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AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Discussing safer sex in HIV counselling: assessing three communication formats a
a
D. Silverman , A. Perakyla & R. Bor
b
a
Department of Sociology , Goldsmiths' College, University of London , b
District AIDS Counselling Unit , Royal Free Hospital and School of Medicine , London, UK Published online: 25 Sep 2007.
To cite this article: D. Silverman , A. Perakyla & R. Bor (1992) Discussing safer sex in HIV counselling: assessing three communication formats, AIDS Care: Psychological and Socio-medical Aspects of AIDS/ HIV, 4:1, 69-82, DOI: 10.1080/09540129208251621 To link to this article: http://dx.doi.org/10.1080/09540129208251621
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AIDS CARE, VOL. 4, NO. 1, 1992
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Discussing safer sex in HIV counselling: assessing three communication formats D. SILVERMAN, A. PERAKYLA & R. BOR’ Downloaded by [York University Libraries] at 17:50 22 December 2014
Department of Sociology, Goldsmiths’ College, University of London and District AIDS Counselling Unit, Royal Free Hospital and School of Medicine, London, UK
Abstract Although it is acknowledged that counselling can be an important factor in behaviour change, we lack information on how HIV counselling works in practice. Research is reported based on transcriptions of audio-tapes of counselling drawn fiom seven hospital centres in England and the USA. It is shown that communication occurs in the context of three diflerent formats. Certain formats and conversational strategies used by counsellors produce far greater patient participation. Such participation may hold out the prospect of greater behavioural change than simply listening to information and advice. Introduction It is now generally accepted that ‘AIDS is primarily a social phenomenon with urgent.. . medical issues attached’ (Miller, 1988, p. 130; see also Neilkin, 1987, p. 980). One of the many tasks of social research is to establish the kind of interventions which are most likely to be successful in promoting change towards safer sexual practices. Despite the problems in isolating the factors which are effective in behaviour change (Miller & Pinching, 1989), we are fairly clear about ineffective forms of intervention. In particular, it has now been established that knowledge itself does not produce behavioural change (Stoller & Rutherford, 1989; Nelkin, 1987; Aggleton, 1989; Greenblat et al., 1989). Moreover, fear-arousal is generally ineffective (Sherr, 1989). This is reflected in the reported lack of success of media campaigns on AIDS even among highly-motivated gay men (Frosner, 1989). Only two factors seem powerful motivators of change in health behaviour: 1. Peer-group support and pressure (Stoller & Rutherford, 1989; Sherr, 1989; Elmslie,
1989). 2. Acquiring skills rather than just knowledge (Stoller & Rutherford, 1989). One of the ways in which relevant skills can be acquired is through appropriate counselling. This is particularly important since there is very little evidence to support the assumption that HIV testing alone can motivate behaviour change (Miller & Pinching, 1989). However, although there is a number of texts on the nature and techniques of HIV
Address for correspondence: Professor David Silverman, Department of Sociology, Goldsmiths’ College, University of London, London SE14 6NW, UK.
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and AIDS counselling (Miller & Bor, 1988 is particularly useful in offering discussion of the process of counselling rather than just its content), until now we lack research based on detailed transcriptions of actual counselling interviews.
What is counselling?
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On the surface, it would appear that we already know what HIV Counselling is. For instance, the WHO GPA definition of HIV Counselling (quoted by Carballo & Miller, 1989, p. 121) states: “HIV counselling is an on-going dialogue and relationship between client or patient and counsellor with the aims of preventing HIV transmission and providing psychosocial support for those affected, directly and indirectly, by HIV. In order to achieve these aims, counselling seeks to encourage and enhance self-determination, to boost selfconfidence, improve family and community relationships and quality of life.” Prevention counselling has five main steps: 1. Determining whether the lifestyle and behaviour of an individual or a group of
individuals presents a risk of HIV infection. 2. Working with them so they understand the risks.
3. Helping to identify the meaning such behaviours may have for them. 4. Helping to identify and define the potential for behaviour change. 5. Working with individuals to achieve and sustain appropriate and chosen changes in behaviour. From this approach to prevention implicitly emerges a supportive and trusting relationship on the basis of which crises and problems emerging from HIV awareness or infection can mutually be addressed and overcome. Despite the length of this definition, Carballo & Miller acknowledge that, without research, we cannot know what counselling looks like in practice nor ‘its overall efficacy in prevention and impact reduction’ (ibid, p. 119). Moreover, this research has yet to be done: ‘few programmes have actually exposed themselves to any rigorous evaluation and few methodologies that have been tried and tested have been evaluated’ (p. 122) This argument is supported by Bor (1989) who suggests that questions which still need answering are: ‘Is counselling effective and what are the different approaches to evaluating HIV counselling?’. Bor also notes how the papers on AIDS Counselling at the 1989 Montreal AIDS Conference concentrated on “approaches to behavioural change, health education and psychosocial support rather than communication in clinical settings.’ The Counselling and Safer Sex Study
With the support of the English Health Education Authority, a study was begun in October 1988 which set out to examine the organization of counselling concerning safer sex within HIV counselling centres in England. The study had three short-term aims: 1. T o describe both the content and structure of counselling of safer sex in England
and to demonstrate how different organizational settings influence the actual practice of advice and information-giving
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2. To identify problems and conflicts which arise in this form of counselling and especially explore how the professional backgrounds of the counsellors and their theories of practice permeate their dealings with clients 3. T o examine in detail the actual process of counselling; the verbal and non-verbal behaviour of professional and client, and demonstrate how the various forms of communication provide very different learning environments for clients, and thereby influence the success or failure of the counselling process. In this paper, we discuss only item 3 (see also Perakyla & Bor, 1990). Items 1 and 2 are discussed elsewhere (see Silverman, 1990).
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Methods Recording and transcription of actual counselling exchanges using techniques from sociological work on naturally-occurring social encounters (see Silverman, 1987). This essentially ethnographic approach is standard in anthropology and political science as well as sociology. Its aim is to discover and illustrate particular types of event-not, usually, to enumerate their frequency. In order to do this, unlike many studies which use tape-recorded data, high levels of transcription quality are required. In particular, such features as pauses and overlapping talk are always included. Sample Audio-recordings of counselling around the antibody test were obtained from five English centres and two US centres. This paper is based on 90 episodes of pre-test counselling and 10 post-test counselling interviews drawn from one US centre which did not offer individual pre-test counselling. Recording was based on the informed consent of patients.
What can the research offer? We need to begin with two notes of caution: (1) Only one of the authors is a counsellor and this paper is not based on any any normative version of counselling. Instead, we seek to discover what actually happens in these interviews. (2) The research design does not include interviews with a panel of patients to identify continuities and changes in their ideas and behaviour-the most common means of evaluating programmes. However, such interviews have to be viewed with caution because they cannot usually separate the impact of a number of independent variables on behaviour, e.g. not only counselling but peer-group pressures, media campaigns, etc. Moreover, the research interview itself may have an impact on patients’ perceptions and behaviour. Nonetheless, the research is able to offer important information to counsellors. First, we seek to identify how communication in counselling works in practice. So we ask what are the main communication formats used in counselling? What is the nature and extent of patient participation in each format? And how is ‘safer sex’ discussed in practice? Second, we seek to offer counsellors and trainers of counsellors an opportunity to consider the consequences of different ways of organizing communication in counselling based not on hypothetical examples but on transcripts of actual counselling interviews. In order to focus the discussion, in this paper we focus largely, although not exclusively, on counselling around the HIV-antibody test with special reference to sexuality. For
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convenience, P will indicate patient and C counsellor-for the appendix below.
