it can he considered as an offer to a Troubles Telling (there will often be some kind of preliminary announcement and negotiation; see Jefferson, 1980). This offer can be accepted or not, where acceptance "I take the form of utterances that express interest in the person of the reporter and willingness to give 'emotional reciprocality'. What we often observe in consultations, and in other kinds of professional-client encounters as well, is that something like an offer to start a Troubles Telling is only minimally accepted by the professional, or completely ignored. We could call this 'an abortive Troubles Telling'.

The case of the convergence with Therapy Talk is more complicated. The context from which that format is borrowed is a close relative of the consulting room. The presuppositions of the two forms are partly different, however, and so are the activity-types that make up those forms. In Therapy, authoritative answers tend to be refused and expertise denied, which is not true in the same way for consultations. From the literature on psychotherapy and therapeutic forms of social work, one gets the impression that the paradoxical intricacies of Therapy Talk are so difficult for clients to grasp that instruction in the client part is a persistent feature of the treatment, while 'resistance' is frequent. It comes as no surprise, therefore, that the often unannounced use of this format within the consultation produces a lot of confusion.

Comparing Troubles Telling and Therapy Talk - both within the context of the General Practice consultation - we may say that both provide the troubles reporter with an occasion for emotional expression. In the case of Troubles Telling this amounts to an - often abortive - attempt to gain some emotional reciprocity from the doctor. In Therapy Talk, it is the physician who invites the patient to express himself or herself emotionally. This invitation, however, is not directed at providing reciprocity. In other words, in both convergences there is a shift from the trouble to the person. In Troubles Telling the reporter projects himself or herself as an experiencing subject and invites the recipient to share in this experience as a person. In Therapy Talk, however, the person of the experiencing subject is focused by the recipient as part of the problem itself, to be considered with critical distance by both the recipient and the subject itself. What is at issue in these convergences is the organisational compatibility of these locally produced identities, especially the identities for the patient-reporter of advice-seeker, experiencer and self-reflecting subject and trouble-source.

I would like to deepen this analysis by reconsidering Extracts 6 and 7. In Extract 7 - the earlier fragment in the encounter - the physician invites the patient to tell him about her family problems. This invitation is accepted, which leads to a long and emotional report, too long to he quoted here. It seems to be a Troubles Telling for the patient, while the physician is working at Therapy Talk. In Extract 6 we see how a summarising statement by the doctor is interrupted by the patient for another round of Troubles Telling. In fact, she seems to take this summary labeling of her feelings as an act of emotional reciprocity and by that as an endorsement of more Troubles Telling, not as a focus on her feelings as part of the problem to be reflexively reconsidered.

So, it does not seem easy to use 'therapeutic techniques' within the consultation, partly because they can be taken up as an occasion for Troubles Telling. In a sense, this seems to be the third kind of 'problematic convergence' in my material, that of Troubles Telling and Therapy Talk. It comes as no surprise, therefore, that many physicians tend to refer patients with vague complaints, emotional problems and imaginary pains to the specialised services of social work and psychotherapy. In fact, during the consultation from which Examples 6 and 7 were extracted an existing social work contact is mentioned by the physician, while the series of encounters from which Extracts 8 and 9 were taken leads to the recommendation to consult a psychotherapeutic service.

The major argument of my paper can be re-formulated in terms of 'the documentary method of interpretation', as described by Garfinkel (1967:78). Participants in consultations are seen to produce the 'typicality' of their encounters by relating its 'documents', i.e. their utterances, to its 'pattern', what I have called its format, the Ideal Sequence for the consultation. Furthermore, some episodes that had an air of 'disturbance' could be clarified by suggesting that some other 'patterns' were concurrently or alter- natively relevant to participants at those moments. This analysis contrasts and connects 'the actual' and 'the ideal' as it exists for, and is displayed by, member-participants. The analyst himself, however, is not in the business of idealisation. Noting a 'Multiplicity' of genres is not a criticism. The analysis is focussed on the ways in which practical actors solve their problems in interaction, oriented to more or less shared ideals as well as to material actualities.

