Invoking and inscribing mental illness: A discursive analysis of diagnostic terminology in inpatient treatment planning meetings

Abstract

Critical feminist analyses document the power of psychiatric labeling, but less attention has been given to the social processes involved in giving and acquiring labels. Utilizing a discursive method based on conversation analysis, this study examined conversations among staff and with patients in treatment team meetings on an adult, involuntary inpatient unit of a state psychiatric hospital in the US, with a focus on how problem formulation and role negotiations are achieved and how diagnostic terminology figures into that work. In this brief report, extracts from treatment planning meetings with two female patients are presented to illustrate how diagnostic terminology steers conversations away from addressing the context of these women’s lives.

Keywords

diagnosis discursive methods conversation analysis labeling treatment planning meetings

Feminist critiques of the Diagnostic and Statistical Manual of Mental Disorders (DSM) have looked at how the application of its diagnostic vocabulary re-traumatizes women with labels that fail to grasp the complexities of their experiences and that attribute problems to them as individuals (Caplan, 1995; Caplan and Cosgrove, 2004). This language pulls for clinicians to look ‘primarily at the individual and the symptoms with which [the patient] presents, while ignoring the contributing factors’ (Bullock, 2004; Gerrard, 2004; Lazaroff, 2006: 9). Women may not get the help they might most benefit from and problematic social structures go unexamined. As Lazaroff (2006: 11) states, ‘This kind of labeling, which blames the individual for their distress, completely overlooks the issues of racism, sexism, ageism, heterosexism, etc.’ She continues, ‘ … the narrowness of focus on the individual can easily lead practitioners to diagnose mental disorder when there is a clash between a woman and her environment, and to direct treatment to the individual, when in fact what may need to be addressed is the dysfunction of the environment in which the woman finds herself’ (p. 12).

When psychiatry claims to be value-free but has historically conflated normalcy with stereotypical male development, then aspects of gender expression, like interdependence and emotionality in women, are at risk of being pathologized. Diagnostic discourses that present ‘historically-contingent, socially-situated moralities, disguised as medico-scientific verities’ (Marecek, 1993: 115) can serve to enforce conformity to dominant definitions of femininity. For example, as Cosgrove and Caplan (2004: 223) discuss, PMDD conveys to women that their ‘negative’ emotions are unfeminine and shameful: ‘Women are increasingly encouraged to overlook the context in which their emotions are manifested …’.

Research has documented the enormous costs to women of labeling, but less critical attention has been given to the social processes involved in giving and acquiring labels. A greater attention to bias in psychiatric diagnosis and its negative impacts than to how people enact diagnostic practices has characterized labeling theory research as well. Drawing upon the work of sociologists Goffman (1961) and Scheff (1975), labeling theory maintains that, as tools of social control and through processes of stigmatization, diagnoses serve to confirm people’s identities as patients. Diagnosed individuals are expected to adopt psychiatric views of themselves and comply with socially prescribed illness behavior: ‘The offender, through the agency of labeling, is launched on a career of “chronic mental illness”’ (Link et al., 1989; Scheff, 1975: 10).

From a discursive perspective, labeling theory has been criticized for ‘largely overlook[ing] practices of talk, action, and social interaction. Consequently, even in research arguing most fervently that labeling profoundly affects the lives of individuals, the acts of giving and acquiring labels appear as obscure, disembodied events’ (Gill and Maynard, 1995: 11; Raybeck, 1988). Although labeling theory research and critical feminist analyses have attended to the ways in which diagnostic language permeates clinical, scientific, and academic discourse about mental illness and to the ill effects of this discourse, less research has been done on how diagnostic terminology enters into conversations among clinicians and between clinicians and patients and to what local ends.