other transcription symbols see
The three formats
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Medical sociologists have demonstrated how practitioner-patient communication occurs within a set of cultural assumptions which shape the behaviour of both parties. For instance, doctors and patients in fee-for-service medicine assume different obligations and make different claims than in tax-paid medicine (Strong, 1979; Silverman, 1984). We take from this work the concept of ‘role-format’ to describe the rolls of professional and client at various stages of a counselling consultation. Three such formats have been identified:
1. Interview. 2. Information-delivery. 3. Service encounter. We will give examples of each format below, using material where sexual matters are discussed. A fourth format (advice-giving) has also been identified but is excluded here for reasons of space (see Silverman, 1992). At the beginning of consultations in all centres, talk about sexual matters occurs by the P providing answers to questions asked by the C. We call this an interview format: Extract A (Code: 21 AP 9) (male) 1 C: right (1.0) umm (0.5) you’ve come just for an HIV test 2 P: hhum 3 C: (0.5) can I just ask you briefly er one or two questions 4 before we start? (0.5) have you ever had a test before? 5 P: no 6 C: no (0.5) have you ever injected drugs? 7 P: no 8 C: (3.0) have you ever had a homosexual relationship? 9 P: (0.5) no (0.5) and that’s not really (0.5) not really put 10 me in a high risk group now [has it? 11 c: [no no it doesn’t Extract A begins with the C setting up an interview format where the P delivers answers to a series of questions. In the P’s final answer, however, he tacks on a question which reverses the roles of questioner and answerer. Where the C is answering the P’s questions, we call this a service encounter. What seems to be happening at the start of this extract is a communication pattern modelled on a medical history-taking (we return later, however, to the positioning of C’s question on line 8). Although Cs are not specifically concerned with diagnosis, the use of an interview format at this stage is probably a useful way for the C to assess Ps’ sense of their risks and so to tailor the later discussion to the P’s individual needs and fears. After this initial use of an interview format, Cs differ widely in the communication format which they use to discuss sexual behaviour. In most centres, quite early in the consultation, Cs use a third footing to discuss safer sex: information-delivery. The difference between the information-delivery format and the interview format is very simple: in the former, the C does almost all of the talking, whereas in the latter, the C asks questions and the P provides answers.
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Shortly afterwards, in the same consultation, the C addresses safer sex in an information delivery format: Extract B 173 C. 174 175 P: 176 C. 177 178 P: 179 C 180 181 182 P: 183 C: 184 185 186 187 P: 188 C. 189 P: 190 C: 191 P: 192 C: 193
as far as sex is concerned it means keeping to the safer sex guidelines [hmm [for two reasons (0.5) firstly to try and prevent them passing it on to anyone else hmm umm and secondly because really they can’t afford to catch you know some of the other sexually transmitted diseases that are around well yeah um uh (0.5) and basically it means either sticking to noninsertive sex like mutual masturbation um (0.5) massage that kind of thing or else if they do you know carry on having full sex to use a condom um preferably with a spermicidal backup as well yeah (1.0) is there anything you want to ask (0.5) so far you no uh heh heh right (2.0) one of the biggest drawbacks with having this test is as far as insurance (0.5) is concerned.. .
In Extract Bythe C delivers a package of information to the P about safer sex. At this stage of pre-test counselling, almost identical packages are used with other Ps attending this Centre. This seems to happen because Cs do not pursue an interview format in order to establish each P’s own beliefs and practices regarding ‘safter sex’. By contrast, the information-delivery format used at this early stage makes the P a passive recipient of generalized information. Predictably, the P here offers nothing more than a few monosyllabic responsetokens and then turns down the offer of a service-encounter by indicating that he has no questions. At another Centre, a very similar information package is offered to a young female P. Once again, within an information-delivery format, the P produces only a minimal response. Following a two second pause, the C has to ask ‘okay?’ (line 71) before the P says anything at all: Extract 61 C: 62 63 64 65 66 67 68 69 70
C (42B NH4) (Female) so you know it’s not hh dead set on ten years hh now there are other people who could be HIV positive but not actually develop AIDS as such hh so they could be (.) carriers they could (.) stay well hh but pass the virus to people that they have sex with hh this is why we say hh if you don’t know the person that you’re with (0.6) and you’re going to have sex with them hh it’s important that you tell them to (0.3) use a condom (0.8) or to practice safe sex that’s what using a condom is (2.0)
74 D.SILVERMAN, A. PERAKYL.A 81 R. BOR 71 72 73
C: okay? P: mm (2.0)
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Immediately afterwards, however, the C moves into an interview format to try to elicit the P’s own experience in this area: Extract 74 C: 75 76 P: 77 78 C: 79 P: 80 C: 81 82 P: 83 C: 84 85
D (42B NH4) has your partner ever used a condom with you? (1 -2) no: (1.2) do yer know what a condom looks like? no (
1
have you perhaps (1 .O) a condom shown to you (.) at school or: no yer didn’t right okay hhh (2.0) is there anything that yer worried about in terms of yer test if it’s done today? (.)
Since there is an obligation to give answers to questions, the interview format can be expected to produce a fuller P response than information-delivery. In Extract D, the C’s questions do at least produce some answers about the P’s experience and knowledge. However, perhaps because of the P’s uniformly negative answers, the C switches topics from sex to the P’s fears (lines 84-86). Later the C tries an extended discussion of safer sex in an interview-footing. The extract illustrates the difficulty that professionals face in eliciting any sort of response from many adolescents, particularly when the topic relates to delicate matters (see Silverman, 1987; Silverman & Perakyla, 1990). In particular, we can note the use of repeated questions and long pauses by the C to try to elicit an answer and the multiple coughs and sniffs that are often the major tokens of the P’s presence: Extract E (42B NH4) 170 C: hh and yer not protecting yerself 171 (1.2) 172
173 174 175 176 177 178 179 180 181 182 183 184 185 186
C:
that’s worrying isn’t it?
C: P: C:
tt [will yer talk to yer boyfriend about maybe using a
(4.0)
P:
[coughs] condom? (3.5) probably (.) I dunno (1.0)
mm it is important (1 -3) C: mm? (0.8) C: do you know where you could get condoms? (0.8) P: ( 1 C:
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C: P:
where would you ( ) buy? chemists? (1 *o> c: right tt (.) and I know that (1.0) hhh you don’t have any income (0.7) and: apart from pocket money from heh yer parents probably hh and (0.4) yer boyfriend’s not working is he? ( ) he’s not working so it’s [going to cost P: [coughs] C: quite a lot of money isn’t it? hh so you can get condoms from family planning clinics (1.4) okay? (1 *o> C: do yer know where your nearest family [planning clinic is P: [sniffs] (2.0) P: no (1 -7) P: Y Road I think (1 *o> C: ri::ght (C gives phone number of clinic and packet of condoms to P)
Extract E shows C valiantly using the interview format to try to elicit the P’s own knowledge and past, present and future behaviour. Although the P’s responses are minimal, they indicate at least the possibility of behaviour change because the C is getting her to address her own particular situation rather than simply providing pre-packaged information. Indeed, the turn that this counselling session now takes suggests that the early move into information-delivery that we saw in Extracts B and C is unhelpful. Safer sex in an interview format
We now turn to consultations where the sequence of formats is reversed. In the extracts below, the Cs stay in an interview-footing during the first half of the consultation. Only later do they use an information-delivery format and then they deliver recipient-designed rather than pre-packaged information. Extract F (SSV3p.l) (Male haemophiliac P recently married) 1 C: um what are you actually doing? 2 P: we’re just using er condoms (0.3) 3 C: [umm 4 P: [for safe sex 5 C: umm 6 P: um we (0.5) intend to use spermicide 7 C: umm 8 P: er but we don’t intend to use (0.3) the cap Extract G (SSVl5) (pre-test counselling of gay man) so say if it’s negative how would that affect your c: relationship (0.3) with A? 3 P: I don’t [think it would 1 2
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c:
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
P: C:
P:
c: P:
C: P: C: P:
c: P: C: P: C:
P: C:
P: C:
[I mean apart from your present plans [to move in [Yes with him? I honestly don’t think it would hh I mean obviously some er ihh sexual plans would have to be taken but (0.3) that’s no big deal um what do you know about that? (2.5) well I mean I I I’ve read safe sex literature and er (1.0) been exposed to to that (0.5) um penetration passage of body fluids (0.3) are things to be avoided (0.5) [um [right and (0.3) using condoms yeah quite and er spermicide yeah (0.3) sure (1.0) do you think that would be a problem [for you= [no =no or something you’re used to yeah it really wouldn’t be a problem at all what about to A? no not to him certainly not = =right (0.5) just think too only what if it’s positive? mm (5.0) what for you would be your greatest concern do you think about that test result?
