An analysis of data extracts in a healthcare encounter through the lens of cross-cultural pragmatics and politeness theory
As the contentious history of applied linguistics suggests, a necessary component of any framework is that it applies across cultures and illuminates any universal principles that might exist. With this in mind, the source will be analysed through the lens of cross-cultural pragmatics and politeness theory.
Initially, attention will focus on the latter: identifying the different strategies used to express politeness in a culture, considering why they are used at all, and assessing how far they illuminate the interaction. Initial contextualisation will draw on Erving Goffman’s (1922-1982) theories of social interactions and self-presentation, Penelope Brown and Stephen Levinson's expansion of that idea, and then Helen Spencer-Oatey’s ‘rapport management’ model. In addition to having underlying rules for how to structure conversations, such as turn-taking, backchanneling and adjacency pairs (structure), rules govern the social expectations of linguistic behaviour (politeness). However, analysis of the source suggests that these frameworks are not mutually exclusive: both are essential to interpersonal pragmatics and face-to-face (situated) interactions (Culpeper, Haugh, 2014, p.198).
Politeness theory examines how people balance the need to be positively thought of against the desire not to be overly imposed upon. Goffman asserts that we are all conscious to some extent of how we are perceived by others, and that we generally try to present a positive image (2003, p.7). This is ‘face’. If we lose face, our image is damaged. ‘Face’ includes ‘Notions such as reputation, prestige and self-esteem’ (Culpeper, Haugh, 2014, p.205). Speech acts, such as greetings, apologies and requests, help to manage interpersonal relationships and get things done in the world. ‘Interactional goals’, which can be ‘relational’ and/or ‘transactional/task focused’, are fulfilled through politeness (Spencer-Oatey, 2008, p.17): for example, compliments are aimed at creating a sense of ‘solidarity’ (relational), and might bank future reciprocations (transactional). Utterances are often crafted to reduce the risk of damaging the face of others. This is a ‘face-need’ (Spencer-Oatey, 2008, p.17). Maintaining our own image while protecting another person’s is often called ‘face management’. But Spencer-Oatey offers the term ‘rapport management’, because the latter includes ‘the management of sociality rights and interactional goals’, and emphasises the extension of face-saving needs in ourselves to an awareness of the face-needs of others (2008, p.12). She also emphasises the importance of personal ‘values’ and how they apply to our understanding of face (Spencer-Oatey, 2005, p.336). However, there is a tension between the need to promote solidarity and the desire to mitigate our obligations to others and maintain our autonomy (Spencer-Oatey, 2008, p.13). Brown and Levinson propose two types of face: positive and negative (Spencer-Oatey, 2008, p.12). The former deals with the need to feel liked and appreciated: ‘positive politeness’, and includes speech acts that are designed to show solidarity and understanding to a participant. Negative face on the other hand concerns the need not to be imposed upon.
Almost all speech acts contain a potential threat to face, so people generally strive to avoid ‘face threatening acts’ (FTA). This is why simply saying ‘please’ and ‘thank you’ is often critical, at least in a British English speaking context. Every speech act that is a request is also an imposition on the addressee. Politeness then ‘concerns the management of harmony-disharmony amongst people’ (Culpeper, Haugh, 2014, p.219). Negative politeness strategies include the use of modal verbs, such as ‘could’, when asking for personal information (Culpeper, Demmen, 2011, p.51): for example “Could you tell me how much you drink?”. This acknowledges the imposition and appreciates the addressee’s negative face needs. Notably, the Doctor (D) does not use this strategy at all, for example: “...how much do you drink?” (22). D’s requests are not imperatives, so there is some attention paid to the Patient’s (P) face-needs, but the former’s linguistic choices register Spencer-Oatey’s ‘rapport neglect orientation’: a relative lack of concern in the quality of relations in the exchange (2008, p.32). The absence of intonation data in the transcript attenuates the safety of this interpretation, but the pattern of conversation may register an asymmetric power balance.
The amount of negative-face-setting required to achieve the goal of a particular speech act is relative to the ‘distance’: ‘social distance, solidarity, closeness, familiarity, relational intimacy’ (Spencer-Oatey, 2008, p.35). Brown and Levinson include the ‘relative power of the speaker over the hearer’ (Culpeper and Haugh, 2014, p.209). Spencer-Oatey notes that definitions of ‘power’ vary widely (1996). Here ‘relative power’ relates to the institutional context. Brown and Levinson categorise five ‘pragmatic super-strategies’ that relate to FTAs (Culpeper, Haugh, 2014, pp.210-211):
Bald, ‘on the record’: “Stop drinking alcohol.”