Drawing on a mix of conversation analytic and discursive analytic methods, this study examines conversations between clinical staff members and patients during treatment team meetings on a unit for involuntarily committed adults at a state psychiatric hospital in the US. The research focuses on the work that symptom terminology does in staff–patient treatment planning interactions. Attending to the local consequences of diagnostic terminology, the research addresses the following questions: How does this terminology figure into problem formulation and role negotiations? How does diagnostic terminology inscribe some individuals as experts on mental illness and others as patients? How does this terminology individualize patients’ distress and to what ends?

Interactional aspects of diagnosis have been a topic of discursive research. As Gale (2000: 2) states of conversation analysis, ‘Utterances are viewed as practical activities that both create and maintain our social selves … our social institutions are constructed through the managed practices of the participants themselves’. One of the first studies of psychotherapy that was inspired by conversation analysis was aimed at problematizing entrenched beliefs about the ‘essentially factual nature of diagnosis’ (Davis, 1986: 45). Of further significance to the present study is that Davis took a critical stance toward the analyzed interactions. She situated her research within feminist critiques that maintain that much of therapeutic discourse ‘individualizes women’s problems. The client’s difficulties are completely taken out of her social context and placed squarely in the realm of personal shortcomings’ (p. 46). Davis notes too that ‘feminist analyses have provided convincing arguments that individualization exists as a wide-scale form of social control … What is missing, however, is an investigation into how individualization occurs within the actual interaction between therapist and client’ (p. 46). Examining the transcript of an initial psychotherapy interview, Davis looked at how the therapist used formulations (that is, utterances that offer recipients an understanding of what has been said and/or done) as the main conversational device by which to transform his client’s account of her difficulties with her situation as housewife and mother into her problem with not expressing her feelings openly and honestly. The therapist built a case that the real problem, the problem worthy of further attention in therapy, was the client’s style of talking – her ‘tight grip on her emotions – her façade’ (p. 59).

Subsequent to Davis’ landmark study, conversation analyses of psychotherapy and other interactions in mental health contexts have continued to look at the role of formulations and other interactional devices in diagnostic work (Bergmann, 1992; Peräkylä et al., 2008; Gill and Maynard, 1995). Madill et al., (2001), for example, shed light on the unsuccessful outcome of an eight-session psychodynamic-interpersonal therapy by attending to how the client and therapist pursued competing attributional projects. As in Davis’s (1986) study, they found that the therapist attempted to define the problem in terms of the client’s character, while the client persisted in attributing the problem to her partner’s behavior. Antaki et al., (2005: 633), in their analysis of therapy with patients reporting ‘psychotic’ phenomena, found that formulations were a resource by which practitioners could pull out ‘the elements of the situation which imply institutionally provided for, therapy-implicative, diagnosis’. The local advantage of formulations over questions is that their format ‘masks the non-neutrality of the therapist’s description’ (p. 641).

A major theme of these studies is that psychotherapy and psychiatric consultations are sites ‘for the negotiation of versions’ (Antaki et al., 2005). As Madill et al. (2001: 415) put it, ‘Problem identification is not, however, a matter of straightforward and objective diagnosis’. A second major theme is that clinicians recast clients’ experiences and accounts in ways that promote institutional objectives. The current study takes up these themes in the context of treatment planning and review with patients in an involuntary psychiatric hospital.

Discursive approaches, including conversation analysis, provide useful tools for examining the reproduction of power at the level of interactional detail and in line with the participants’ own orientations to situations, making them useful for feminist research. As Kitzinger (2000: 168) says of conversation analysis, ‘CA … does commit us to a broadly ethnomethodological view one in which people are understood not simply as victims of an all-powerful social order but also as agents actively engaged in methodical and sanctioned procedures for producing and resisting, colluding with or transgressing, the taken-for-granted social world’.

Method

This research was conducted in a state mental hospital in the US with a population of about 500 adult patients. Data were collected on one of two locked admission units, each with 40 patients. These patients had been committed by a court hearing for not more than 90 days, following the expiration of involuntary treatment orders at a community hospital. They had received a range of serious and chronic mental illness diagnoses.