In both Extracts F and G, the Cs are displaying their professional skills by not offering information but by asking questions. As in Extract E, these questions centre around the practical and social context in which the Ps are currently acting. However, unlike Extract E, they precede the use of an information-delivery format by the C. The sceptical reader will have noted that Extracts F and G involved patients belonging to groups whose health knowledge in this area is higher than the general population. If we exclude gay men and seropositive haemophiliacs, can the interview format be used to discuss safer sex in HIV counselling? Take Extract H which occurs early on in pre-test counselling with a heterosexual man: Extract 1 C: 2 3 P: 4 5 6 7 8 9 C: 10 11 P:
H (SSV6) what do you understand about your own risk for HIV? (1.0) well (1.0) I suppose I’m in one of the high risk categories because I’ve had a lot of partners I don’t know what I’d call a lot I’ve certainly had over a hundred erm (1.0) and that this is why I think the doctor said it would perhaps be a good idea because of that because it does put me into a high risk category right (0.5) when you’ve had intercourse with your partners have you used any kind of protection at all= =I have in the last two years um (1.0) certainly I
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12 13 14 C: 15 P: 16 C: 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34
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haven’t had unprotected haven’t had unprotected sex for the last two (0.5) years so what have you been doing for the last two years? always used condoms right do you use anything else [does your [no
P: C: girlfriend use the cap as well do you use spermicide or P:
no like that sometimes can increase the [the P: [Yes c: protection because as you know condoms sometimes aren’t necessarily one hundred percent [safe P: [no I I accept that no [just condoms C: [from the point of view of pregnancy P: erm no as it happens my last two regular girlfriends um neither of them were on the pill er but I I used a condom anyway C: yes sure the pill wouldn’t protect you from HIV at all P: no c: right what made you think about (0.5) starting to use a er condom a couple of years ago?
c
The extract begins in the interview format with a question that is asked at early stages of pre-test counselling in all Centres participating in the study. However, in most Centres Cs treat the P’s answer about sense of ‘risk’ as relevant to history-taking and speedily move into information-delivery. Here, on the other hand, the C stays in an interview format by asking the P to specify his answers. A certain amount of information is conveyed by the C (about other forms of protection than condoms) but this is tailored to the P’s answers and also serves to explain the rationale behind the C’s questions. The extract concludes with the C using the interview format to encourage the P to talk about what has influenced his behaviour in regard to condom use. As seen in Extract H, the interview format can be used to encourage Ps to specify their sexual beliefs and practices. However, there can be problems when the C too rapidly exits from this format without having asked the P for such specification. Take the discussion of ‘safer sex’ in Extract I below. Extract I (9 BP 8) (Pre-test counselling with a gay man) 1 C: okay (1.0) do you want to tell me why you want the test 2 so that we can sort of [umm 3 P: [umm= 4 C: =work out a few things to say to you 5 P: well I’m I’mguy= 6 C: =right 7 P: and (1.0) hh I have (0.3) a an affair 8 C: right 9 P: er and (0.3) just want to be stay sure in my own mind= 10 C: =okay (0.3) fine umm (0.5) obviously umm your your
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11 12 13 14 15 16 17 18 19
homosexuality is the reason why you’re [here P: [yeah = =really umm do you do you practice safer sex at all [or C: P: [Yes C: you do so umm umm that (1.0) that must give you a little bit of comfort [anyway P: [Yes C: fine (0.5) can I just ask you while I’m asking you these questions have you ever used intravenous drugs?
In I, the C begins with the usual question. However, she does not pursue the P’s answer about his ‘affair’ and offers her own gloss for his self-description (‘gay’ becomes ‘homosexuality’). Nonetheless, she stays in the interview format to ask a question about safer sex. Once again, rather than getting the P to specify his answer, she offers another gloss (‘that must give you a little bit of comfort’) and then returns to a history-taking use of the interview format related to an entirely different topic. Extract J (also pre-test counselling with a gay man) reveals how the topic of safer sex can be pursued further within an interview format: Extract J (10ASD2) 17 C: You’re a gay man? 18 P: yeah 19 C: do you have a regular partner? 20 I?: no 21 (5.0) 22 C: and you practice safe sex normally 23 P: yes 24 C: what does safe sex mean to you? 25 P: (0.5) umm (2.0) no fucking 26 C: right (.) non penetrative 27 P: yes C’s question at line 24 succeeds in getting a specification from P of his knowledge, although this too is followed by the C’s own gloss at line 26. These extracts have shown the different impact of two communication formats. Information-delivery works smoothly since it only requires Ps to offer informationacknowledgments, like ‘mm’ (Extracts B and C). Thereby, Cs do not need to invite Ps comments on potentially delicate topics and Ps do not need to provide such comments. By the same token, however, without such comments, it is difficult to know how relevant the information is to the patient. Conversely, the interview format generates more P response. However, it can also take a long time, particularly where Ps seem reluctant to speak (Extract E). Even when Ps produce answers, a concentration on rapid history-taking can mean that Cs simply shift to another topic (Extract I). This can mean that questions are framed in ‘loaded’ ways with an unknown relevance to the P perceptions (Extract A). Again, in Extract A, the C’s choice of the term ‘homosexual relationship’ (line 8), is placed after questions about two relatively ‘deviant’ activities (having more than one HIV-test and being a drug-injector). Strategies which encourage patients to speak We have already noted that one of the advantages of the interview format is that, by tying
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the structure of the C’s talk to a series of questions, it encourages the P to speak. This is simply because question-answer sequences are a form of what conversation analysts call ‘adjacency-pairs’. In such pairs, there is an expectation that the conversation cannot go on until a response has been given. One of the difficulties of most professional-client encounters is that clients are not usually able to claim the floor in the same way as professionals. In practice, this can mean that while the C speaks as of right, the P has to engage in complicated manoeuvres in order to gain the floor. Take this example: Extract 81 P: 82 83 P: 84 85 C: 86 P: 87 C: 88 P: 89 C: 90 P: 91 92
K well we continue ter you know we try to be safe (0.7) er: (1.0) er: but I have a coupla questions for you (0.5) su[re [about how we can be safe ( ) go ahead= =if that’s okay aha er (1.0) erm (.) there are a coupla things that that we like to do and I was wondering you know like tt the safety factor of this
What is remarkable here is that, instead of asking his questions directly, the P engages in an elaborate build up. First, he projects that he will have questions to ask (line 83). This leads into the establishment of a service encounter format. Second, he asks permission to ask these questions (line 88). Only then does he get round to asking his questions. Note, moreover, the ‘perturbations’ (hesitations, pauses and self-repairs) that are present in both the question-projection and the question itself. Extract K is a strong example of the general rule that patients only speak if they are invited to. Without such an invitation, elaborate work from the P is needed. Yet perhaps there is a tacit invitation to speak here. Note the pause at line 82. This indicates that the C has declined his opportunity to take the floor at this point and thus begins the chain that ends up with the P setting up what we have called a ‘service-encounter’ format. As it turns out, declining to take the floor during pauses is a powerful weapon which Cs can use to encourage Ps to speak. Look at this example from an earlier point in the same consultation: Extract L (51A WH1) 44 C: okay your result came back (.) negative 45 P: mm hm 46 (0.5) 47 C: is that what you expected? 48 P: ye:ah 49 (1.0) 50 P: you see I really don’t (0.5) I haven’t engaged in (.) anal sex (.) or even oral sex heh I’ve been (.) pretty 51 safe and er: (.) I’m just a bit of a worry (wart?) 52 53 (0.3) 54 P: [you know
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C: [hm hm P: I mean there are some people who get anxious about (0.7) their health C: mm (0.8) P: er: (1.0) then I just wanted to be sure like (.)
