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Journal of Pragmatics 105 (2016) 59--73
www.elsevier.com/locate/pragma
Formulations in occupational therapy: Managing talk about
psychiatric outpatients’ emotional states
Elina Weiste
Finnish Centre of Excellence in Research on Intersubjectivity in Interaction, P.O. Box 4, Vuorikatu 3 A,
FI-00014 University of Helsinki, Finland
Available online 30 September 2016
Abstract
Working with clients’ emotional states is important in psychiatric care. The clients’ conditions often involve non-adaptive emotions or
difficulties in emotion regulation. However, the clinicians in mainstream psychiatry also need to focus on other activities, such as solutions
to problems of daily life. How do clinicians balance between emotional alignment with the client and other, more practical tasks? Based on
conversation analysis of 15 video-recorded occupational therapy encounters at a psychiatric outpatient clinic, this article analyses two
types of formulation sequences that the clinicians use for managing talk related to the clients’ emotional states. In the first, the clients
describe their emotional states from a perspective of competence and the clinicians endorse that perspective. In the second, the clients
take a negative stance towards their experiences and the clinicians’ formulations attend to the clients’ troublesome experiences.
Immediately after the formulations, the clinicians redirect the talk, often occurring through the clinicians’ mention of a different topic to the
one currently being discussed by the client. The article contributes to research on institutional interaction and emotions in interaction by
describing how the management of talk on emotions in occupational therapy encounters of psychiatric care combines interactional
features of psychotherapeutic and medical work.
© 2016 Elsevier B.V. All rights reserved.
Keywords: Conversation analysis; Institutional interaction; Psychiatry; Occupational therapy; Formulation; Emotion
1. Introduction
The common factors theory of psychotherapy (e.g., Wampold, 2001) proposes that one action in successful
treatments, across different psychotherapeutic approaches, is that the therapist directs the clients’ attention to emotional
experiences (Lambert and Barley, 2001). Clients’ increasing awareness of emotions and enhancing emotion regulation
have been recognized as critical in promoting therapeutic change (e.g., Greenberg, 2002). In facilitating change, a crucial
task of therapists is attuning themselves to the clients’ emotional states and validating them (Greenberg, 2002; Lambert
and Barley, 2001).
Most of the research on relevance of emotional expressions and empathy in therapeutic process and treatment outcome
arises from the psychotherapeutic context. Mainstream psychiatric settings, particularly those for the treatment of clients
with severe mental illnesses, share some features with psychotherapy, while they also have some distinct goals (e.g.,
Priebe and McCabe, 2006). In psychiatry, the focus is often on medical intervention and practical support and treatment
aims more at stability than change in the client’s cognitive and emotional processes (Priebe and McCabe, 2006). The
counselling sessions in psychiatric outpatient clinics (the focal context in this research) come close to psychotherapeutic
work in their purpose of exploring the thoughts, feelings and behaviours of clients for increasing well-being and achieving
E-mail address: [email protected].
http://dx.doi.org/10.1016/j.pragma.2016.08.007
0378-2166/© 2016 Elsevier B.V. All rights reserved.
60 E. Weiste / Journal of Pragmatics 105 (2016) 59--73
higher levels of functioning. However, the professionals in these clinics are also responsible for evaluating the client’s
overall situation, including medication, functional capacity, financial matters and other support needs. To fulfil these varying
goals, the treatment is provided in multidisciplinary treatment teams. There is not much knowledge on how the
psychotherapy-like tasks are accomplished in the encounters between the clients and the members of such multi-
professional teams (see, however, e.g., McCabe et al., 2013; Thompson, 2013 on encounters between psychiatrists and
clients). Gaining knowledge about these encounters is even more important because outpatient care is increasingly crucial
in psychiatry internationally and there is still only scant research on what constitutes good and effective treatment practice in
this institutional context (e.g., Korkeila, 2009). The present study explores the counselling sessions between clients and
one group of professionals in the multidisciplinary treatment teams, occupational therapists. Occupational therapy is a
client-centred health profession that aims to promote, maintain or restore clients’ functional independence in activities of
everyday life (WFOT, 2012). The focus will be on specific communication practices that are of great importance in
psychiatric care: how the professionals manage the talk on client’s emotional states.