After admission and the initial evaluation process, every patient attends a Comprehensive Initial Treatment Plan session and subsequently meets with staff every 28 days until discharge to discuss the treatment plan and progress toward goals. During these meetings, the clinical staff members also review patient requests for home visits and for ‘ground cards.’ The latter allow patients to have unsupervised leave from the unit to walk the hospital grounds. Granting of these requests is based on police clearance, improved functioning, and progress toward treatment goals.

The data here are drawn from a corpus of two audio-recorded treatment planning meetings, each of which lasted 2.5 hours and involved 7 clinical staff members (psychologist, psychiatrist, clinical nurse specialist, social worker, recreational therapist, and two community liaisons) talking with 6 patients per meeting for about 15 minutes each, with intermittent discussions about each patient among staff members. All staff members and 11 of the 12 patients were informed that the study explored the role of diagnostic talk in patient–staff interactions; one of the patients could not be located. All staff members and 10 of the patients gave written consent for the meetings to be recorded. Portions of the meetings pertaining to the patients who did not give consent were not recorded, nor was a portion of the meeting during which one patient unexpectedly brought in family members. The study was approved by both the affiliated university Institutional Review Board and the hospital’s Institutional Review Board.

The audiotaped meetings were transcribed guided by the system standard to most conversation analyses (Atkinson and Heritage, 1984). Following transcription, I began the analysis by identifying all diagnostic terms, including Axis I or II diagnoses and terms used in the DSM to indicate diagnostic criteria (emotional and behavioral states) and associated symptoms. After identifying diagnostic terms, I analyzed the functional significance of the terms for problem formulation and role negotiations. I attended to lexical choice, sequence of utterances, and turn design, which are dimensions of conversation that Drew and Heritage (1992) propose as relevant to institutional talk.

In this brief report I present extracts from the treatment planning meetings with two female patients to whom I give the pseudonyms Katie and Sheri. Katie was a 36-year-old, single, Caucasian woman diagnosed with Chronic Paranoid Schizophrenia. Sheri was a 53-year-old, married, Caucasian woman, diagnosed with Bipolar Disorder, Mixed, and Personality Disorder NOS with Dependent Traits. For a fuller treatment of the research method and findings, see Goicoechea (2006).

Analysis

The first extract was drawn from early in Katie’s meeting, just after she has inquired into and attempted to negotiate for a ground card, a request that she initiated and support for which she indexes (in line 1) another doctor’s positive assessment. The psychologist’s use of the lexical item ‘hyperverbal’ puts into play the psychiatric vocabulary of symptoms to provide Katie with feedback about her functioning on the unit.

Extract 1 [Katie = K; Psychologist = Psy; Recreational therapists = Rec1, Rec2]

01 K: well, I talked to Dr. (( )) yesterday and he

02 said I was doing good.

03 Psy: Yeah, you are doing good. You are doing

04 better uh maybe a little less hyperverbal

05 but I think you have those times

06 when you get hyperverbal. Am I right?

07 Rec1: You know what he’s saying? When you

08 talk, talk, talk, talk, talk.

09 Rec2: Like Sunday at ceramics, you were quite=

10 Psy: = was she talk, talk, talking

11 Rec2: Talk, talk, talkin a:::nd smokin

12 K: It wasn’t- oh, yeah(.) I was.

13 Psy: Okay. Okay. But I think at times you’re

14 doing better.