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In this US Centre, where Ps have not had an individual interview with a counsellor prior to their test, test results are usually not given until some way into post-test counselling. However, we are concerned here more with the strategies that the C uses to encourage the P to talk. We note the following: 1. At line 46, the C does not take up the available turn immediately (0.5 second pause). 2. When this fails to produce any elaboration by the P on his enigmatic response at line 45, the C asks another question. 3. When the P again gives a short answer (line 48), the C allows a 1.0 silence to pass without speaking. 4. Subsequently, he utters only neutral response-tokens (lines 55 and 58) and allows a pause to develop at line 59. In the event, the P uses the turn-slots created by the C”s strategies to talk about what he understands by safer sex. If Extract K has illustrated how difficult it is for Ps to take the floor, Extract L shows how they can be encouraged to speak by Cs remaining silent. Just as the questions within the interview format demand answers, so silences encourage Ps to take the next turn to talk. An important exception to this can be found if we refer back to Extract B. We observe two long silences at lines 190 and 192. Despite the silence, the P does not speak. The constraining factor here seems to be that these pauses occur after the C has spent some time delivering information. In this kind of communication format, Ps are not expected to offer more than information-acknowledgments (like ‘mm’). It therefore seems likely that pauses by the C in the information-delivery format are functionless from the point of view of P participation. Instead, they seem to function here simply to mark changes of topic.
Conclusions In comparison with the interview, the information-delivery format is far less complicated for the C. The C is less dependent on the P’s contribution to the conversation because only recipiency (mms etc) and little talk is required from the P. This has two advantages for the hard-pressed C. First, the C can deliver pre-designed information packages without much reflection. Second, a similar range of issues can be covered within a shorter period of time, particularly because the greater dependency of the interview format upon the P’s contribution makes it more liable to the kind of communication difficulties we saw in Extract E. This is not an irrelevant consideration given the pressures on Cs in many Centres. However, as we have seen, much depends on the sequence in which formats are placed. In our material, Cs using the interview format to discuss safer sex do quite often also offer Ps their own views on the topic. But that happens only after a long sequence of questions and answers and is grounded on the P’s own account of what they are thinking and doing. This suggests that favouring an interview format is not incompatible with giving the P the latest expert information-indeed it is highly compatible with delivering that information in a way specifically designed for its recipient. following a long question-answer sequence in
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the interview-format. Counsellors who concentrate on the interview format reveal that effective HIV counselling involves considerably more than careful listening to the patient and appropriate information delivery. Rather, faced with the potential delicacy of the topics involved, successful counsellors must work very hard at getting their patients to speak (Silverman & Bor, 1991).
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Health education implications Our findings have strong parallels with a study of tape-recordings of general practice consultations carried out in the 1970s (Byrne & Long, 1976). In almost two-thirds of the authors interviews, doctors simply announced their diagnosis or limited themselves to an instruction to their patients. In only a quarter of the cases, did the doctor encourage the patient to participate in the decision about what was to be done. For Byrne & Long, patients should be involved in their own treatment and doctors should encourage offers of changed behaviour. Such patient-centred medicine would be characterized by open-ended questions, the exploration of patients own ideas and attempts to negotiate bargains. However, like Byrne & Long, our data does not in itself validate any claims about the therapeutic effects of particular ways of organizing communication. Nevertheless, if we assume, as most counsellors do, that the effects of counselling derive from Ps putting their problems into words, then the interview format inevitably appears to be the most effective. Equally, the lack of impact of information alone on behavioural-change suggests that to rely solely upon the use of an information-delivery format for the discussion of safer sex is probably inadequate. The research has provided examples of Cs using communication formats which generate the P’s own version of their problems are possible solutions rather than simply delivering advice and information. This seems to be an effective way to satisfy items 3-5 of the WHO GPA definition of HIV Counselling. Equally, given that what most trainee counsellors fear is having to ‘play God’, our emphasis on the constructive potential of the professional remaining silent and abstaining from generalizer information statements may be welcome. Acknowledgements We gratefully acknowledge the help of workers and patients at a number of centres who made this research possible. We particularly thank Riva Miller and Eleanor Goldman (Royal Free Hospital Haemophilia Centre) and Heather Salt (Royal Free Hospital District AIDS Unit) whose counselling practice has been a constant source of insights to us. The English Health Education Authority and Glaxo Holdings plc funded the research upon which this paper is based and we are delighted to acknowledge their support. References AGGLETON,P. (1989) Evaluating health education about AIDS in: P. AGGLETONet al. AIDS: Social Representations, Social Practices (Basingstoke, Falmer Press). BOR, R. (1989) AIDS counselling, AIDS Care, 1(2), pp. 184-187. BYRNE,P. & LONG,B. (1976) Doctors Talking to Patients (London, DHSS). CARBALLO, M. & MILLER,D. (1989) HIV Counselling: problems and opportunities in defining the new agenda for the 1990’s, AIDS Care, 1(2), pp. 117-123. ELMSLIE,K.D. (1989) AIDS and women, AIDS Care, 1(1), pp. 219-222. FROSNER, G. (1989) How efficient is ‘safer sex’ in preventing HIV infection? Infection, 17(1), pp. 1-3.
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82 D. SILVERMAN, A. PER4KYLA & R. BOR GREENBLAT, C. et al. (1989) An innovative program of counselling family member and friends of seropositive haemophiliacs, AIDS Care, 1(1), pp. 67-75. MILLER,D. (1988) HIV and social psychiatry, British Medical Bulletin, 44(1), pp. 130-148. MILLER,D. & PINCHING,A.J. 11989) HIV tests and counselling: current issues, AIDS, 3 (suppl. l), pp. S187-193. MILLER,R, & BOR,R. (1988) AIDS-A guide to Clinical Counselling (London, Science Press). NELKIN,D. (1987) AIDS and the social sciences: review of useful knowledge and research needs, Reviews of Infectious Diseases, 9(5), pp. 980-987. PERAKYLA, A. & BOR, R. (1990) Interactional problems of addressing ‘dreaded issues’ in HIV-counselling, AIDS Care, 2(4), pp. 325-338. SHERR,L. (1989) Health Education, AIDS Care, 1(2), pp. 188-192. SILVERMAN, D. (1984) Going private: ceremonial forms in a private oncology clinic, Sociology, 18(2), pp. 191-204. SILVERMAN, D. (1987) Communication and Medical Practice (London, Sage). SILVERMAN, D. (1990) The social organization of HIV counselling in: P. AGGLETON et al. (Eds) AIDS: Individual, Cultural and Policy Perspectives (Basingstoke, Falmer Press). SILVERMAN, D. & BOR,R. (1991) The delicacy of describing sexual partners in HIV-test counselling: implications for practice, Counselling Psychology Quarter&, 4(2/3), pp. 177-190. SILVERMAN, D. & PERAKYLA,A. (1990) AIDS counselling: the interactional organization of talk about delicate issues, Sociology of Health & Illness, 12(3), pp. 293-318. SILVERMAN, D. (1992) Advice-giving and advice-reception in AID Counselling in: P. AGGLETONet al. (Eds) AIDS (Basingstoke, Falmer Press). STOLLER,E.J. & RUTHERFORD,G.W. (1989) Evaluation of AIDS prevention and control programs’, AIDS, 3 (SUPPI.l), pp. S289-296. STRONG,P.M. (1979) The Ceremonial Order of the Clinic (London, Routledge).
Appendix Transcription Symbols The symbols used are as follows: (0.3) pause in parts of a second (.) very short pause [overlaps hh outbreaths or inbreaths er:: extended sounds little emphasized words =where next utterance follows immediately after previous one (put at the end of the first utterance and beginning of second) ( ) untranscribeable passage (address)? guess at utterance X insert for name of P when used by C Y, Z etc for other names or places used by either speaker
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Discussing safer sex in HIV counselling: assessing three communication formats a
a
D. Silverman , A. Perakyla & R. Bor
b
a
Department of Sociology , Goldsmiths' College, University of London , b
District AIDS Counselling Unit , Royal Free Hospital and School of Medicine , London, UK Published online: 25 Sep 2007.