The present study builds upon earlier conversation analytic research on emotions (e.g., Peräkylä and Sorjonen, 2012).
In conversation analysis, the displays of emotion are understood in the context of actions in which the participants in the
interaction are involved (Peräkylä and Sorjonen, 2012:9). For instance, Ruusuvuori (2007) studied how professionals in
general practice and homoeopathic consultations respond to patients’ trouble-telling. She demonstrated how the
professionals face a dilemma of fitting together the practical task of solving the client’s medical problem and the emotional
task of showing understanding and empathy. In psychiatric outpatient care the emotional task is of great importance,
because the clients’ conditions often involve atypical or non-adaptive emotions or difficulties in emotion regulation.
However, the professionals also need to focus on other goals and activities, such as how clients solve problems of daily
life, and review the clients’ general well-being. Consequently, in the psychiatric outpatient care, the professionals have to
find the right balance between emotional alignment with the client and other, more practical tasks.
Formulations, conversational actions that propose an altered version of the previous speaker’s turn (Heritage and
Watson, 1979), are central practices that professionals use for managing talk on clients’ emotions. Thompson (2013)
found that the more frequent use of formulations by psychiatrists in psychiatric outpatient care was associated with better
client adherence and more favourable clinician perceptions of the therapeutic relationship. She suggested that by
formulating the implicit emotional and psychological meanings of the client’s talk, the psychiatrists displayed
understanding, resulting in an improved therapeutic relationship (Thompson, 2013). In the study at hand, I will seek to
show how occupational therapists’ formulations reshape and manage the talk on clients’ emotional state.
Ample research evidence shows that in psychotherapy, formulations are a central interactional practice for directing
the clients’ talk on their emotional states (e.g., Antaki, 2008; Stommel and van der Houwen, 2013; Weiste and Peräkylä,
2013). Formulations can also intensify emotional and conflictual issues in the talk (e.g., Hutchby, 2005; Vehviläinen, 2003)
and serve as expressions of empathy (e.g., Beach and Dixson, 2001; Hepburn and Potter, 2007; Weiste and Peräkylä,
2014). Formulations can generate longer phases of topical talk: after a formulation and the clients’ response, the
psychotherapists can, for instance, validate, intensify or work through (e.g., interpret or challenge) the clients’ experience
(e.g., Peräkylä, 2011; Voutilainen et al., 2010; Weiste and Peräkylä, 2014). According to Drew (2003), formulations are
associated with core tasks of participants in different institutional settings. In the context of mental health care, working
with clients’ emotional states seems to be one of those core tasks. Thus, the present study explores the occupational
therapists’ use of formulations; the study examines how formulations reshape the clients’ descriptions of their emotional
states and how the occupational therapists orient to the clients’ emotional states in their following turns. The results are
discussed in relation to what has been found in similar sequential contexts in psychotherapy and medical interaction.
2. Psychiatric outpatient clinics
In Finland, psychiatric outpatient clinics are part of public sector psychiatric services that provide psychiatric
consultation, treatment and rehabilitation for the adult population of the community. A referral from the primary care doctor
is needed. Generally, mild psychiatric problems are treated in primary care and more severe problems in the specialized
psychiatric clinics. A broad range of mental disorders is treated and the course of disorders varies from acute to chronic
states. The services are free of charge for the client.
In the clinics, the interdisciplinary treatment team engages with the client collaboratively developing a plan of care. The
treatment is generally based on medication, family-work, psychoeducation, individual counselling sessions and different
types of group therapies. The clients are assigned a case manager (depending on the clinic, this may be a psychiatric
nurse, an occupational therapist, a social worker or a psychologist) who will regularly meet the client in the individual
counselling sessions. The general aim of these sessions is to review the clients’ wellbeing and mental state, offer support
and sustain or increase the clients’ functional capacity. In addition, the plan of care may also include individual discussions
with specific professionals on designated goals. All these individual counselling sessions constitute the central part of the
treatment delivery.
