Wayne State University
I am attending the Symposium of Health, Medicine & Society for two purposes: I would love to talk about my long-term research program on ethics-in-interaction in medical discourse (Barton 2011); however, I (desperately) need input on my current project on Motivational Interviewing, a method of guided counseling aimed at strengthening internal motivation to change health-related behaviors (Naar-King and Suarez 2011). As measured by fluency in this overview, my research on ethics-in-interaction is a well-developed program in which I have considerable confidence, but the motivational interviewing project is decidedly not.
In American medicine today, bioethics is considered the top-down set of principles – autonomy, beneficence/non-maleficence, justice – that should normatively underlie decision-making (Beauchamp & Childress 2001). Medical decision-making with ethical dimensions, however, most often takes place in interaction among real people, in real time, in (semi-)ordinary language that is often more indirect than direct, and in complex contexts that are institutional and asymmetrical. Yet the actual language of medical decision-making with ethical dimensions has rarely been studied in the literature, and a bottom-up perspective on ethics as interactional and rhetorical is only beginning to emerge in discourse studies.
My current research program on ethics-in-interaction investigates one central question: what are the linguistic means by which ethical issues are raised, explored, negotiated, justified, and settled (or not) in medical decision-making? Based on observational and interactional data (field notes, informal discussions with key informants, and transcripts) and using discourse analysis as my primary method, projects in this research program describe ethically-charged communicative events in medicine, analyzing medical decision-making with ethical dimensions. I have completed two major projects in this research program — the discourse of end-of-life discussions in a surgical ICU, and the discourse of offers to participate in oncology clinical trials. In medical rhetoric, I currently have a two-article series under review at Communication&Medicine entitled Strategies of Persuasion in Offers to Participate in Cancer Clinical Trials I and II: I — Topic Placement and Topic Framing; II — Appeals to Altruism. Both of these articles analyze clinical trial offers in terms of differences by patient race within a health disparities framework.
My new project in this research program is the analysis of deliberation on Institutional Review Boards [IRBs), another discourse with considerable tensions between what is mandated to be the normative top-down application of the principles of bioethics in the review of research with human subjects and the bottom-up negotiation of multiple perspectives on the ethical dimensions of the research protocol at hand in IRB deliberation. The data for this project has been collected from one year of monthly meetings of a Behavioral and Social Sciences IRB, a committee I chaired. I have not yet begun the transcription and analysis of the data, although the working hypothesis is that deliberation on IRBs is a jointly constructed discourse accountable not only to federal regulations and university policies but also to the professional and lay ethics of members as representatives of their backgrounds and communities. At the moment, I am particularly interested in the prominent role of hypothetical narratives in ethical deliberation and their function in contributing to what critics call overregulation and mission creep by IRBs (Gunsalus 2006).
Behavioral medicine, health psychology, and health counseling are growth areas in contemporary medicine as the field (sometimes reluctantly) grapples with the prevention, treatment, and costs of chronic diseases. Often called an American epidemic, obesity is an underlying cause of the top two chronic diseases – heart disease and diabetes – and obesity rates are significantly higher for African-Americans, including children and adolescents. I am currently working on a project investigating the efficacy of Motivational Interviewing in increasing adherence to weight loss recommendations by obese African-American adolescents and their caregivers (primarily mothers who are also obese).
The discourse of MI lies mid-way on a continuum of counseling from non-directional (e.g., genetic counseling) to confrontational (e.g., substance abuse counseling). What is interesting about the discourse of MI sessions, certainly for a linguist and perhaps for a rhetorician, is that the method is centered upon specific linguistic goals: counselors actively and consciously use open-ended questions, offers of information, reflections, and support of client autonomy to try to elicit what is called Change Talk [CT] (desire, ability, reason, and need statements that are precursors to change) and Commitment Language [CML] (statements making specific commitments to change). For example, a statement like I need to eat breakfast every day is Change Talk, but I will eat breakfast every day this week is Commitment Language. The research on MI predicts that the amount and progression of Change Talk and Commitment Language in MI sessions will correlate with positive outcomes, both in attitude (internal motivation to change) and behavior (in this project, adherence to weight loss recommendations), and the American Medical Association has recommended the use of MI communication in discussions of pediatric obesity prevention and treatment (Barlow 2007).
