Participating with limited communication means: Conversation analytical perspectives on the interactional management of participation structures

Introduction

In the following, participation with limited communication means is discussed from an ethnomethodological and conversation analytical (CA) perspective. This perspective establishes a frame for the different contributions to the special issue at hand. The special issue provides a summary of reflections started and research results discussed in an exploratory workshop series on ‘Communicative impairment in interaction. A Nordic perspective on the social organization of disordered talk’, funded by the Joint Committee for Nordic Research Councils in the Humanities and Social Sciences (NOS-HS) in 2014 (Grant number: 229915/F10). The articles are gathered on the basis of two goals. First, we have a methodological interest in CA studies on communication disorders and aim to highlight their impact for clinical practice. We find that an emphasis on CA may contribute to shifting the prevailing research focus on communication disorders from a cognitive impairment perspective to the interactional management of joint activities, which also includes the physical and organisational environments in which persons with limited communication means participate. Second, this special issue derived from an attempt to get an overview of existing CA research on communication impairment in the Nordic countries of Europe, where there is currently a strong and diverse research agenda developing within the field of CA and communication impairment. It should be noted, however, that the collection of articles in this special issue is not exhaustive, and there are many more Nordic researchers working on communication impairment from a CA perspective. However, the contributions to this special issue are representative for the kind of work that is currently going on, and is on the rise.

CA research on communication impairment in Denmark, Finland, Sweden and Norway: A brief history

CA research on communication impairment in the Nordic countries started developing around the turn of the century. In Finland, the first studies within speech and language therapy that applied CA on interaction involving persons with aphasia can be dated back to the mid 1990s (e.g. Klippi, 1996; Laakso, 1997). In Norway and Denmark, CA research on communication impairment began to develop early in the 21st century, as exemplified by Lind’s research (Lind, 2002; Lind, 2005) on interaction involving persons with aphasia in Norway and, further, Jensen & Stax (2005), Brouwer, Hougaard & Hougaard, (2008) and Rasmussen (2010) within speech and language therapy in Denmark. In Sweden, CA research on communication impairment also started out in the early 2000s, exemplified by Anward (2003) on aphasia, followed by two projects on interaction involving children with language impairment and adults with acquired aphasia (e.g. Plejert & Samuelsson, 2008; Plejert, Samuelsson & Anward, 2010; Samuelsson, Plejert, Nettelbladt & Anward, 2010). These studies laid a basis for further research, revealing a novel perspective on atypical interaction and bringing about a broader understanding of the specificities of interaction involving persons with limited communication means in different contexts and those who are speakers of Finnish, Norwegian, Danish or Swedish. The work mentioned above, and further Nordic research in the same line of reasoning, we believe are worth making visible in a scientific landscape that to a large extent has been concerned with communication impairment in English-speaking contexts.

Participation as individual involvement: The ICF model

The point of departure of this special issue is the concept participation. How persons with communicative impairment can become part of social life is a major concern for practitioners as well as researchers. Participation has, for example, been a focal area within speech and language theory, as witnessed by the social model (Byng & Duchan, 2005; Simmons-Mackie, 2000), and by the functional approach (Worrall & Frattali, 2000). It is also one of the key terms in the International Classification of Functioning, Disability and Health (ICF) published by the World Health Organisation (WHO). The ICF framework was developed to enable practitioners to categorise the unique shape of the individual’s ‘functioning and disability’ so it can be contrasted and compared to other cases in clinical practice or social work. The ICF defines participation in relation to the term activity: ‘Actions and tasks executed by individuals are defined as Activities, and involvement in life situations is defined as Participation’ (WHO, 2013, p. 35). Thereby ‘[e]very action, particularly when executed in a social environment, may be considered participation, and participation always entails the execution of an action or task’ (WHO, 2013, p. 36). For measurement, these terms are split up in sub-categories such as Learning, Communication and Mobility (which again are built on different variables), and the practitioners are asked to record the individual’s abilities in a checklist, in which each variable is qualified by a number that indicates the severity of the individual’s limitation or restriction [in all, there are 5 levels from 0 (no problems or within normal limits) to 4 (complete or profound disability)]. Even though the ICF is open to personal aspects and contextual features, we find it limited (see also Duchan, 2004; Rasmussen, 2016). The ICF definition of activity focuses on ‘individual’s actions and tasks’ rather than actions and tasks as emergent social and dialogical processes that always involve more than one person. The definition of participation thus implies that participation is about an individual’s involvement in life situations, disregarding how other participants act to include and exclude them in interactional processes. Furthermore, Rasmussen (2016) shows that the use of abstract categories that split up the complex situated and interactive interplay through which individuals construct actions and participation in collaboration with others and fails to understand the situated construction of categories within the ongoing interaction. Rasmussen concludes that the ICF model used in practice ‘loses sight of the very phenomena it aims at describing’ (Rasmussen, 2016, p. 217). In contrast to the ICF’s abstract and monological view of participation, the articles of this issue offer a dialogical (process-oriented) view on participation with a focus on the situated constructions of participation which the participants themselves orient to and make relevant in their interaction with each other.