E. Weiste / Journal of Pragmatics 105 (2016) 59--73 61
No specific theoretical frameworks are applicable to all counselling sessions in psychiatric clinics; the training of the
professional and the problem of the client generally shape the course of the session. In occupational therapy, there is
much variation in clinicians’ theoretical orientations. The general knowledge base of occupational therapy in mental health
care consists of holistic and humanistic views of human beings (Creek, 2014). According to the holistic principle, people
are understood as physical, intellectual, emotional and social beings that operate in their natural environment (Creek,
2014). The humanistic concept highlights the importance of finding the clients’ competencies; the clients have the ability to
influence their own health through meaningful activities (Creek, 2014). The humanistic concept that is most important in
occupational therapy is client-centeredness. According to the client-centred view, the clinician should understand the
clients’ perspective and reach towards a shared understanding of the clients’ problem (e.g., Law, 1998).
3. Materials and method
The data for this study consists of 15 video-recorded counselling sessions in psychiatric outpatient clinics, involving
approximately 16 h of interaction. The sessions are from three different dyads. The clinicians are professionally qualified
occupational therapists working in two different public sector clinics in urban areas of Finland. Typical to occupational
therapy, in four of the sessions the participants are engaged in different types of activities (cooking in one of the sessions
and artwork in three of the sessions). Eleven sessions are more traditional counselling sessions in which the participants
mainly talk. The occupational therapists were recruited to the study on the basis of their connections with academia and
their openness to research. In addition, they did not have any additional formal training (e.g., psychotherapy) besides their
professional training.
All clients were women, ages 25--56. The first client suffered from schizophrenia, the second client from depression
and anorexia and the third client from schizoaffective disorder. At the moment of the data-gathering, clinicians and their
clients were engaged in ongoing relationships that had lasted from six months to two years. In this type of psychiatric
service (differing from psychotherapy), the treatment processes were open-ended. Regular meetings took place
approximately every two weeks.
The municipal health authority and the ethical board of the University Central Hospital gave permission to collect the
data. The researcher was not present in any of the therapy encounters: a video camera was placed on a tripod in the
corner of the room and the therapist turned it on at the beginning of the session. The clinicians recruited the clients whose
treatment would be disturbed as little as possible because of the recordings (for example, by excluding clients with
paranoid symptoms). All clients and professionals gave an informed consent for the data to be recorded and used in
research, and all identifying information has been changed in the following data extracts.
The recordings were analysed using conversation analysis (CA) which seeks to explain the sequentiality of social
actions. That is, it shows how participants in interaction design their utterances in such a way that makes these utterances
related to preceding and subsequent utterances (Peräkylä et al., 2008). The data were transcribed according to CA
conventions (Jefferson, 2004; see Appendix A). The analysis of the data was carried out in three stages.
First stage. All the formulation sequences were collected from the data at hand. The formulation is understood
according to Heritage and Watson (1979) as an utterance that displays understanding of the previous speaker’s turn by
proposing an altered version of it. The formulation makes relevant the client’s confirming or disconfirming response.
From the data used in this research, 71 formulations were found. Formulations were similarly found in both activity-
focused and talking-focused sessions (in activity-focused sessions the participants may also discuss topics similar to
those in talking-focused sessions).