After initially agreeing in line 3 with Katie’s formulation of another doctor’s assessment, the psychologist proposes a modified assessment, a downgrade. Drawing on a psychiatric vocabulary, the psychologist embeds the symptom term ‘hyperverbal’ within a litotes (‘a little less hyperverbal’ in lines 4–5), a rhetorical device that describes the matter being addressed through the negation of its opposite. As Bergmann (1992) found of psychiatrists’ deployment of litotes in psychiatric intake interviews, this litotes, along with the preface ‘I think’ in lines 5–6, displays caution on the part of the psychologist. The psychologist, though, immediately reverses the litotes – ‘you have those times when you when you get hyperverbal’ (lines 5–6) – and follows up with the question, ‘Am I right?’, a question that normatively occasions agreement, particularly in the context of asymmetrical professional relationships. This confirmation-type question does not invite elaboration and makes it unlikely that Katie can disagree with his assessment. The psychologist’s initial displays of caution serve to avoid straightforwardly disagreeing with the previous doctor’s assessment and to secure Katie’s agreement with his own assessment, rather than to display tentativeness about the accuracy of his judgment.

In line 7 at the TPR (transition relevance place) occasioned by the psychologist’s closed question, the recreational therapist takes the floor. This serves to rescue the patient from having to agree or disagree with the psychologist’s assessment. The recreational therapist makes explicit that she will provide a formulation for Katie of the psychologist’s utterance. Her formulation, built on lexical substitution, ‘talk talk talk talk talk’ serves to translate diagnostic terminology into lay terms. This translation ostensibly serves to make the psychologist’s assessment intelligible to Katie, but more subtly also serves to fortify staff claims to medical knowledge and authority and to position patients as lacking and in need of this knowledge. Further assisting with clarification, another recreational therapist offers an example of when and where she noticed this behavior, which then also serves as an evidential formulation, a device found to balance diagnostic authority with accountability to patients (Peräkylä, 1998). As a team, the two recreational therapists constructed Katie’s ‘hyperverbality’ as objective fact.

Katie begins to disagree, but in a self-initiated repair, she produces instead a tentative uptake. The psychologist appears to orient to her agreement with the recreational therapists’ characterization of her behavior on Sunday as an uptake of his more general assessment, that she gets hyperverbal, for he moves toward closing this part of the meeting and on to the next action. But first in lines 13–14, the psychologist shrouds the bad news with a positive assessment, a strategy found often in clinical settings (Maynard, 2003), making it more agreeable to Katie.

Analyzing this extract within the larger interaction sequence of the meeting shows how in the context of offering to Katie an assessment to support denial of a ground card, the staff members recast as ‘hyperverbal’ what they have described prior to her arrival at the meeting as her talking a lot about her boyfriend and her anxiety about their recent breakup. The following extract was drawn from this earlier part of the meeting, just after the staff has read Katie’s written request for the ground card.

Extract 2 [Katie = K; Psychologist = Psy; Recreational therapist = Rec2; Clinical Nurse = CNS]

01 Psy:Katie yeah I’d like to see a little more

02stability although she’s doin’ better but ( )

03wanna wait=

04 CNS:=Yesterday she was very anxious. She kept

05on asking about her boyfriend and this thing

06wanting ( ) and their break[ups

07 Rec2:]oh yeah=

08 CNS:=and it star[ted

09 Rec2:]he broke up with her over the weekend

10 CNS:and she asked me thirty different questions.

11one more question one more question

12about cigarettes and when she’s gonna

13get her ground card. And she said (Rec2) told

14uh her this isn’t the best place to form relationships in the

15world=

16 Rec2:=Yes

17 CNS:And I said yeah listen to what (Rec2)’s tellin ya

The psychologist’s statement in lines 1–3 that he’d like to see more stability in Katie draws indirect agreement from the clinical nurse and the recreational therapist through their account of earlier events. As a formulation for the patient of the upshot of this earlier conversation, the term hyperverbal draws out and preserves only one feature of the nurse’s and therapist’s account, the excessive amount of talking Katie did. It ignores other features, such as the context of her behavior, her feeling state as they gauged it, and their disapproval about forming romantic relationships in the hospital (lines 14–17). The term hyperverbal avoids making the assessment hearable as subjective or personal opinion. Moreover, in referencing the events of Sunday, the staff signal to Katie, if only indirectly, that they judge that reserve about romantic interests is a criterion for progress.