One aspect of the practical circumstances of participants in consultations deserves a special mention in this respect: the time available for the encounter. The Ideal Sequence for the consultation, by focussing on a specific problem to he defined and at least provisionally solved within the encounter's limits, seems perfectly suited for structuring encounters on topics of varying complexity when the overall time available is severely restricted. Defining the problem and suggesting a way to solve it provides a basis for a natural ending. For Troubles Telling and Therapy Talk, on the other hand, no such natural completion structures are available. On the contrary, both the celebration of emotional reciprocity and the institution of therapeutic change are infamous for the time they can take. Jefferson (1980, 1984) has demonstrated that occasions of Troubles Telling in ordinary conversation evolve gradually and that the transition to other topics is instituted in a step-wise fashion. This seems hard to imitate within the confines of an encounter that is part of a crowded consulting hour. In psychotherapy and therapeutic social work, on the other hand, we sec the practice of fixed appointments and time-slots, as well as the extension of treatments into longer series of meetings, suggesting in this way that therapy does not have any 'natural' ending. These contrasting characteristics of Troubles Telling and Therapy Talk, on the one hand, and the consultation, on the other, may also partly account for the problematic aspects of the convergences observed. The consultation, in short, is a rather limited and restricted device for the definition and treatment of troubles, at least in comparison with some other genres with which it sometimes momentarily converges.


1. Text originally published in: B. Torode, ed. Text and Talk as Social Practice. Dordrecht/Providence, R.I.: Foris Publications (1989): 115-35 - the current one is only different in typographical details. A more extensive version of this paper can he found in ten Have (1987), chapter 4 (pages 142-74). A much earlier version was read at the Xth World Congress of Sociology, Ad Hoe Group on Phenomenological Sociology, Mexico City, 1982, as 'Sequencing and the Formulation of Trouble in Expert-Client Conversations'. I am grateful for the numerous suggestions and criticisms I have received on that and other occasions.

2. The fragments quoted are given in a rough English translation of the original Dutch transcriptions, with an approximate indication of how the original utterances were spoken. These originals can be found in the appendix to this paper. The transcript conventions used in both versions are a restricted selection from the set developed by Gail Jefferson, in general use within Conversation Analysis, see Atkinson and Heritage (1994:1X-XIV) for an explanation. In all transcripts A = physician, P = patient.

3. Extracts 8 and 9 were adapted front a transcript made by a colleague who failed to provide the usual details of speech delivery, except untimed pauses. Since the recording was no longer available, I could not make up for this defect.

4. My analysis of Therapy Talk partly builds on Blum (1970), Turner (1972), Schwartz (1976) and Wootton (1977).


Atkinson, J.M., J. Heritage, eds. (1984) Structures of Social Action: Studies in Conversation Analysis. Cambridge: Cambridge University Press

Blum, A.F. (1970) 'The sociology of mental illness'. In: J.D. Douglas, ed. Deviance and respectability: the social construction of moral meanings. New York: Basic Books: 31-60

Byrne, P.S., B.E.L. Long (1976) Doctors talking to patients: a study of the verbal behaviour of general practitioners consulting in their surgeries. London: H.M.S.O.

Garfinkel, H. (1967) Studies in ethnomethodology. Englewood Cliffs, N.J.: Prentice-Hall

Have, P. ten (1986) 'Ritual aspects of doctor-patient interaction'. Paper read at the Conference for Erving Goffman: An interdisciplinary appreciation, University of York, July 1986

Have, P. ten, (1987) Sequenties en formuleringen; aspecten van de interactionele organisatie van huisartsspreekuurgesprekken [Sequences and formulations: aspects of the interactional organization of general practice consultations]. Dordrecht: Foris

Heritage, J. (1984) Garfinkel and Ethnomethodology. Cambridge: Polity Press

Jefferson, G. (1978) 'Sequential aspects of story telling in conversation'. In: J.N. Schenkein, ed., Studies in the organization of conversational interaction. New York: Academic Press: 213-48