Positive politeness: “Do you think that you could stop drinking alcohol?”
Negative politeness: “I know it’s hard, but could you stop drinking alcohol”
‘Off the record’: “Wouldn’t life be better without alcohol?”
Not doing the FTA.
Requests are not often ‘on the record’: for example, the ‘direct’ “Stop drinking” makes no face-saving attempt at all (although intonation might attenuate its force). ‘Off the record’ requests offer the participants a way to save face: for example, the ‘indirect’, “Wouldn’t life be better without alcohol?” Often, linguistic choices seek a middle ground that are ‘on the record’ but contain mitigations: “I know it’s hard, but could you stop drinking alcohol?” This acknowledges the imposition and maintains solidarity. Unfortunately, the source does not transcribe this part of the exchange. Yet D’s questioning strategy is revealing.
Questions form part of a cooperatively managed conversation. In particular contexts, participants might feel normatively compelled to answer: according to John Corbett ‘when individuals communicate, they bring to their interpersonal interactions sets of assumptions and beliefs about normative practices, including communicative practices, that result from their socialization into a set of broad and specific ‘cultures’’ (2011, p.308). With ‘normative accountability’ (Seedhouse, 2013) cross-cultural pragmatics begins to blend with politeness theory. It involves the notion that questions place an addressee under an obligation to respond, which makes them a powerful tool in interactions. Their effects extend beyond the pragmatic necessity of the doctor helping the patient. They can also illuminate the relative status and power of the participants. The source suggests that the ‘distance’ between the participants is not great in terms of education and rank. Conversely, they seem far apart in terms of familiarity and relational intimacy, so FTA mitigation might be expected to manage face-needs when asking personal questions. However, in the cultural context of a medical setting, participants are influenced by ‘institutional goals’ (Harvey, Koteyko, 2013, p.15). D’s monopolisation of the questions implies that he is the more powerful participant in the exchange, which registers notions of ‘expert’ and ‘legitimate’ power (Spencer-Oatey, 2008, p.35). The asymmetry is suggestive of relative ‘sociality rights’, whereby the participants assume that D, the ‘expert’ with ‘legitimate power’ in the healthcare context, has the right to control the interaction. Evidence suggests that sociality rights are important in British English speaking contexts (Spencer-Oatey, Jiang, 2003).
Questions assert power through normative pressure and control the direction of the discourse. The amount of power in a question depends on the form being used. The two basic structures are: polar yes/no, and non-polar wh-. The former tend to have a preferred response that is implicit in their use. This is called polarity. Confirming the question with a ‘yes’ is a typically preferred response. If a recipient responds with a negative then an explanation is often needed to explain the dispreferred answer. D asks “Does it burn over here?” (4). The polar response is left explicitly optional, but D ignored P’s request for clarification (2, 3); in this sense, Line 4 is a dispreferred response. D seems to interpret P’s utterance as a ‘tag question’ (2,3); although a tag question is generally polar, with the preferred response included in the utterance. Normative pressure on P and time pressure on D ensures that the latter accepts P’s query as an answer, while an asymmetric power balance allows D to ignore the adjacency pair. 93 percent of D’s utterances are questions: of these 38 percent are polar; 62 percent are wh-. In contrast, only one of P’s utterances is a question (which at 7 percent is the exact inverse of D’s) and it is unanswered. The exchange shows a pattern of conversational dominance in favour of D, because he controls the adjacency pairs by asking the questions. This control is immediately apparent: the context notes that D opens with the ‘good morning’ adjacency pair sequence, but does not wait for a preferred response and instead asks a question. An explicit question and answer session is an archetype of the adjacency pair. Wh- questions are open-ended and generally give an addressee more freedom to respond. However, P is often not given time to frame a comprehensive response: the embedding of an underlying power structure is further suggested by D’s interruptions of P’s speaking turn (4, 13, 17, 27).
‘Interruptions’ differ from ‘overlaps’. The latter are miscues of the turn-taking sequence and typically occur near the ‘turn relevance place’ (TRP). According to Emanuel Schegloff, interruptions happen when the speaker ‘is not near possible completion’ (Bilmes, 1997, p.508). Communication strategies are influenced by the type of communication that is taking place. Turn-taking and topic control, for instance, is established by: ‘the degree to which an individual can exploit turn-taking norms in order to control an interaction’ (Spencer-Oatey, 2008, p.38). Research suggests that interruptions occur more often in exchanges where power is asymmetric (Morand, 2000, pp.240-242).