Participation in interaction

The analysis of how communicative abilities are affected when persons live with limited communication means is traditionally based on cognitive models (Ellis & Young, 1988). These models focuses on the cognitive abilities of the individual, and these abilities are primarily tested in isolation from his or her everyday interactional context. Although linguistic and cognitive testing provides valuable information regarding communicatively important functions, test results do not give a complete picture of the level of functioning in everyday life. However, in recent years a new perspective, focussing on the interaction involving participants also with communicative impairments, has evolved, many within the field of conversation analysis (Sacks, Schegloff, & Jefferson, 1974; Sidnell & Stivers, 2012) and interaction analysis (Goodwin, 2000; Heath et al., 2010).

The special quality of CA studies provides a detailed analysis of the sequential organisation of talk-in-interaction based on video recordings of interactions of everyday practices of adults and/or children. A strong focus is set on the collaborative and situated processes of meaning-making, in which the participants perform and coordinate their actions in close relation to one another. Such an approach opens up for the participants’ understanding and interpretation of participation, ability and (dis)ability. Within this paradigm, tests and other assessments can also be analysed as interactional situations. In this way, the analysis does not centre on isolated sentences or single elements of speech, but on the interactional and emergent production of meaning in the lived, social world of the individual.

CA (and discourse analytical) research has demonstrated that interaction involving persons with communicative disabilities is typically linguistically asymmetrical. The participants living with limited communication means may experience different kinds of problems in their speech performance, ranging from word-finding problems to severe problems in speech production. An essential question concerns the ways the linguistically challenged participant is able to construct her/his turn and how the partner is able to infer the meaning of a turn. Turn constructions that are sparse on linguistic and prosodic information and often elliptically composed may threaten the establishment of intersubjective understanding. This makes the question of how, then, intersubjective understanding is established, checked and remediated in these conversations? Remediation in this case refers to the need for interactional work that is manifested as self-initiated or other-initiated repair. For this reason, long and sometimes complex repair sequences are common in interaction involving persons with communicative disabilities, and collaboration between the participants is needed (Laakso & Klippi, 1999). Detailed analysis of interaction may also reveal instances where persons with limited communication means demonstrate their interactional competence, despite their linguistic problems—instances that might have been overlooked within other theoretical frameworks. A CA perspective on the interactional management of communication impairment shifts the analytical focus to ‘the joint projects that participants resolve’ (Norén, Samuelsson, & Plejert, 2013b, p. 3).

The use of video recordings enables focusing on the entire situated context, and participants’ interplay with and use of several different semiotic resources (Goodwin, 2000; Rasmussen, Hazel, & Mortensen, 2014; Streeck, Goodwin, & LeBaron, 2011; Klippi, 2015) that construct meaningful activities and thus are beneficial for participation (cp. WHO’s definition mentioned earlier). In this work, concepts such as participation framework, multimodality, material objects, the framing of activities within the interactive framework (e.g. a game), etc. are used, alongside linguistic analysis, to emphasise the intrinsic nature of any meaning-making situation as materially based and embodied. A prominent example is Goodwin’s (1995, 2004) demonstration of how a man with aphasia who can speak three words only (‘yes’, ‘no’ and ‘and’) can become a competent participant in interaction by the use of prosody, gesture and embodied displays. Even more importantly, the participant with aphasia uses the resources of the non-impaired participants in the interaction by making them co-construct his contributions. This complex, situated and multimodal interplay of the context and the interaction that is shaped by, and reshapes the context of the situation, is missing in the cognitive model, as well as in the ICF approach.