Second stage. A sub-collection of the sequences in which the client talked about an emotion-related experience and
the occupational therapist formulated that experience was formed. The rest of the formulations, which are not studied in
this paper, were typically found in the interactional context in which the occupational therapists reviewed the clients’
daily life or general well-being. For example, the therapist might say, ‘So you have a lot of plans for the weekend’ or ‘So
you notice that tiredness affects your ability to concentrate on reading’. The sequences were found in two interactional
environments: after the client’s narrative descriptions of her feelings in some past situation (demonstrated in Extracts 1,
2 and 3) and after the client’s expression of her here and now emotion in the therapeutic encounter (demonstrated in
Extract 4). Although the telling about an experience and the display of an emotion in these data extracts seem to be
different actions (telling or recounting in the first ones and complaining in the last one), the occupational therapists’
responses to both of these types of turns were explored. This was to unravel the formulation practices the occupational
therapists used for managing talk on the clients’ emotional states. There were 34 formulations that focused on a client’s
emotional state. The construction of the formulation showed that the occupational therapists paraphrased the clients’
feelings (e.g., so you feel X), and they often included turn-beginning particles, such as eli/nii et/että (so/so that),
showing that they were inferences from previous talk (Sorjonen, 2014).
62 E. Weiste / Journal of Pragmatics 105 (2016) 59--73
Third stage. The occupational therapists’ post-formulation turns, i.e., occupational therapists’ turns that came after the
formulations, were explored. The aim of analysing these turns was to unravel how the occupational therapists further
oriented to the clients’ emotional descriptions.
4. Results: managing talk on clients’ emotional states
The occupational therapists oriented to the clients’ descriptions of their emotional states differently depending on the
emotional stance (see Stivers, 2008) the clients themselves took towards their experiences. When the clients’
descriptions took a positive stance, the occupational therapists formulated that side of the description and provided
feedback on how well the client managed the situation under discussion (this occurred in 13 out of 34 cases). However, if
the clients took a negative stance, the occupational therapists’ formulations refocused the clients’ talk to less affective
content of the particular experience or they moved to other agendas of the session (in 21 cases). Thus in general, the
occupational therapists supported the clients to identify and attend to their own competencies and closed down
emotionally-loaded trouble-talk. I will begin with formulation sequences that endorsed the clients’ agency and
competence.
4.1. Endorsing the clients’ descriptions on agency and competence
In sequences where the clients took a positive stance towards their experiences and described their agency,
competence or personal strength, that stance was endorsed by the occupational therapists. The occupational therapist’s
formulation selected the positive aspect of the client’s description, deleting some other aspects of it. These formulations
are close to the optimistic formulations, described by Stommel and van der Houwen (2013) in online chat counselling:
formulations presupposed the optimism that emphasized the client’s agency to achieve improvement. As Hutchby (2005)
found in child counselling encounters, these formulations preserved the selected aspects of the clients’ utterances as the
topic of the talk and invited more talk about it. In their following turn the clinicians provided evaluations and feedback on
how well the clients managed the situation under discussion.
The first extract is an example of a sequence that endorses the client’s agency and competence. The extract is taken
from one of the activity-focused sessions in which the participants make little note cards that have some anxiety reducing
messages. Along with making the cards they talk about the client’s anxiety attacks. One psychoeducational goal of the
sessions has been to find ways to manage these attacks. Prior to the extract, the client reported a recent attack she had on
the bus to the city. The occupational therapist asked how the client managed the situation. Here, at the very beginning of
the sequence (lines 1--17), the client describes what she did.
Extract 1 (CL = client, OT = occupational therapist)
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64 E. Weiste / Journal of Pragmatics 105 (2016) 59--73
As a response to the occupational therapist’s question (not shown in the extract), the client provides a description of
what she did to manage the anxiety: she stood outside in the sun (lines 3, 7), drank some water (line 6) and walked around
(lines 11--12) until she took a bus back home (lines 16--17). In line 18, the occupational therapist formulates the essence of
the client’s description: so the anxiety passed. The turn-beginning particle eli (so) formulates the understanding as one
that recognizes what the client said as a valid description of what has been talked about, but it transforms the frame of
talking about the issue (Sorjonen, 2014). The relevant frame for the occupational therapist is how the client managed the
anxiety. The formulation highlights the positive implication of how she managed it: the anxiety passed. The client confirms
the first part of the formulation in lines 19--20 by repeating the main part of it (It passed, yes, it passed).