D’s “Hm”s in line 8 must be analysed separately, because they might signal a cognitive event, such as a change in the addressee’s knowledge state (Heritage, 2005, p.196), and therefore might not be interruptive. Short interjections are called ‘backchannels’ or ‘minimal responses’. Senko Maynard identifies six categories to describe their function: continuer, understanding, agreement, support and empathy, emotive, and minor additions. She notes that ‘continuer’ seems to be primary in English (1997). Backchanneling signals that the addressee is paying attention to the speaker. D might use “Hm”s to maintain the conversation cooperatively: indicating that meaning is understood; that repair is unnecessary at that time. Backchanneling then is a positive feedback loop, critical to the co-construction of a conversation. However, backchanneling is also multifunctional and can express disinterest (West, Zimmerman, 1975), or it might encourage the speaker to get to the point. The absence of intonation in the transcript impedes an analysis of D’s intention. Assumptions have to be made. The ‘compound backchannel’ (Cutrone, 2014), [ Hm hm [ Hm hm [ Hm hm (8), seems superfluous, which might attenuate its function as positive feedback. Contextual factors support this interpretation: D likely feels time pressure, because the institutional goals include an objective of 10 minutes per consultation, and the context implies his lagging schedule.
However, cultural features inform how face-saving strategies are used in discourse. Research suggests that some slavic cultures ‘appreciate pragmatic clarity [and associate] directness with honesty’ (see Ogiermann (2009) for a range of references). This registers the qualitative questionnaire: P, of Polish origin, considers that the interaction was ‘pleasant’. A possible interpretation is that D’s questioning technique and interruptions were not perceived by P as FTAs at all. P displays little reticence when discussing her drinking habits (18-33). Her overall ‘contextual judgement’ might consider D’s directness necessary in the medical setting, which supports the idea that face is ‘discursively constructed within situated interactions’ (Culpeper, Haugh, 2014, p.201,217). Yet the participants’ perceptions of the interaction diverge. Politeness theory alone is insufficient. It is necessary to delve deeper into cross-cultural pragmatics.
Tannen defines culture as:
a fuzzy set of attitudes, beliefs, behavioural conventions, and basic assumptions and values that are shared by a group of people, and that influence each member’s behaviour and each member’s interpretations of the ‘‘meaning’’ of other people’s behaviour. (2005, p.338)
According to Corbett, culture varies in the following ways: collectivism versus individualism; degrees of power distance; gender roles; the attainment of social status; systems of politeness (The Open University, 2016). Similarities with the notion of ‘distance’ in politeness theory are notable and support the view that the frameworks complement each other. Corbett also notes that ‘Cultures are discursively constructed and always in process’ (Corbett, 2011, p.307). With this in mind, it is important to note that ‘cross-cultural’ is distinct from ‘intercultural’ in that the former generally compares communication in one culture with another. This analysis does not view the source interaction as cross-cultural, because all communication is interpersonal (Corbett, 2011, p.308), and apart from the confusion about ‘sour stomach’, which arguably would need clarifying for native language speakers, and P’s curtailed contractions: ‘it[’s]’ (6), the participants exhibit relatively equal communicative competence in terms of ‘appropriateness’ (Hymes, 1971). Instead, the framework will illuminate normative communication practices that result from socialisation into specific cultures.
In our integrated world linguistic behaviours are organic and driven by context, so there is a definite need to avoid generalisations (Mills, 2009; Spencer-Oatey, 2008). However, a preference for directness is evident in slavic languages. Therefore it likely incurs less face-threatening potential in some contexts. Conflating indirectness with politeness is often indicative of an Anglo-Saxon perspective and does not necessarily explain the communication problems in the source. According to Tannen, ‘high involvement’ cultures feature frequent overlap, faster speaking rates and infrequent pauses between turns (Tannen, 1994, p.36, 53-79). This creates a sense of solidarity and might attenuate Schegloff’s general definition of ‘interruption’. Instances in the source could be interpreted as ‘cooperative overlap’: (3-4, 10-11, 12-13, 16-17, 26-27) (Tannen, 1994, p.53). Tannen argues that the distinction between overlap and interruption is not easily pinned down (1983; 1994; 2005); rather the relationship between the speakers and the context of the conversation must be included in the assessment. Interruptive activity is interpretive (Tannen, 1994, p.53). D’s interruptions might be considered cooperative, because he has not changed the topic of conversation (Heritage, 2009, p.196). Therefore, P considers the interaction ‘pleasant’. Tannen does not agree that culture, ‘in all its meanings and with all its affiliated concepts, is always situational, and always depends on the context in which concrete interactions occur’, because culture must be applied to individuals and ‘variability is inevitable’ (2005, p.341). Therefore it seems unsafe to analyse the extract purely in terms of ethnic cultural norms.