I have two roles in this project, first in instrument development and now in data analysis for publication. The research literature on MI has a standardized instrument for coding the sequential interaction in MI sessions with non-minority adults (MI-SCOPE: Motivational Interviewing Sequential Code for Observing Process Exchanges). We adapted this instrument to develop an additional standardized instrument for coding MI sessions with African-American youth and MI sessions with caregivers (MY-SCOPE: Minority Youth Sequential Coding for Observing Process Exchanges). Research assistants have coded a corpus of 37 one-time MI sessions with a three-part structure: counselor and teen, counselor and caregiver, and counselor, teen, and caregiver all together (IRR k=.696). My job is now to analyze this data in two studies. The first is sequential, probably of interest primarily to MI researchers and linguists. Previous MI instruments code clients’ talk for Change Talk and Commitment Language only, while our instrument also coded high and low uptake in clients’ talk: high uptake is a client turn with content, although not Change Talk or Commitment Language, while low uptake is a minimal client response (mm-hmm, yeah, OK). We also coded for blunting: a non-cooperative response that does not develop the ongoing topic on the table (for example, an exchange like What brought you here today? My mother brought me.). This study is not going well: low-uptake utterances seem mostly to be routine sequence-closers, while high-uptake turns seem to be a kind of Other category, both without meaningful patterns in terms of Change Talk and Commitment Language, although I’m still reading the transcripts and running the numbers. (Sigh.) Blunting seems promising, perhaps especially to a rhetorician, because it is a direct expression of resistance to the counselor’s talk. Blunting, though, is rare in the corpus, with too few instances to analyze for significance within the quantitative methods used in the MI literature. (Sigh 2.)
The second study is more sociocultural, perhaps of interest to rhetoricians as well as MI researchers. MI counselors explore ambivalence about change with their clients, eliciting, reflecting, and reformulating what clients see as barriers to change. There is a specific code for Ambivalence in the MY-SCOPE instrument, and a number of recommended sequences for the management of ambivalence (e.g., follow ambivalence with a nonargumentative reflection, reflect discrepancies between goals/values and ambivalence). Ambivalence, however, might be the most difficult kind of discourse for MI counselors to manage. In training, they are taught not to brush aside ambivalence prematurely by turning too quickly to the linguistic and behavioral goals of the session (eliciting Change Talk and Commitment Language and making a client-centered plan for healthy eating and exercise), but they are also taught not to dwell upon ambivalence because reflecting ambivalence can generate Counter Change Talk [CCT] and Counter Commitment Language [CML] and no viable plan for adhering to weight loss recommendations. A content-oriented study of ambivalence in MI discourse, however, might provide insight into the specific barriers African-American teens and caregivers face in terms of changing the family’s management of food and exercise as well as differences in attitude and motivation between teens and adults. So far, a number of interesting themes have emerged from my recursive readings of the transcripts, including significant differences, even conflict, in the assignment of responsibility for food management and exercise as well as different expectations of accountability across teens and caregivers.
Keywords to describe work
Medical communication, medical ethics, discourse analysis, end-of-life, clinical trials, cancer, obesity, health disparities
Work in relation to symposium keywords
The words connections and dissemination relate most to my work.
With the exception of the IRB project (a labor of love), all of my work over the past decade has been as a collaborating member of NIH-funded grant teams, which forces me to articulate not only the value but also the operationalization of concepts and methods from linguistics and rhetoric within projects developed primarily within a medical model. To be of value in terms of dissemination requires publication in health journals as well as linguistics and rhetoric journals, a challenging writing task, to say the least, one complicated by the complexities of co-authorship.
Defining What We Do: making connections, in my experience, requires minimization, as in the definition of medical rhetoric above, in terms of recognized problems in medicine. Maintaining connections requires ongoing contributions to study design, data collection and analysis, and publication.
Relations among Fields: I’ve found that disciplinarity is considerably easier to achieve than interdisciplinarity, especially in terms of theoretical and methodological frameworks. If the ideal of interdisciplinarity, in Klein’s (1990) idealistic terms is a true (gloss: co-equal, somehow) merger of multiple disciplines (e.g., women’s studies, neuroscience), then I don’t achieve it or aspire to it in terms of the relationships among medicine, linguistics, and rhetoric. Put bluntly, when I’m on medical teams, I work within a medical model. When I’m writing linguistic discourse analyses, I work within a social science model. When I’m writing essays for composition/rhetoric journals, I work within a humanities model as best I can.
Research Challenges: writing articles for health journals has been difficult for me. In my projects discussed here, I’ve managed only one health journal article per project (a discourse analysis EOL study in Qualitative Health Research, a quantitative clinical trials study in Health Expectations, and, I hope, my current content-analysis MI study of ambivalence which I expect to submit a journal like Patient Education and Counseling). Luckily, my PIs get something of a kick out of publishing in linguistics journals, so I most often default to publishing in Communication&Medicine, currently my favorite venue. To be honest, writing linguistic discourse analysis articles is the easiest genre for me, one with a well-defined audience and a well-developed research literature that is recognized in medicine to a certain extent. I have published medical discourse analysis articles in composition/rhetoric journals (CCC, believe it or not, Written Communication, and JBTC), but I’m never sure that these articles reach an interdisciplinary audience, and this area and these journals are not well known to my teams: as one of my co-authors always asks when I suggest journals, “is it indexed in PubMed?”). For a long time I used to deliberately alternate between publishing in linguistics and in composition/rhetoric. I haven’t recently, but perhaps I should take up that pattern again. Is one goal of this symposium the establishment of the Journal of Medical Rhetoric? If so, what are its ambitions for an (inter)disciplinary audience?