In lines 21--22, the occupational therapist continues the formulation by emphasizing the client’s agency in the
management of her anxiety: the client calmed herself down by standing in the sun. The client eagerly confirms the
formulation (Yeah, yeah, yeah, I did, line 23). In her following turn, the occupational therapist provides positive evaluations
(really good) of the client’s behaviour (lines 24 and 26--27). The evaluations are produced with a type of voice quality that
enacts calming down: the pitch is low and the first vowel of the words calm and really is lengthened. In lines 31--39, the
occupational therapist endorses the client’s agency. She describes the client as a competent actor who has means to
calm herself down. She also focuses on the positive implications: the client does not need to leave the tasks she is doing
unfinished because she has the means to calm herself down. Considering the psychoeducational goal of the sessions is
to find ways to manage the anxiety, the occupational therapist gives positive feedback on the client’s progress: the client
has actively calmed herself down and succeeded in overcoming the anxiety attack. The client agrees with the
occupational therapist’s compliments by repeating the main parts of them: I calmed myself (line 25) and Then I could
continue (line 40).
Extract 2 is another example of a formulation sequence endorsing the client’s description of agency and competence.
Just before the extract, the client describes major difficulties in her social relationships. In the first lines (1--4), she finds
something positive in her current situation: she has gotten rid of the people who have caused her constant pain. The client
also describes how she has gotten the strength to influence her current situation (lines 6--10).
E. Weiste / Journal of Pragmatics 105 (2016) 59--73 65
Extract 2
66 E. Weiste / Journal of Pragmatics 105 (2016) 59--73
In lines 11--12, the occupational therapist formulates the gist of the client’s description: the client needs to protect
herself. By selecting the behavioural aspect of the description ( protecting), the occupational therapist describes the
client as an active actor in her situation. In her formulation, että Ø pitää suojella itseään, so Ø needs to protect Ø-self,
the occupational therapist also chooses not to specify whose experience is in question. In Finnish, this type of zero
person construction is used to frame an experience as generally understandable---as something that everyone would
E. Weiste / Journal of Pragmatics 105 (2016) 59--73 67
feel or do in a similar situation (e.g., Halonen, 2008). Thus, the occupational therapist is not making an assessment of
the client, but deflects a negative personal connotation of the client to one that reflects a principle or guideline that
everyone in society should follow. The client immediately agrees (line 13) and the occupational therapist continues
her formulation by adding that the client also needs to monitor that burden (lines 14--15). The client confirms the
formulation and provides an extended response (lines 16--19). She connects the formulation to her reluctance to
participate in the activities of the patients’ association, something the occupational therapist proposed earlier (not
shown in the extract). Apparently, the client implies that by refusing to participate, she protects herself from possibly
difficult social relationships.
In lines 22--23, the occupational therapist initiates a turn by stating that the client is active. Her turn is, however,
intermitted by the client. The client initiates a description of how she relates with other people (lines 24--34): for the client,
the small talk in a tram or shop is enough and something she enjoys (That’s nice, line 34). As a response, the occupational
therapist provides a positive evaluation endorsing the client’s competence to regulate her participation in social
relationships (lines 35--38). The client’s way of relating with other people (small talk in a tram) is very different from what
the occupational therapist’s proposal conveyed when she suggested that the client could participate in the activities of the
patients’ association where the aim is to help people with mental illness increase their social skills. Nonetheless, the
occupational therapist finds something positive in the client’s very limited social skills, validates her perspective and
endorses the client’s competence to regulate her participation.
In sum, it was found that when the clients described their emotional state from the perspective of agency or
competence, the occupational therapists’ formulations highlighted that perspective. The clients confirmed the
formulations. In their following turn, the occupational therapists explicitly endorsed the clients’ description on agency
and competence by providing positive feedback and evaluation on how the clients managed the situation under
discussion.