CA studies on atypical interaction have become an established field of research. This is demonstrated by an increasing amount of panels on this topic in important international conferences such as the 4th International Conference on Conversation Analysis (ICCA) in Los Angeles in 2014, the Conference of the International Institute for Ethnomethodology and Conversation Analysis (IIEMCA) in Kolding, Denmark in 2015, or the Atypical Interaction Conference in Sheffield, UK in 2014, and in Odense, Denmark in 2016. Further, the field is represented in a dedicated chapter in the Handbook of Conversation Analysis (Antaki & Wilkinson, 2012) [see also the contributions in Goodwin (2003), Norén, Samuelsson, & Plejert (2013a) and special issues on the topic, e.g. in the Journal Aphasiology (Wilkinson, 1999; Wilkinson, 2015)].

Bases on a CA perspective, the articles of the present special issue understand participation as ‘actions demonstrating forms of involvement performed by parties within evolving structures of talk’ (Goodwin & Goodwin, 2004, p. 222). Thus, participation is approached as a situated phenomenon that is accomplished by linguistic, embodied and material aspects of interaction that constitute the ongoing activity.

Aim and scope of the special issue

As all articles in this issue focus on data in which the person with communication impairment, in one way or the other, is involved in social interaction, we are already dealing with participation that is taking place. However, it is nonetheless quite important to come to terms with and ask ourselves what, in fact, participation is, and what is NOT participation? Participation does not just happen. The articles of this issue focus on how participation is interactionally achieved. This achievement includes interactional work; it is something that is made possible, that is oriented to and made relevant in the actions by the participants. Furthermore, persons participate in different ways and use different practices to include or exclude present parties from the ongoing interaction, or from parts of it. Persons may participate as speakers, addressed recipients, bystanders or objects of conversation (cp. Goffman, 1981; Levinson, 1988). As Goodwin & Goodwin (2004) exemplify, based on Goffman’s differentiation of the speaker, a person can speak the words that are actually authored by the person with impairment. In addition to the issue of how persons participate in here-and-now interaction, the topic of participation is also linked to the societal debate within health communication on how to include or empower patients or persons with disabilities in activities, such as decision-making or intervention processes. From a CA perspective, empowerment and inclusion are interactional practices that are achieved by participants in various activities. Some of the articles in this special issue bring up this discussion and demonstrate practices in which persons with limited communication means not only take part in an interaction, but their here-and-now participation has consequences for their participation in future practices. For instance, people participate in decision making processes that have consequences for their own intervention processes (Plejert, Samuelsson and Anward) or they participate in the evaluation of welfare technologies they or other users should use later (Krummheuer and Raudaskoski). Raudaskoski (2013, p. 109) calls this Participation, with‘big P’.

Instead of focusing on one communication disorder, the special issue has gathered research on different settings and different kinds of communication disorders. The articles have analysed interactions from, for instance, speech and language therapy with children and adults, communication with persons with aphasia and dementia, or persons with learning disabilities or acquired brain injury. The interactions were situated in private, therapeutic and institutional settings and thus opened up to rich and complex practices, in which communication impairment becomes interactionally consequential. This complexity should invite the reader to reflect upon how participation and (dis)ability are dealt with in different settings, and whether or not it is possible to identify good practices that may have implications for one’s clinical and/or private practices.

Three of the articles approach the topic of participation by examining aphasic communication and speech and language therapy. Plejert, Samuelsson and Anward identify five different practices that are applied in communication with a man with aphasia that enable to make his viewpoints on language and communication, and on the goals of his intervention, come across. They argue that these practices serve a supportive purpose, and help include and engage persons with aphasia in the formation of their intervention programmes. In this respect, the practices identified may be viewed as a tool for patients’ empowerment.

Tuomenoksa, Pajo and Klippi explore the use of CA in outcome measurement to compare everyday conversation samples from a person with aphasia and a familiar communication partner before and after intensive language action therapy. They combine the method of CA with frequency measurements, which is rarely applied within the field of CA. Their results imply that examining the type and function of collaborative repair actions might provide insights into therapy-related changes in conversation following impairment-focused therapy.