The following extracts from the team meeting with Sheri illustrate how the use of the diagnostic term ‘passive dependent’ relocates the problem from the context of Sheri’s relationship with her husband to her own inadequacies. The extract below was drawn from a significantly extended turn of the psychologist in which he responds to Sheri’s request that he clarify a comment he had made about her returning to the hospital. He shares with her his concern that if she is discharged to her home, where problems persist between her and her husband, she will be at risk of ‘decompensating.’ The psychologist and Sheri jointly construct an account of her difficulties in relational and everyday terms:

Extract 3 [Sheri = S; Psychologist = Psy]

01 Psy: I think the difficulty that exists between

02 you and your husband has not ye::t

03 been resolved.

… ((12 lines omitted))

15 He would yell

16 and scream (.) you would get angry and upset

17 with yourself and it wouldn’t be very long

18 before you’re talking about hurting yourself,

19 before you’re back in the hospital.

… ((34 lines omitted))

53 What I think what happens Sheri, and you

54 correct me, but I think you get angry and

55 you never speak up, you never assert

56 yourself=

57 S: =Yeah, I go into a ball and stay there

58 Psy: See that’s what happens. And I think once

59 (S’s husband) yells and screams it’s off his chest.

60 It’s done with. But you:::’re not done with it

61 and you take it in.

With Sheri’s collaborative completion in line 57, the psychologist and Sheri reach alignment about how Sheri retreats from her husband in order to protect herself. Although the psychologist appears to place the burden on Sheri for not being ‘done with it’ when her husband yells and screams, he cites conflict between Sheri and her husband as the source of Sheri’s difficulties. He also introduces a description of Sheri’s husband’s behavior that other staff members subsequently find relevant. The next extract, which is drawn from the staff conversation just after Sheri’s departure from the meeting, shows how initially the staff members orient to this account as a compelling one. The social worker’s and the recreational therapist’s upshot formulations that Sheri’s husband is accountable for her problems (lines 1–2) build upon the psychologist’s description of Sheri’s husband’s behavior. The psychologist implicitly agrees with their modified account, but at line 22, the clinical nurse deploys a symptom term that works to shift the attribution of the problem back to Sheri.

Extract 4 [Psychiatrist = PsyA; Recreational Therapist = Rec2; Social Worker = SW;

Psychologist = Psy; Clinical Nurse = CNS; Community Liaison = CL]

01 SW:He’s the one who’s accountable=

02 Rec2:=and not Sheri.

03 Psy:I’ve told him.

04 PsyA:And but another thing, is (.) people in this

05 hospital are too scared of him because he causes

06 ((everybody talking at once))

07 SW: Well I think we need to tell Dr. (the head of psychiatry)

08 that this man is the reason she keeps coming back=

09 PsyA: =he knows. He told me two days ago he’s

10 gonna come for the hearing and all of the

11 sudden he tells me, ‘You go. You go. You’re the

12 (). I’m not coming.’ He changes=

13 SW: =Sheri comes here and has to do all this work

14 to get stabilized and then go back to that

15 ridiculous situation.

16 Psy: I agree and that’s what I’ve told him and

17 that’s why I I wanted to testify today

18 because that’s the reason she’s=

19 SW: =here.

20 Psy: Exactly. I mean she doesn’t take much

21 responsibility for it really=

22 CNS: =she’s very passive dependent. Um this

23 relationship has been going on for how long

24 Psy: Twenty-seven years

25 CNS: Is it ever going to cha::nge? Probably not and they’ll

26 be together for the next seventeen years ‘til they

27 both die and regardless of what we:: do they’re

28 going to be together.