To cite this article: D. Silverman , A. Perakyla & R. Bor (1992) Discussing safer sex in HIV counselling: assessing three communication formats, AIDS Care: Psychological and Socio-medical Aspects of AIDS/ HIV, 4:1, 69-82, DOI: 10.1080/09540129208251621 To link to this article: http://dx.doi.org/10.1080/09540129208251621
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AIDS CARE, VOL. 4, NO. 1, 1992
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Discussing safer sex in HIV counselling: assessing three communication formats D. SILVERMAN, A. PERAKYLA & R. BOR’ Downloaded by [York University Libraries] at 17:50 22 December 2014
Department of Sociology, Goldsmiths’ College, University of London and District AIDS Counselling Unit, Royal Free Hospital and School of Medicine, London, UK
Abstract Although it is acknowledged that counselling can be an important factor in behaviour change, we lack information on how HIV counselling works in practice. Research is reported based on transcriptions of audio-tapes of counselling drawn fiom seven hospital centres in England and the USA. It is shown that communication occurs in the context of three diflerent formats. Certain formats and conversational strategies used by counsellors produce far greater patient participation. Such participation may hold out the prospect of greater behavioural change than simply listening to information and advice. Introduction It is now generally accepted that ‘AIDS is primarily a social phenomenon with urgent.. . medical issues attached’ (Miller, 1988, p. 130; see also Neilkin, 1987, p. 980). One of the many tasks of social research is to establish the kind of interventions which are most likely to be successful in promoting change towards safer sexual practices. Despite the problems in isolating the factors which are effective in behaviour change (Miller & Pinching, 1989), we are fairly clear about ineffective forms of intervention. In particular, it has now been established that knowledge itself does not produce behavioural change (Stoller & Rutherford, 1989; Nelkin, 1987; Aggleton, 1989; Greenblat et al., 1989). Moreover, fear-arousal is generally ineffective (Sherr, 1989). This is reflected in the reported lack of success of media campaigns on AIDS even among highly-motivated gay men (Frosner, 1989). Only two factors seem powerful motivators of change in health behaviour: 1. Peer-group support and pressure (Stoller & Rutherford, 1989; Sherr, 1989; Elmslie,
1989). 2. Acquiring skills rather than just knowledge (Stoller & Rutherford, 1989). One of the ways in which relevant skills can be acquired is through appropriate counselling. This is particularly important since there is very little evidence to support the assumption that HIV testing alone can motivate behaviour change (Miller & Pinching, 1989). However, although there is a number of texts on the nature and techniques of HIV
Address for correspondence: Professor David Silverman, Department of Sociology, Goldsmiths’ College, University of London, London SE14 6NW, UK.
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and AIDS counselling (Miller & Bor, 1988 is particularly useful in offering discussion of the process of counselling rather than just its content), until now we lack research based on detailed transcriptions of actual counselling interviews.
What is counselling?
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On the surface, it would appear that we already know what HIV Counselling is. For instance, the WHO GPA definition of HIV Counselling (quoted by Carballo & Miller, 1989, p. 121) states: “HIV counselling is an on-going dialogue and relationship between client or patient and counsellor with the aims of preventing HIV transmission and providing psychosocial support for those affected, directly and indirectly, by HIV. In order to achieve these aims, counselling seeks to encourage and enhance self-determination, to boost selfconfidence, improve family and community relationships and quality of life.” Prevention counselling has five main steps: 1. Determining whether the lifestyle and behaviour of an individual or a group of
individuals presents a risk of HIV infection. 2. Working with them so they understand the risks.
3. Helping to identify the meaning such behaviours may have for them. 4. Helping to identify and define the potential for behaviour change. 5. Working with individuals to achieve and sustain appropriate and chosen changes in behaviour. From this approach to prevention implicitly emerges a supportive and trusting relationship on the basis of which crises and problems emerging from HIV awareness or infection can mutually be addressed and overcome. Despite the length of this definition, Carballo & Miller acknowledge that, without research, we cannot know what counselling looks like in practice nor ‘its overall efficacy in prevention and impact reduction’ (ibid, p. 119). Moreover, this research has yet to be done: ‘few programmes have actually exposed themselves to any rigorous evaluation and few methodologies that have been tried and tested have been evaluated’ (p. 122) This argument is supported by Bor (1989) who suggests that questions which still need answering are: ‘Is counselling effective and what are the different approaches to evaluating HIV counselling?’. Bor also notes how the papers on AIDS Counselling at the 1989 Montreal AIDS Conference concentrated on “approaches to behavioural change, health education and psychosocial support rather than communication in clinical settings.’ The Counselling and Safer Sex Study
With the support of the English Health Education Authority, a study was begun in October 1988 which set out to examine the organization of counselling concerning safer sex within HIV counselling centres in England. The study had three short-term aims: 1. T o describe both the content and structure of counselling of safer sex in England
and to demonstrate how different organizational settings influence the actual practice of advice and information-giving
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2. To identify problems and conflicts which arise in this form of counselling and especially explore how the professional backgrounds of the counsellors and their theories of practice permeate their dealings with clients 3. T o examine in detail the actual process of counselling; the verbal and non-verbal behaviour of professional and client, and demonstrate how the various forms of communication provide very different learning environments for clients, and thereby influence the success or failure of the counselling process. In this paper, we discuss only item 3 (see also Perakyla & Bor, 1990). Items 1 and 2 are discussed elsewhere (see Silverman, 1990).
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Methods Recording and transcription of actual counselling exchanges using techniques from sociological work on naturally-occurring social encounters (see Silverman, 1987). This essentially ethnographic approach is standard in anthropology and political science as well as sociology. Its aim is to discover and illustrate particular types of event-not, usually, to enumerate their frequency. In order to do this, unlike many studies which use tape-recorded data, high levels of transcription quality are required. In particular, such features as pauses and overlapping talk are always included. Sample Audio-recordings of counselling around the antibody test were obtained from five English centres and two US centres. This paper is based on 90 episodes of pre-test counselling and 10 post-test counselling interviews drawn from one US centre which did not offer individual pre-test counselling. Recording was based on the informed consent of patients.
What can the research offer? We need to begin with two notes of caution: (1) Only one of the authors is a counsellor and this paper is not based on any any normative version of counselling. Instead, we seek to discover what actually happens in these interviews. (2) The research design does not include interviews with a panel of patients to identify continuities and changes in their ideas and behaviour-the most common means of evaluating programmes. However, such interviews have to be viewed with caution because they cannot usually separate the impact of a number of independent variables on behaviour, e.g. not only counselling but peer-group pressures, media campaigns, etc. Moreover, the research interview itself may have an impact on patients’ perceptions and behaviour. Nonetheless, the research is able to offer important information to counsellors. First, we seek to identify how communication in counselling works in practice. So we ask what are the main communication formats used in counselling? What is the nature and extent of patient participation in each format? And how is ‘safer sex’ discussed in practice? Second, we seek to offer counsellors and trainers of counsellors an opportunity to consider the consequences of different ways of organizing communication in counselling based not on hypothetical examples but on transcripts of actual counselling interviews. In order to focus the discussion, in this paper we focus largely, although not exclusively, on counselling around the HIV-antibody test with special reference to sexuality. For
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convenience, P will indicate patient and C counsellor-for the appendix below.