Laakso and Godt analyse the interactive management of problematic speech, focusing on how recipients address expressive aphasic problems in everyday conversation with relatives and in institutional settings. Based on their results, they suggest that the type of aphasia may have an impact on the participation structure in conversation. However, the variation related to everyday vs. institutional settings does not seem to be large.

Two other studies focus on participation structures during learning processes, in which several participants find out how to use technology to support everyday practices of a person living with impairments. Similar to Plejert et al.’s article, participation expands the situated interaction as the person living with communicative and cognitive impairment participates in the in situ interaction, while at the same time the learning process aims to support the person’s abilities in social life in general.

Norén and Pilesjö analyse the emergence of a question posed by the user of a communication board in aided interaction, which is a rarely studied phenomenon. The analysis is based on an interactional episode in which a speech and language therapist shows a family member how she and her niece, a child with severe speech and physical impairment and moderate intellectual disability, may use a communication board in their everyday life to enable the child to pose a question. The authors highlight how different participation frameworks are modelled through the course of action: on the one hand, a pedagogical framing with the aim of demonstrating the board’s usage for partner-focused questions; on the other hand, a framework in which the child’s speakership and recipiency is achieved despite her low cognitive and linguistic abilities.

Krummheuer and Raudaskoski combine CA with insights from science and technology studies, and analyse a situated learning process in which three participants, one of whom has a brain injury, adjust a walking help to an impaired body and assess the walking performance. They differentiate two iterative phases of the learning process (the adjustment and assessment of the body–device relation, and the performance and assessment of the walking trial). The study shows how the person living with brain injury does not only become an active participant in the adjustment and assessment of the walking help, but also become an independent walker.

Lindholm and Rasmussen both investigate situations in which persons with limited communication means might unwillingly be positioned in unintended participation roles based on an inattentiveness to interactional phenomena. Lindholm studied participation as the responsive action of an older woman with dementia, focusing on her use of the Swedish response token ‘jaså’ (uhuh; I see). Analyses demonstrated that the use of gaze by the woman with dementia was reduced and that she seemed to mostly rely on the auditory channel. It was also shown that the interlocutors did not in all situations treat her as a ratified participant, in spite of her attempts to contribute to the interaction. The article has clear clinical implications, pointing to the importance of attending also to unconventional interactional practices by persons with dementia.

Rasmussen shows how general recommendations for therapists and family members on how to engage a person with limited communication means in interaction can have negative consequences. One of the guidelines on how to involve the person with impairment suggests that practitioners present a request for confirmation, an easy-to-answer (yes/no) question format about the correct comprehension by the speaker. Rasmussen shows that when requests for confirmations on a given answer are used repeatedly, they can be used to show amazement or otherwise prompt or proffer an initiated topic, often leaving the building of the further talk to the original speaker. But repeated understanding requests may also result in communication troubles if the speaking responsibility moves to the person with impairment, who might have difficulties expanding on their answer.

The use of CA in clinical practice is still sparse within the Nordic countries, although its merits pointed out in this special issue are obvious. This may be due to the fact that there are no specific assessments based on CA. There are not many CA-based intervention methods (see Finlay et al., 2011; Wilkinson, 2011), and the established CA-based intervention program Supporting Partners of People with Aphasia in Relationships and Conversation (SPPARC) (Lock et al., 2001), originating in the UK, has not yet spread to any great extent in the Nordic countries. In order for clinicians to use CA on an everyday basis, methods for assessment and interventions need to be offered.

Declaration of interest

The authors report no conflict of interest.

Acknowledgements

We would like to thank the anonymous reviewers for their constructive comments on all the articles of this special issue.

Funding

We would like to thank the Joint Committee for NOS-HS for funding the exploratory workshop series on ‘Communicative impairment in interaction. A Nordic perspective on the social organization of disordered talk’ in 2014 (Grant number: 229915/F10), from which the contributions to this special issue arose.

Additional information

Funding

We would like to thank the Joint Committee for NOS-HS for funding the exploratory workshop series on ‘Communicative impairment in interaction. A Nordic perspective on the social organization of disordered talk’ in 2014 (Grant number: 229915/F10), from which the contributions to this special issue arose.