… ((20 lines omitted; staff discuss treatment options))

48 CL:Can we make him go? We can’t do that. I mean who is the patient here?

The account offered by the psychologist and Sheri challenged the routine medicalization of relational problems in living. In this extract, the staff orient to this rupture in their taken-for-granted discourse, and their talk crescendos as they jointly work to arrive at a formulation that includes Sheri’s husband’s part in her suffering. The social worker leads the discussion, claiming that Sheri’s husband is to blame. The psychiatrist’s additional claim that even staff members are afraid of Sheri’s husband (lines 4–5) serves to support the account that Sheri’s behavior is not symptomatic of illness, but rather an understandable response to her husband. The psychiatrist’s subsequent response (lines 9–12) to the social worker that the head of psychiatry has attempted to avoid testifying about the situation at Sheri’s commitment hearing suggests that the staff’s own fear of the husband is a contributing factor in Sheri’s suffering.

Although the psychiatrist’s utterances make claims about the staff’s own passivity in relation to Sheri’s husband, a man they themselves experience as threatening and controlling, the clinical nurse deploys a psychiatric and moralizing term to describe Sheri – ‘passive dependent.’ As the staff grapple with the connections that the psychologist and Sheri had drawn between her behavior and a husband who yells and screams, this term, occasioned by an abruptly delivered claim regarding Sheri’s responsibility (lines 20–21), shifts them to a discourse that assigns blame to her. This term passive dependent works to prevent staff from having to struggle further toward a formulation that draws a meaningful connection between the individual (Sheri) and the social (her world), and it may even work to prevent them from having to grapple with their own passivity in response to the husband.

In the context of attributional work, deployment of the diagnostic term ‘passive dependent’ serves to discount a contextual understanding of Sheri’s problems. It also works to make claims about the hopelessness and futility of the staff’s treatment efforts. Paradoxically, the nurse’s use of the term is oriented to and reinforces their role as providers of treatment for individuals with mental illness, but simultaneously displays frustration with that role. The community liaison’s rhetorical questions (line 48) explicitly confirm Sheri’s identity as patient and also display frustration with how that ascription limits the staff members’ role.

Conclusion

For clinical staff, diagnostic terms can be resources with which they can authoritatively and expertly justify to patients their treatment decisions and with which they can avoid the task of formulating connections between the individual and the social, including their own culpability in relation to a patient’s struggles. The analyses of extracts from the staff meetings with these two female patients show how aspects of the women’s relationships with men in their lives are formulated in terms of psychiatric symptoms, terms that attribute difficulties to them as individuals. Analyses such as this may assist clinicians in becoming more cognizant of possible interactional functions of diagnostic terms, functions that go unacknowledged when diagnostic language is understood simply as an objective description of illness. We are reminded of Cosgrove and Riddle’s (2004: 129) remark: ‘This way of speaking is enormously costly and oppressive, for it silences groups, individuals, communities; indeed, it silences conversations about the connection between social injustice based on sex and gender and emotional distress’.

This analysis suggests that potentially fruitful areas for further research include how diagnostic terms are used in the context of clinical discussions about and in relation to particular diagnoses and how those contexts are discursively constructed. For example, given that feminists have claimed that PMDD discourse leads women into ‘constant self-surveillance’ (Cosgrove and Caplan, 2004: 223), it would be useful to analyze actual conversations in which this phenomenon is likely to occur. Also, researchers could look at patients’ use of diagnostic terminology and their strategies for uptake of diagnostic terms or resistance. Finally, researchers might examine what interactional work diagnostic terms do in treatment contexts where the recovery model is adopted, a model that while strength and empowerment based, may still from ‘a linguistic point of view … [be] saddled with the baggage of pathological and deficit-based vocabularies’ (Walker, 2006: 777).

Footnotes

Jessie Goicoechea holds an M.A. and a Ph.D. in clinical psychology from Duquesne University, and a B.A. in psychology from the University of Dallas. She is an Assistant Professor of Psychology at Duquesne University and is Director of Duquesne's Psychology Clinic, the primary training facility for the doctoral students. Her interests are in overseeing the community clinic and coordinating doctoral training, including providing individual and group supervision and teaching courses on assessment and child and couples therapy. Dr Goicoechea is also a psychotherapist in private practice.

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