other transcription symbols see
The three formats
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Medical sociologists have demonstrated how practitioner-patient communication occurs within a set of cultural assumptions which shape the behaviour of both parties. For instance, doctors and patients in fee-for-service medicine assume different obligations and make different claims than in tax-paid medicine (Strong, 1979; Silverman, 1984). We take from this work the concept of ‘role-format’ to describe the rolls of professional and client at various stages of a counselling consultation. Three such formats have been identified:
1. Interview. 2. Information-delivery. 3. Service encounter. We will give examples of each format below, using material where sexual matters are discussed. A fourth format (advice-giving) has also been identified but is excluded here for reasons of space (see Silverman, 1992). At the beginning of consultations in all centres, talk about sexual matters occurs by the P providing answers to questions asked by the C. We call this an interview format: Extract A (Code: 21 AP 9) (male) 1 C: right (1.0) umm (0.5) you’ve come just for an HIV test 2 P: hhum 3 C: (0.5) can I just ask you briefly er one or two questions 4 before we start? (0.5) have you ever had a test before? 5 P: no 6 C: no (0.5) have you ever injected drugs? 7 P: no 8 C: (3.0) have you ever had a homosexual relationship? 9 P: (0.5) no (0.5) and that’s not really (0.5) not really put 10 me in a high risk group now [has it? 11 c: [no no it doesn’t Extract A begins with the C setting up an interview format where the P delivers answers to a series of questions. In the P’s final answer, however, he tacks on a question which reverses the roles of questioner and answerer. Where the C is answering the P’s questions, we call this a service encounter. What seems to be happening at the start of this extract is a communication pattern modelled on a medical history-taking (we return later, however, to the positioning of C’s question on line 8). Although Cs are not specifically concerned with diagnosis, the use of an interview format at this stage is probably a useful way for the C to assess Ps’ sense of their risks and so to tailor the later discussion to the P’s individual needs and fears. After this initial use of an interview format, Cs differ widely in the communication format which they use to discuss sexual behaviour. In most centres, quite early in the consultation, Cs use a third footing to discuss safer sex: information-delivery. The difference between the information-delivery format and the interview format is very simple: in the former, the C does almost all of the talking, whereas in the latter, the C asks questions and the P provides answers.
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Shortly afterwards, in the same consultation, the C addresses safer sex in an information delivery format: Extract B 173 C. 174 175 P: 176 C. 177 178 P: 179 C 180 181 182 P: 183 C: 184 185 186 187 P: 188 C. 189 P: 190 C: 191 P: 192 C: 193
as far as sex is concerned it means keeping to the safer sex guidelines [hmm [for two reasons (0.5) firstly to try and prevent them passing it on to anyone else hmm umm and secondly because really they can’t afford to catch you know some of the other sexually transmitted diseases that are around well yeah um uh (0.5) and basically it means either sticking to noninsertive sex like mutual masturbation um (0.5) massage that kind of thing or else if they do you know carry on having full sex to use a condom um preferably with a spermicidal backup as well yeah (1.0) is there anything you want to ask (0.5) so far you no uh heh heh right (2.0) one of the biggest drawbacks with having this test is as far as insurance (0.5) is concerned.. .
In Extract Bythe C delivers a package of information to the P about safer sex. At this stage of pre-test counselling, almost identical packages are used with other Ps attending this Centre. This seems to happen because Cs do not pursue an interview format in order to establish each P’s own beliefs and practices regarding ‘safter sex’. By contrast, the information-delivery format used at this early stage makes the P a passive recipient of generalized information. Predictably, the P here offers nothing more than a few monosyllabic responsetokens and then turns down the offer of a service-encounter by indicating that he has no questions. At another Centre, a very similar information package is offered to a young female P. Once again, within an information-delivery format, the P produces only a minimal response. Following a two second pause, the C has to ask ‘okay?’ (line 71) before the P says anything at all: Extract 61 C: 62 63 64 65 66 67 68 69 70
C (42B NH4) (Female) so you know it’s not hh dead set on ten years hh now there are other people who could be HIV positive but not actually develop AIDS as such hh so they could be (.) carriers they could (.) stay well hh but pass the virus to people that they have sex with hh this is why we say hh if you don’t know the person that you’re with (0.6) and you’re going to have sex with them hh it’s important that you tell them to (0.3) use a condom (0.8) or to practice safe sex that’s what using a condom is (2.0)
74 D.SILVERMAN, A. PERAKYL.A 81 R. BOR 71 72 73
C: okay? P: mm (2.0)
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Immediately afterwards, however, the C moves into an interview format to try to elicit the P’s own experience in this area: Extract 74 C: 75 76 P: 77 78 C: 79 P: 80 C: 81 82 P: 83 C: 84 85
D (42B NH4) has your partner ever used a condom with you? (1 -2) no: (1.2) do yer know what a condom looks like? no (
1
have you perhaps (1 .O) a condom shown to you (.) at school or: no yer didn’t right okay hhh (2.0) is there anything that yer worried about in terms of yer test if it’s done today? (.)
Since there is an obligation to give answers to questions, the interview format can be expected to produce a fuller P response than information-delivery. In Extract D, the C’s questions do at least produce some answers about the P’s experience and knowledge. However, perhaps because of the P’s uniformly negative answers, the C switches topics from sex to the P’s fears (lines 84-86). Later the C tries an extended discussion of safer sex in an interview-footing. The extract illustrates the difficulty that professionals face in eliciting any sort of response from many adolescents, particularly when the topic relates to delicate matters (see Silverman, 1987; Silverman & Perakyla, 1990). In particular, we can note the use of repeated questions and long pauses by the C to try to elicit an answer and the multiple coughs and sniffs that are often the major tokens of the P’s presence: Extract E (42B NH4) 170 C: hh and yer not protecting yerself 171 (1.2) 172
173 174 175 176 177 178 179 180 181 182 183 184 185 186
C:
that’s worrying isn’t it?
C: P: C:
tt [will yer talk to yer boyfriend about maybe using a
(4.0)
P:
[coughs] condom? (3.5) probably (.) I dunno (1.0)
mm it is important (1 -3) C: mm? (0.8) C: do you know where you could get condoms? (0.8) P: ( 1 C:
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187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205
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C: P:
where would you ( ) buy? chemists? (1 *o> c: right tt (.) and I know that (1.0) hhh you don’t have any income (0.7) and: apart from pocket money from heh yer parents probably hh and (0.4) yer boyfriend’s not working is he? ( ) he’s not working so it’s [going to cost P: [coughs] C: quite a lot of money isn’t it? hh so you can get condoms from family planning clinics (1.4) okay? (1 *o> C: do yer know where your nearest family [planning clinic is P: [sniffs] (2.0) P: no (1 -7) P: Y Road I think (1 *o> C: ri::ght (C gives phone number of clinic and packet of condoms to P)
Extract E shows C valiantly using the interview format to try to elicit the P’s own knowledge and past, present and future behaviour. Although the P’s responses are minimal, they indicate at least the possibility of behaviour change because the C is getting her to address her own particular situation rather than simply providing pre-packaged information. Indeed, the turn that this counselling session now takes suggests that the early move into information-delivery that we saw in Extracts B and C is unhelpful. Safer sex in an interview format
We now turn to consultations where the sequence of formats is reversed. In the extracts below, the Cs stay in an interview-footing during the first half of the consultation. Only later do they use an information-delivery format and then they deliver recipient-designed rather than pre-packaged information. Extract F (SSV3p.l) (Male haemophiliac P recently married) 1 C: um what are you actually doing? 2 P: we’re just using er condoms (0.3) 3 C: [umm 4 P: [for safe sex 5 C: umm 6 P: um we (0.5) intend to use spermicide 7 C: umm 8 P: er but we don’t intend to use (0.3) the cap Extract G (SSVl5) (pre-test counselling of gay man) so say if it’s negative how would that affect your c: relationship (0.3) with A? 3 P: I don’t [think it would 1 2
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4
c:
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
P: C:
P:
c: P:
C: P: C: P:
c: P: C: P: C:
P: C:
P: C:
[I mean apart from your present plans [to move in [Yes with him? I honestly don’t think it would hh I mean obviously some er ihh sexual plans would have to be taken but (0.3) that’s no big deal um what do you know about that? (2.5) well I mean I I I’ve read safe sex literature and er (1.0) been exposed to to that (0.5) um penetration passage of body fluids (0.3) are things to be avoided (0.5) [um [right and (0.3) using condoms yeah quite and er spermicide yeah (0.3) sure (1.0) do you think that would be a problem [for you= [no =no or something you’re used to yeah it really wouldn’t be a problem at all what about to A? no not to him certainly not = =right (0.5) just think too only what if it’s positive? mm (5.0) what for you would be your greatest concern do you think about that test result?