Within the institutional context, doctors and patients in a GP surgery develop a ‘community of practice’ (Wenger, 1998): patients wait to be called, enter a private room with a doctor, exchange greetings, describe symptoms, appreciate notions of confidentiality, and so on. This ‘regularity’ creates the culture. P’s hesitation before entering the consultation room might indicate unfamiliarity, and D disrupts the exchange of greetings. Tannen points out that ‘in specific encounters, people can uphold, manipulate or drop cultural practices, according to their goals, preferences and so on’ (2005, p.342). D is influenced by time pressure. With limited resources, politeness is a utilitarian calculation, and interactional goals can diverge. Harvey and Koteyko identify three purposes of doctor–patient communication: ‘building a good inter-personal relationship, exchanging information and making decisions about treatment’ (2013, p.8). These might be considered ‘interactional goals’. D does not appear to deviate too much from what Paul ten Have calls the ‘ideal sequence’: opening, complaint, examination, test, diagnosis, treatment or advice, closing (Harvey, Koteyko, 2013, p.8). Although, the absence of an accurate opening and closing transcription is keenly felt. But D’s interactional goals are influenced by institutional goals. In terms of rapport neglect orientation ‘building a good inter-personal relationship’ is abridged, and ‘exchanging information’ attenuated: P’s disclosure exemplifies the latter, “I’ve cheated and I’ve been drinking which I shouldn’t have done” (18-19). In a cooperatively-managed conversation we might expect D to follow this thread, but he responds with a polar question. D directs the interaction to make a rapid decision about treatment. Institutional goals and the perception of sociality rights create a misalignment in the participants’ interactional goals and communication is impeded. Tannen emphasises the notion of values in interactions (2005; 2007). They are often asserted as axioms in cultures - but, as anyone who has tried to teach British Values will attest, they are myriad, subjective and often competing. In an institutional sense, we might assume that D’s values correlate with the manner in which he constructed his speech acts: they probably included his obligation to see many more patients that day. In this sense, Spencer-Oatey’s ‘sociopragmatic interactional principles’ (SIPs) are a useful extension of Geoffrey Leech’s (1936-2014) ‘politeness maxims’ (2014), because the former are more firmly aligned with notions of values and beliefs, and are therefore conducive to cross-cultural pragmatic interpretations (Spencer-Oatey, Jiang, 2003).
D seems to acknowledge that the manner with which he dealt with P was not ideal, but thinks that the consultation was effective; conversely, P seems to have been satisfied with the manner of the consultation, but is not convinced that it was effective. Both frameworks illuminate the disagreement: rapport neglect management did not threaten P’s face-needs (face SIP); rather it impeded D’s attention to the first two purposes of doctor-patient communication. The cultural pressure was not ethnic, it was institutional: time pressure on D and normative pressure on P (rights and obligations SIP) disrupted the interaction. This misalignment supports Spencer-Oatey’s criticism of ‘agreement–disagreement’ (Leech 1983; Spencer-Oatey, Jiang, 2003, p.1635). There is no optimum point of agreement here, because the perception of the less powerful participant (P) does not support a universal notion of politeness norms. Spencer-Oatey’s preference for SIPs suggests that different points on a rapport management scale may be preferred by individuals in different contexts (2003, p.1635): D is influenced by institutional goals and prioritises a concern for task accomplishment (task SIP).
The safety of this conclusion is attenuated by the absence of key data: particularly, intonation, paralanguage and a transcription of the opening and closing. The former illuminate the intentions of speech acts; the latter are key moments in which the conduct of adjacency pairs, for instance, offer rich detail about the interaction. Notions of universal SIPs establish a useful framework, but cultural and situational variations modulate how they are upheld.
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