4.2. Redirecting the clients trouble descriptions
There were, however, several sequences in the data in which the clients did not take such a positive perspective
towards their own experience. In these sequences, the clients’ accounts of negative experiences could be considered as
trouble-telling, extensively discussed in CA (e.g., Jefferson and Lee, 1981; Jefferson, 1988; Ruusuvuori, 2007;
Ruusuvuori and Voutilainen, 2009). When the clients described their troubles by taking a negative emotional stance
towards their experiences, the occupational therapists’ formulations topicalized the clients’ difficult emotional states. In
their following turns, however, the occupational therapists shifted the talk to the less affective content of the clients’
experience or they moved to other agendas of the sessions. The clients most often followed the occupational therapists’
topic or activity shifts by abandoning the talk on emotional state.
Extract 3 is an example of a formulation sequence that redirects the talk to the less affective content of the experience
under discussion. In the first lines (1--12) the client (suffering from depression and anorexia) describes a problematic cycle
in the management of her life: when she has a better mood and she enjoys doing different activities, she forgets to eat and
rest. As a consequence she loses all her strength and feels bad again.
Extract 3
68 E. Weiste / Journal of Pragmatics 105 (2016) 59--73
The occupational therapist’s formulation (lines 13--15) provides a rather general summary of the client’s problems ( for
a longer period of time, feeling of tiredness and exhaustion). It orients to the client’s problematic experience, but, at the
same time, it deletes the client’s description of her life-management problems. Thus, differently from the first and second
extracts, this formulation does not preserve the topic the client initiated in her description.
In line 16 the client minimally responds with a particle mm that is produced with a slightly falling intonation, weakly
acknowledging the occupational therapist’s formulation (Gardner, 1997). The formulation seems to rush towards the
occupational therapist’s next turn that explicitly redirects the talk to explore the client’s experience from a very different
perspective. The occupational therapist initiates an in-breath at the end of her turn in line 15 and it lasts until the beginning
of line 17. Thus, the in-breath latches her two turns and she keeps the floor for the upcoming talk (Schegloff, 1998).
In her post-formulation turn (lines 17--18), the occupational therapist asks about the client’s use of iron and vitamin D
supplements. This is not an entirely new topic. The client’s feelings of tiredness and exhaustion (formulated in lines 14--15)
can be caused by low levels of iron and vitamin D, considering that the client is suffering from malnutrition caused by
anorexia. Thus, the formulation skilfully reshapes the client’s description in ways that enable the shift to continue the talk
on the topic from a different, less affective, perspective. The client follows the shift and begins to talk about her use of the
supplements.
The fourth extract is an example of a similar type of formulation sequence. In this example, however, the redirecting of
the talk is done by moving to another agenda item of the session. The extract is taken 25 min after the beginning of the
session (80 min in total). Before the extract takes place, the occupational therapist and client have discussed the
upcoming meetings between the client and the members of her interdisciplinary treatment team. One subject has been
the meeting with the psychiatrist for getting the medical certificate that is needed for the Social Insurance Institution. This
triggers the client’s complaint about being mistreated in the management of her social security benefits (lines 1--4).
Unlike described in the previous three extracts, in here the client is not describing her past experience, but makes an in
situ display of anger and indignation by using a high, loud and tense voice (Couper-Kuhlen, 2012) and swear words
(jumaliste/goddammit in line 2 and vituttaa/pisses me off in lines 3--4).
E. Weiste / Journal of Pragmatics 105 (2016) 59--73 69
Extract 4
1
In Finnish response particle, nii can be used to mark affiliation (Sorjonen, 2001). As in these cases there is not an equivalent translation for the
particle in English, it has not been translated.
70 E. Weiste / Journal of Pragmatics 105 (2016) 59--73
At the beginning of the formulation (line 6 and already in line 5) the occupational therapist affiliates with the client’s
emotional stance by using a response particle nii (Sorjonen, 2001). The formulation, these money-matters have been a
terrible struggle for you (lines 6--9) preserves the client’s problematic experience concerning her money-matters. At the
same time, however, it deletes the client’s general concern regarding her feeling (why do I have this feeling, lines 2--3) and
the client’s display of her feeling at the moment (it really pisses me off so badly, lines 3--4). By preserving the client’s
problematic experience but deleting the client’s feeling display, the formulation remarkably transforms the description of the
client’s emotional experience (see Heritage and Watson, 1979:130). In her response, the client confirms the formulation
minimally (mm, line 10) and continues to complain about her bad feeling (lines 11--18), implying that the transformed
description of her experience did not adequately grasp the meaning or importance of her previous turns of talk.