In both Extracts F and G, the Cs are displaying their professional skills by not offering information but by asking questions. As in Extract E, these questions centre around the practical and social context in which the Ps are currently acting. However, unlike Extract E, they precede the use of an information-delivery format by the C. The sceptical reader will have noted that Extracts F and G involved patients belonging to groups whose health knowledge in this area is higher than the general population. If we exclude gay men and seropositive haemophiliacs, can the interview format be used to discuss safer sex in HIV counselling? Take Extract H which occurs early on in pre-test counselling with a heterosexual man: Extract 1 C: 2 3 P: 4 5 6 7 8 9 C: 10 11 P:
H (SSV6) what do you understand about your own risk for HIV? (1.0) well (1.0) I suppose I’m in one of the high risk categories because I’ve had a lot of partners I don’t know what I’d call a lot I’ve certainly had over a hundred erm (1.0) and that this is why I think the doctor said it would perhaps be a good idea because of that because it does put me into a high risk category right (0.5) when you’ve had intercourse with your partners have you used any kind of protection at all= =I have in the last two years um (1.0) certainly I
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12 13 14 C: 15 P: 16 C: 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34
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haven’t had unprotected haven’t had unprotected sex for the last two (0.5) years so what have you been doing for the last two years? always used condoms right do you use anything else [does your [no
P: C: girlfriend use the cap as well do you use spermicide or P:
no like that sometimes can increase the [the P: [Yes c: protection because as you know condoms sometimes aren’t necessarily one hundred percent [safe P: [no I I accept that no [just condoms C: [from the point of view of pregnancy P: erm no as it happens my last two regular girlfriends um neither of them were on the pill er but I I used a condom anyway C: yes sure the pill wouldn’t protect you from HIV at all P: no c: right what made you think about (0.5) starting to use a er condom a couple of years ago?
c
The extract begins in the interview format with a question that is asked at early stages of pre-test counselling in all Centres participating in the study. However, in most Centres Cs treat the P’s answer about sense of ‘risk’ as relevant to history-taking and speedily move into information-delivery. Here, on the other hand, the C stays in an interview format by asking the P to specify his answers. A certain amount of information is conveyed by the C (about other forms of protection than condoms) but this is tailored to the P’s answers and also serves to explain the rationale behind the C’s questions. The extract concludes with the C using the interview format to encourage the P to talk about what has influenced his behaviour in regard to condom use. As seen in Extract H, the interview format can be used to encourage Ps to specify their sexual beliefs and practices. However, there can be problems when the C too rapidly exits from this format without having asked the P for such specification. Take the discussion of ‘safer sex’ in Extract I below. Extract I (9 BP 8) (Pre-test counselling with a gay man) 1 C: okay (1.0) do you want to tell me why you want the test 2 so that we can sort of [umm 3 P: [umm= 4 C: =work out a few things to say to you 5 P: well I’m I’mguy= 6 C: =right 7 P: and (1.0) hh I have (0.3) a an affair 8 C: right 9 P: er and (0.3) just want to be stay sure in my own mind= 10 C: =okay (0.3) fine umm (0.5) obviously umm your your
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11 12 13 14 15 16 17 18 19
homosexuality is the reason why you’re [here P: [yeah = =really umm do you do you practice safer sex at all [or C: P: [Yes C: you do so umm umm that (1.0) that must give you a little bit of comfort [anyway P: [Yes C: fine (0.5) can I just ask you while I’m asking you these questions have you ever used intravenous drugs?
In I, the C begins with the usual question. However, she does not pursue the P’s answer about his ‘affair’ and offers her own gloss for his self-description (‘gay’ becomes ‘homosexuality’). Nonetheless, she stays in the interview format to ask a question about safer sex. Once again, rather than getting the P to specify his answer, she offers another gloss (‘that must give you a little bit of comfort’) and then returns to a history-taking use of the interview format related to an entirely different topic. Extract J (also pre-test counselling with a gay man) reveals how the topic of safer sex can be pursued further within an interview format: Extract J (10ASD2) 17 C: You’re a gay man? 18 P: yeah 19 C: do you have a regular partner? 20 I?: no 21 (5.0) 22 C: and you practice safe sex normally 23 P: yes 24 C: what does safe sex mean to you? 25 P: (0.5) umm (2.0) no fucking 26 C: right (.) non penetrative 27 P: yes C’s question at line 24 succeeds in getting a specification from P of his knowledge, although this too is followed by the C’s own gloss at line 26. These extracts have shown the different impact of two communication formats. Information-delivery works smoothly since it only requires Ps to offer informationacknowledgments, like ‘mm’ (Extracts B and C). Thereby, Cs do not need to invite Ps comments on potentially delicate topics and Ps do not need to provide such comments. By the same token, however, without such comments, it is difficult to know how relevant the information is to the patient. Conversely, the interview format generates more P response. However, it can also take a long time, particularly where Ps seem reluctant to speak (Extract E). Even when Ps produce answers, a concentration on rapid history-taking can mean that Cs simply shift to another topic (Extract I). This can mean that questions are framed in ‘loaded’ ways with an unknown relevance to the P perceptions (Extract A). Again, in Extract A, the C’s choice of the term ‘homosexual relationship’ (line 8), is placed after questions about two relatively ‘deviant’ activities (having more than one HIV-test and being a drug-injector). Strategies which encourage patients to speak We have already noted that one of the advantages of the interview format is that, by tying
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the structure of the C’s talk to a series of questions, it encourages the P to speak. This is simply because question-answer sequences are a form of what conversation analysts call ‘adjacency-pairs’. In such pairs, there is an expectation that the conversation cannot go on until a response has been given. One of the difficulties of most professional-client encounters is that clients are not usually able to claim the floor in the same way as professionals. In practice, this can mean that while the C speaks as of right, the P has to engage in complicated manoeuvres in order to gain the floor. Take this example: Extract 81 P: 82 83 P: 84 85 C: 86 P: 87 C: 88 P: 89 C: 90 P: 91 92
K well we continue ter you know we try to be safe (0.7) er: (1.0) er: but I have a coupla questions for you (0.5) su[re [about how we can be safe ( ) go ahead= =if that’s okay aha er (1.0) erm (.) there are a coupla things that that we like to do and I was wondering you know like tt the safety factor of this
What is remarkable here is that, instead of asking his questions directly, the P engages in an elaborate build up. First, he projects that he will have questions to ask (line 83). This leads into the establishment of a service encounter format. Second, he asks permission to ask these questions (line 88). Only then does he get round to asking his questions. Note, moreover, the ‘perturbations’ (hesitations, pauses and self-repairs) that are present in both the question-projection and the question itself. Extract K is a strong example of the general rule that patients only speak if they are invited to. Without such an invitation, elaborate work from the P is needed. Yet perhaps there is a tacit invitation to speak here. Note the pause at line 82. This indicates that the C has declined his opportunity to take the floor at this point and thus begins the chain that ends up with the P setting up what we have called a ‘service-encounter’ format. As it turns out, declining to take the floor during pauses is a powerful weapon which Cs can use to encourage Ps to speak. Look at this example from an earlier point in the same consultation: Extract L (51A WH1) 44 C: okay your result came back (.) negative 45 P: mm hm 46 (0.5) 47 C: is that what you expected? 48 P: ye:ah 49 (1.0) 50 P: you see I really don’t (0.5) I haven’t engaged in (.) anal sex (.) or even oral sex heh I’ve been (.) pretty 51 safe and er: (.) I’m just a bit of a worry (wart?) 52 53 (0.3) 54 P: [you know
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C: [hm hm P: I mean there are some people who get anxious about (0.7) their health C: mm (0.8) P: er: (1.0) then I just wanted to be sure like (.)
