Negotiating roles and making claims as a patient in the psychiatric consultation: a frame analysis

My thesis develops an understanding of patient role and identity performances in psychiatric consultations. Recent increased attention to shared-decision making and patient-centred care in psychiatry is in large part influenced by changing ideas about the doctor-patient relationship, challenging power discrepancies and reconsidering notions of ‘expert’ and ‘lay’ contributions. Previous work surrounding this field has mostly focused on psychiatrists’ talk, asking ‘how can psychiatrists improve shared-decision making skills?’ While important, I argue that this focus is at odds with the principles behind shared-decision making by failing to consider patients’ own performances in their talk with psychiatrists. I re-analyse recorded interactions in 92 psychiatric consultations with patients prescribed anti-psychotic medication. Drawing on the work of Goffman, I identify frames which are negotiated throughout the consultations and explore how these shape the roles and ‘footing’ adopted by patients. I demonstrate techniques used by patients to maintain a balance between making credible and influential claims and maintaining an acceptable patient role. Finally I consider the impact of family members attending these consultations. I explore how they collaborate and compete with patients in making claims, and the impact of their presence on patients’ own performances. The thesis makes the case for considering patients as active participants in constructing the interaction in psychiatric consultations and the need to understand the work being undertaken by patients to construct their place in the immediate discourse and in their wider social connections. It moves towards developing this understanding by providing a detailed review of various techniques seen in this data set. In using a frame analysis it also provides a relatively new perspective on considering discourse and demonstrates how this kind of approach can be useful when analysing institutional talk.