After the occupational therapist responds, mm (line 12), she shifts her gaze from the client to the calendar on her desk
and starts to thumb through it. A shift in gaze and body posture away from the other participant towards a computer or
papers on a desk, displays a misalignment from the reception of the upcoming talk, sequence closure and orientation
towards another activity (e.g., Ruusuvuori, 2001; Tiitinen and Ruusuvuori, 2014). In her post-formulation turn (lines 20--21),
the occupational therapist explicitly shifts the focus away from the client’s emotional state and moves back to planning the
upcoming meetings; this time she sets up a day for a home visit. The client aligns with the activity shift by taking up her
calendar and the talk on the client’s emotional state is concluded.
In sum, when the client took a negative stance towards his or her experience, the occupational therapist’s formulation
topicalized the client’s difficult experience. However, right after the formulation (or sometimes already during it), the
occupational therapist initiated a shift towards a less affective content of the experience or another agenda of the session.
5. Discussion
This research described formulations the occupational therapists used for managing talk related to the clients’
emotional states. The findings contribute to the previous research on formulations by investigating the specific sequential
feature of formulations: connectedness of the formulation to the next action the formulation speaker produces in his/her
following turn of talk. The findings indicate that formulations had a significant role in reshaping the clients’ descriptions in
ways that enabled the occupational therapists to focus on certain aspects of the descriptions and guide the talk to those
directions (see double duty of formulations, Heritage and Watson, 1979). The direction to which the occupational
therapists were guiding the talk was manifested in their following turns of talk in which they endorsed the positive aspects
of the clients’ experiences or shifted the talk to the less affective contents. These types of third position turns (given that
the formulation is the first and the client’s response is the second position) have been found to be essential in performing
institutional tasks (e.g., Lee, 2007) and revealing the therapists’ larger interactional projects (Peräkylä, 2011).
An analysis of the third position turns also reveals the specific nature of the institution in question. By formulating the
clients’ emotional states and their natural implications, the occupational therapists displayed understanding (e.g., Beach
and Dixson, 2001; Thompson, 2013). In this respect, the function of formulations came close to what has been found in the
context of psychotherapy (e.g., Weiste and Peräkylä, 2013). However, the turns following the formulations were
remarkably different from those found in psychotherapy. In psychotherapy, the sequences that deal with clients’ emotional
states continue after the therapists’ affiliating utterances, generating clients’ self-reflections (Ruusuvuori and Voutilainen,
2009). The psychotherapists (from cognitive and psychoanalytic approaches) most often validated or worked through
(e.g., interpreted or challenged) the clients’ emotional states (see data examples of such sequences, e.g., Weiste and
Peräkylä, 2014). However, in occupational therapy encounters, the formulations were followed by an endorsement of the
clients’ competence or a shift from the trouble-talk to another (less affective) perspective or activity.