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In this US Centre, where Ps have not had an individual interview with a counsellor prior to their test, test results are usually not given until some way into post-test counselling. However, we are concerned here more with the strategies that the C uses to encourage the P to talk. We note the following: 1. At line 46, the C does not take up the available turn immediately (0.5 second pause). 2. When this fails to produce any elaboration by the P on his enigmatic response at line 45, the C asks another question. 3. When the P again gives a short answer (line 48), the C allows a 1.0 silence to pass without speaking. 4. Subsequently, he utters only neutral response-tokens (lines 55 and 58) and allows a pause to develop at line 59. In the event, the P uses the turn-slots created by the C”s strategies to talk about what he understands by safer sex. If Extract K has illustrated how difficult it is for Ps to take the floor, Extract L shows how they can be encouraged to speak by Cs remaining silent. Just as the questions within the interview format demand answers, so silences encourage Ps to take the next turn to talk. An important exception to this can be found if we refer back to Extract B. We observe two long silences at lines 190 and 192. Despite the silence, the P does not speak. The constraining factor here seems to be that these pauses occur after the C has spent some time delivering information. In this kind of communication format, Ps are not expected to offer more than information-acknowledgments (like ‘mm’). It therefore seems likely that pauses by the C in the information-delivery format are functionless from the point of view of P participation. Instead, they seem to function here simply to mark changes of topic.
Conclusions In comparison with the interview, the information-delivery format is far less complicated for the C. The C is less dependent on the P’s contribution to the conversation because only recipiency (mms etc) and little talk is required from the P. This has two advantages for the hard-pressed C. First, the C can deliver pre-designed information packages without much reflection. Second, a similar range of issues can be covered within a shorter period of time, particularly because the greater dependency of the interview format upon the P’s contribution makes it more liable to the kind of communication difficulties we saw in Extract E. This is not an irrelevant consideration given the pressures on Cs in many Centres. However, as we have seen, much depends on the sequence in which formats are placed. In our material, Cs using the interview format to discuss safer sex do quite often also offer Ps their own views on the topic. But that happens only after a long sequence of questions and answers and is grounded on the P’s own account of what they are thinking and doing. This suggests that favouring an interview format is not incompatible with giving the P the latest expert information-indeed it is highly compatible with delivering that information in a way specifically designed for its recipient. following a long question-answer sequence in
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the interview-format. Counsellors who concentrate on the interview format reveal that effective HIV counselling involves considerably more than careful listening to the patient and appropriate information delivery. Rather, faced with the potential delicacy of the topics involved, successful counsellors must work very hard at getting their patients to speak (Silverman & Bor, 1991).
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Health education implications Our findings have strong parallels with a study of tape-recordings of general practice consultations carried out in the 1970s (Byrne & Long, 1976). In almost two-thirds of the authors interviews, doctors simply announced their diagnosis or limited themselves to an instruction to their patients. In only a quarter of the cases, did the doctor encourage the patient to participate in the decision about what was to be done. For Byrne & Long, patients should be involved in their own treatment and doctors should encourage offers of changed behaviour. Such patient-centred medicine would be characterized by open-ended questions, the exploration of patients own ideas and attempts to negotiate bargains. However, like Byrne & Long, our data does not in itself validate any claims about the therapeutic effects of particular ways of organizing communication. Nevertheless, if we assume, as most counsellors do, that the effects of counselling derive from Ps putting their problems into words, then the interview format inevitably appears to be the most effective. Equally, the lack of impact of information alone on behavioural-change suggests that to rely solely upon the use of an information-delivery format for the discussion of safer sex is probably inadequate. The research has provided examples of Cs using communication formats which generate the P’s own version of their problems are possible solutions rather than simply delivering advice and information. This seems to be an effective way to satisfy items 3-5 of the WHO GPA definition of HIV Counselling. Equally, given that what most trainee counsellors fear is having to ‘play God’, our emphasis on the constructive potential of the professional remaining silent and abstaining from generalizer information statements may be welcome. Acknowledgements We gratefully acknowledge the help of workers and patients at a number of centres who made this research possible. We particularly thank Riva Miller and Eleanor Goldman (Royal Free Hospital Haemophilia Centre) and Heather Salt (Royal Free Hospital District AIDS Unit) whose counselling practice has been a constant source of insights to us. The English Health Education Authority and Glaxo Holdings plc funded the research upon which this paper is based and we are delighted to acknowledge their support. References AGGLETON,P. (1989) Evaluating health education about AIDS in: P. AGGLETONet al. AIDS: Social Representations, Social Practices (Basingstoke, Falmer Press). BOR, R. (1989) AIDS counselling, AIDS Care, 1(2), pp. 184-187. BYRNE,P. & LONG,B. (1976) Doctors Talking to Patients (London, DHSS). CARBALLO, M. & MILLER,D. (1989) HIV Counselling: problems and opportunities in defining the new agenda for the 1990’s, AIDS Care, 1(2), pp. 117-123. ELMSLIE,K.D. (1989) AIDS and women, AIDS Care, 1(1), pp. 219-222. FROSNER, G. (1989) How efficient is ‘safer sex’ in preventing HIV infection? Infection, 17(1), pp. 1-3.
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82 D. SILVERMAN, A. PER4KYLA & R. BOR GREENBLAT, C. et al. (1989) An innovative program of counselling family member and friends of seropositive haemophiliacs, AIDS Care, 1(1), pp. 67-75. MILLER,D. (1988) HIV and social psychiatry, British Medical Bulletin, 44(1), pp. 130-148. MILLER,D. & PINCHING,A.J. 11989) HIV tests and counselling: current issues, AIDS, 3 (suppl. l), pp. S187-193. MILLER,R, & BOR,R. (1988) AIDS-A guide to Clinical Counselling (London, Science Press). NELKIN,D. (1987) AIDS and the social sciences: review of useful knowledge and research needs, Reviews of Infectious Diseases, 9(5), pp. 980-987. PERAKYLA, A. & BOR, R. (1990) Interactional problems of addressing ‘dreaded issues’ in HIV-counselling, AIDS Care, 2(4), pp. 325-338. SHERR,L. (1989) Health Education, AIDS Care, 1(2), pp. 188-192. SILVERMAN, D. (1984) Going private: ceremonial forms in a private oncology clinic, Sociology, 18(2), pp. 191-204. SILVERMAN, D. (1987) Communication and Medical Practice (London, Sage). SILVERMAN, D. (1990) The social organization of HIV counselling in: P. AGGLETON et al. (Eds) AIDS: Individual, Cultural and Policy Perspectives (Basingstoke, Falmer Press). SILVERMAN, D. & BOR,R. (1991) The delicacy of describing sexual partners in HIV-test counselling: implications for practice, Counselling Psychology Quarter&, 4(2/3), pp. 177-190. SILVERMAN, D. & PERAKYLA,A. (1990) AIDS counselling: the interactional organization of talk about delicate issues, Sociology of Health & Illness, 12(3), pp. 293-318. SILVERMAN, D. (1992) Advice-giving and advice-reception in AID Counselling in: P. AGGLETONet al. (Eds) AIDS (Basingstoke, Falmer Press). STOLLER,E.J. & RUTHERFORD,G.W. (1989) Evaluation of AIDS prevention and control programs’, AIDS, 3 (SUPPI.l), pp. S289-296. STRONG,P.M. (1979) The Ceremonial Order of the Clinic (London, Routledge).
Appendix Transcription Symbols The symbols used are as follows: (0.3) pause in parts of a second (.) very short pause [overlaps hh outbreaths or inbreaths er:: extended sounds little emphasized words =where next utterance follows immediately after previous one (put at the end of the first utterance and beginning of second) ( ) untranscribeable passage (address)? guess at utterance X insert for name of P when used by C Y, Z etc for other names or places used by either speaker