Jefferson, G. (1980) 'On "trouble-premonitory" response to inquiry', Sociological Inquiry 50: 153-85

Jefferson, G. (1984) 'On stepwise transition from talk about a trouble to inappropriately next-positioned matters'. In: Atkinson, J.M., J. Heritage, eds. Structures of Social Action: Studies in Conversation Analysis. Cambridge: Cambridge University Press: 191-222

Jefferson, G., J.R.E. Lee, (1981) 'The rejection of advice: managing the problematic convergence of a "TroublesTelling" and a "Service Encounter"', Journal of Pragmatics 5: 399-422

Sacks, H. (1984) 'Notes on methodology'. In: Atkinson, J.M., J. Heritage, eds. Structures of Social Action: Studies in Conversation Analysis. Cambridge: Cambridge University Press: 2-27

Schegloff, E.A., H. Sacks (1973) 'Opening up closings', Semiotica 8: 289-327

Schutz, A. (1962) Collected papers I: The problem of social reality. The Hague: Nijhoff

Schutz, A. (1972) The phenomenology of the social world. {tr. G. Walsh & F. Lehnert), London: Heinemann

Schwartz, H. (1976) 'On recognizing mistakes: a case of practical reasoning in psychotherapy', Philosophy of the Social Sciences 6: 55-73

Turner, R. (1972) 'Some formal properties of therapy talk'. In: Sudnow, ed. Studies in social interaction. New York: Free Press: 367-96

Wootton, A.J. (1977) 'Sharing: some notes on the organization of talk in a therapeutic community', Sociology 11: 333-50

Appendix: Dutch originals of the quoted transcription extracts

P = patient, A = physician, M = mother of patient

Extract 1

   27 P (.7) zo (1.2) ja daar zitten we weer (hè)
   28 A daar zitten we weer ja
* 29 P ik heb t'r nog twee dingen bij dat eh moet u dus even naar kijken
   30 A en dat is
* 31 P (eerst es) naar m'n keel en naar deze knie
   32 A goed (.) en hoe is 't verder met u?

Extract 2

* 34 A 'hh nou we zullen es kijken d't kan eh (.) eenvoudig (.) 'te zijn
   35 A dat ze wat tekort aan bloed heeft ze is negen [jaar
   36 M                                                                    [(ja heb ik ook al)
37 A 'hhh de leeftijden
         . . . . .
* 45 A 'k wee- niet of het wat is maar we kunnen even (prikken)

Extract 3

* 138 A 'h en nou (z) wat ik je nou wilde voorstellen is om een pijnstiller
   139 A te nemen (.) tegen die pijn
   140 P (hmhm)

Extract 4

   23 A (.) jà (.) goed zo (.) ja doe maar weer naar binnen jôh =
* 24 M =en dat moe daar klaagt ze een hele poos over en ja ze slaapt dus

Extract 5

   148 A en zodra je (.) toch niet eh tevreden bent 'hh [(    )
   149 P                                                ['t is e:h
* 150 'snachts is 't 't ergste hè

Extract 6

   146 A lijkt me heel best waarschijnlijk 'hhh nou (.) dus met deze medi-
   147 A cijnen los ik dat probleem niet op (.) maar ik vind dat u d't wel
   148 A erg goed e::h ziet hoe hoe dat zit eigenlijk (.) hoe machteloos u
* 149 P ja::
   150 A zich vo[elt hè
* 151 P            [ja: dat is 't 'm juist ik heb 'm gezegd jôh breng je kleren
   152 P thuis dan zal ik ze wassen

Extract 7

* 32 A 'hh (.6) waar kan dat nou vandaan komen denkt u?
   33 P nou ik dacht eigenlijk misschien heel raar van m'n hoofdpijn tablet
   34 (.)
   35 A (hun)
   36 P want die neem ik op het ogenblik erg veel ik want ik barst van de hoofdpijn
   37 (.7)
* 38 A e:n hoe komt-tattan
   39 P e:h (.) nou dat zal wel weer door alle hhh (eh) alle dingetjes bij
   40 P el[kaar komen
   41 A   [(heheum)
   42 P dat is weere:h lekker allemaal aan het rollen
* 43 A wat is dat allemaal?
   44 P nou weer van Leo ik ben dus van de week opgebeld door ze hospita