Previous research supports the idea that the use of formulations for closing down the trouble-talk might be a more
general feature of outpatient consultations. Thompson (2013) found that psychiatrists’ formulations in outpatient
consultations were geared towards sensitively closing particular trouble-telling trajectories and managing topic
transitions. While formulations displayed understanding of the client’s account, sequentially they simultaneously edited
and deleted the client’s contribution, focusing instead on the psychiatrist’s agenda (such as reviewing the client’s overall
state). Beach and Dixson (2001) found a similar type of pattern in medical appraisal interviews: formulations provided a
sensitive way to orient to the client’s talk while closing the topic and moving on in the interview agenda. The findings are
also close to those from primary care consultations, where general practitioners have been observed to affiliate with
patients’ trouble-telling descriptions but then produce a quick closure to the sequence and return to the main activity of the
session (Ruusuvuori, 2007). Moreover, moving away from the clients’ difficult emotional states does not seem to be
restricted to formulation practices in the occupational therapy encounters. The occupational therapists in my data use also
other interactional means for responding to the clients’ emotionally loaded trouble-talk and complaints (e.g., follow-up
questions and evaluations); these means seem to both orient to the client’s troublesome experience but move away from
the client’s difficult emotional state (Weiste, forthcoming). However, this may have problematic aspects, if seen in the
context of the more general aims of mental health care. Even if the goal of a session is not to work through the clients’
E. Weiste / Journal of Pragmatics 105 (2016) 59--73 71
difficult emotional experiences, the moments in which the clients disclose something painful or make an in situ display of
emotion are of great importance. The proper validation of the clients’ difficult experiences strengthens the therapeutic
relationship and gives the clients a sense of being understood (e.g., Greenberg, 2002).
Rather than focus on the client’s difficult emotional experiences, the literature of occupational therapy highlights the
importance of positive empathic interaction with an emphasis on optimism and the clients’ strengths (e.g., Abreu, 2011;
Taylor, 2008). However, the clinical literature does not describe how this positive empathy is manifested in on-going
interaction between the therapist and client. The findings of this research complement the professional stocks of
interactional knowledge (Peräkylä and Vehviläinen, 2003) of occupational therapy by suggesting that the occupational
therapists’ formulations that focus on the positive aspects of the clients’ talk and further endorse the clients’ agency,
competence and personal strength might be one sequential place where this positive empathy could occur.
The way in which the clients and occupational therapists manage their emotion displays shows their understanding of
the institutional nature of the situation (Ruusuvuori, 2007). Importantly, the clients in my data also adapted their emotional
displays to the institutional constraints of the situation. Firstly, the clients themselves produced positive, competence-
focused descriptions unlike what has been found in solution-focused psychotherapy. In MacMartin’s (2008) study of that
particular context, the clients almost always resisted the therapists’ questions that involved presuppositions of clients’
competence or agency. Secondly, formulations of the clients’ difficult emotional states seemed to be sufficient for showing
affiliation in occupational therapy encounters. The clients followed the clinicians’ shift in the activity context and rarely
moved back to their trouble-talk. The reoccurring pattern of clients avoiding pursuing emotion related talk leads us to
assume that clients did not treat the sessions as psychotherapy-like encounters and they treated them as a clinician--
client interaction that focused on medical intervention and practical support. To conclude, it seems that occupational
therapy encounters in psychiatric outpatient clinics fall somewhere between medical and psychotherapeutic encounters,
at least in respect to the therapists’ use of formulations and management of talk on emotions.
Acknowledgements
Many thanks to Anssi Peräkylä, Maari Kivioja, Melisa Stevanovic, Liisa Voutilainen, Timo Kaukomaa, Mika Simonen,
Mikko Kahri and Sonja Koski for our joint data sessions and your valuable comments on an early version of this article. The
research was funded by University of Helsinki.
Appendix A. Transcription symbols
Symbol Meaning
CL/OT Speaker identification: CL = client, OT = occupational therapist
! Line containing phenomenon discussed in text
[ ] Overlapping talk
= No space between turns
(.) A pause of less than 0.2 s
(0.0) Pause: silence measured in seconds and tenths of a second
8word8 Talk lower volume than the surrounding talk
WORD Talk louder volume than the surrounding talk
.hh An in breath
hh An out breathe
mt, krhm Vocal noises
#word# Spoken in a creaky voice
((word)) Transcriber’s comments
( ) Transcriber could not hear what was said
word Accented sound or syllable
- Abrupt cut-off of preceding sound
: Lengthening of a sound
>word< Talk faster than the surrounding talk
↑↓ Rise or fall in pitch
? Final rise intonation
, Final level intonation
. Final falling intonation
72 E. Weiste / Journal of Pragmatics 105 (2016) 59--73
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