Abstract
Doctor-patient communication is at the heart of healthcare service delivery, and discourse analysis is thus useful for exploring how sociopolitical, historical, and cultural factors affect interactions between patients and medical staff. Discourse and Mental Health explores the discursive practices of individuals in the Argentinian medical setting, focusing on how people with differing sociocultural and linguistic backgrounds adopt discursive strategies to access mental healthcare in a context of profound inequality. The book, which comprises seven chapters, presents the outcome of 5 years’ ethnographic work at a public mental healthcare center in Buenos Aires.
Chapter 1 introduces the three underlying theoretical standpoints of this study: singularity, voice, and emergent discourse, which emphasizes discursive sensitivity in everyday communication. Chapter 2 unfolds the complex context of Argentinian public health, where local norms of professional-patient communication as well as historical and political processes of institutionalization shape the unequal power relationship between patients and psychoanalysts, and the tension between psychoanalysts and psychiatrists. Chapter 3 invites a visit to the discursive landscape of public healthcare. Bonnin has played a role of a traveler in experiencing and analyzing this visible and invisible landscape, describing ‘a double process of privatization of public communication and invisibilization of linguistic diversity in the public space’ (p. 7).
Chapters 4–6 are devoted to the interpretation of interactions between medical staff and patients with diverse backgrounds in admission interviews, elucidating how exclusion happens in consultations, how patients manage to resist potential exclusion, and how patients and psychoanalysts reduce asymmetry and inequality through ‘speaking with the other’s voice’. Chapter 4 is concerned with the contradictory relations between patients’ expectations and psychoanalysts’ actual practices in admission interviews; it argues that this counter-expectation is likely to cause exclusion and communicative failure. Chapter 5 unveils patients’ tactics in answering bureaucratic questions with expanded answers to resist potential exclusion, demonstrating the negotiation process involved in getting access to mental healthcare. Chapter 6 shows how speakers accommodate to the voice and social range of the recipient for the sake of reducing inequality and facilitating communication. For instance, patients index upper-level voices (bureaucratic voice and psychiatric voice), while professionals adopt lower-level voices in accordance with the age, socioeconomic class, ethnicity, and religion of the patient.
Chapter 7 employs three case studies to examine the debate about the National Law of Mental Health, illustrating the features of three modes of contestation: dissent, protest, and resistance, which are all oriented to confront the social reality of profound inequality. However, a conclusion for the whole book is not seen in this final chapter. It is found in the following epilog where Bonnin has provided a summary of this study and appealed to discourse analysts to learn from the people whose discourse they analyze.
Throughout the book, there is a consistent focus on ‘people in events’ (Bolívar, 2010). Bonnin has observed interactions between patients and professionals in admission interviews and has participated in person in interactions with street vendors and patients in the waiting room. It might make a more compelling case if the observation for admission interview was accompanied by a follow-up interview with the patients, in order to minimize researcher’s subjectivity when interpreting data from admission interviews. Nevertheless, the focus on people and interaction has shown a genuine attempt to learn from people in events in complement to analyzing texts in contexts.
On the one hand, the book critically suggests that diversity and inequality are closely intertwined in the Argentinian medical setting. The cultural, linguistic, and socioeconomic diversity of individuals produces and reproduces inequality in access to mental healthcare services. The diverse social trajectories and backgrounds of individuals help better understand the wider contextual conditions. On the other hand, the book reveals that the structure of mental health discourse in Argentina can be a miniature of inequalities and asymmetries in the societal, political, and cultural macrostructures of wider global societies.
Bonnin’s research has both theoretical and methodological implications for discourse analysts. As indicated in this book, it is unrealistic to have a universally default method or theory capable of interpreting all specific data given that new data and new problems emerge from heterogenous cultural contexts. Instead of merely relying on one single theory or methodology, the author has drawn upon conversation analysis, linguistic landscape studies, interactional sociolinguistics, and discourse analysis to understand doctor-patient communication in medical discourse. Furthermore, the book arouses readers’ awareness of the relations between diverse speakers in real interactions and the inequality caused by the wider sociopolitical, historical, and cultural factors. Overall, the book is a valuable asset to sociolinguistics and medical discourse analysis.