Extract 8

   1 A nee, het gaan natuurlijk niet alleen over dat tijdstip
   2 A van overlijden het gaat natuurlijk om uh (.) de hele situatie (.)
   3 P ja (.) ja (.) ja (.) dat wel ja (.) ook de voorgeschiedenis die
   4 P daaraan vooraf geweest is (.) hè (.) maar ja, ik bedoel (.)
   5 P ken ik daar die pijnen van hebben (.)
   6 A ja, dan kan wel (.)
   7 P dat bedoel ik maar (.) en wat is daartegen te doen (.)
* 8 A ja wat voelde u nou toen u de vorige keer bijvoorbeeld zo
* 9 A geëmotioneerd werd wat voelde u toen in uw lichaam
* 10 A weet u dat nog

Extract 9

   1 P ja maar dan zou ik dus graag willen weten (.) .wat je daar dus aan
   2 P moet gaan doen (.) moet je je gedragspatroon gaan veranderen in
   3 P je leven uh (.) hè, moet je een bepaalde andere wijze gaan volgen,
   4 P dus dat dat dus op een of andere manier achteruit te drukken is te
   5 P genezen is (.) ..
* 6 A mm, wat denkt u daar nou zelf van, want daar heeft u best een idee
* 7 A over (.) .
   8 P ja (.) uh (.) een idee over (.) ik bedoel proberen dus mijn eigen niet
   9 P op te winden over zu zu (.) dingen dus eh (.) me minder
   P druk te maken (.)
* 10 A nou dat denk ik eigenlijk niet (.)
   11 P hè (.) wat?
* 12 A dat denk ik nou net niet
   13 P (    ) (.) nou wat dacht u dan?
* 14 A nee maar gaat u even verder (.) dus u koest houden?
   15 P ja (.) ja (.) ik dacht misschien dat dat een oorzaak kon wezen dat
   16 P dat hè dat je een beetje rustiger moet houden misschien een beetje
   17 P minder druk maken om de hele situatie (.) het is voor mij moeilijk om
   18 P het onder woorden te brengen ik bedoel (.) .kijk als u met mij over
   19 P een bepaald onderwerp gaat praten waar ik dus veel vanaf weet hè (.)
   20 P ja dan ken ik natuurlijk beter m'n woordje doen als over zulke
   21 P situaties (.)
* 22 A maar u weet toch het beste wie u zelf bent?
   23 P ja natuurlijk weet ik wel wie ik mezelf dat ik (.) hoe ik me eigen
   24 P in bedwang moet houe en en dat is logisch, ik bedoel maar (.) .
* 25 A nee maar u weet toch het beste wat er in u omgaat (.) dat kan toch
* 26 A niemand ander kan dat (.) .weet dat toch (.)
   27 P ja zeker weet ik dat wel wat er in mij omgaat (.)
* 28 A dus u bent de expert wat uzelf betreft bent u de enige expert (.)
   29 P jaa (.) goed (.) maar dat dat dat hoeft toch geen oorzaak te wezen
   30 P van die pijn in mijn borst (.)
* 31 A nee (.) nee maar ik zeg ik bedoel (.) wat dat betreft zijn we
* 32 A helemaal gelijkwaardig (.)
   33 P tuurlijk weet (.) .natuurlijk weet ik het gedragspatroon van mezelf,
   34 P hoe ik ben hoe ik leef en hoe ik tegenover mijn vrouw en mijn kind
   35 P sta en hoe ik tegenover m'n collega's sta, dat weet ik best (.)
* 36 A nee maar ik bedoel ook te zeggen (.) .u bent uh (.) wat uw eigen leven
* 37 A betreft bent u eigen dokter in principe (.) daar bent ik niks
* 38 A deskundiger dan uzelf (.)