Rachel Shaw 1 The Complexity of the Patient/Doctor Relationship Each day people are exposed to social interactions that

are highly influential to their worldview and personal identities. These interactions are influenced by a variety of factors and can be understood based on the setting in which they take place, who is interacting with one another, and why the interaction occurs in the first place. In order to make sense of the environment, our minds tend to categorize social situations based on features of oral and written communication that arise from them. Some might define these situations as discourse communities, but others would say that this definition is not complete because it is not always enough to view discourse communities in isolation (Beaufort, p. 59; Devitt, Bawarshi, & Reiff). In fact, as supported by Beauforts (1999) evidence, discourse communities often overlap, as in a Venn diagram (p. 60). This overlap shows how a communitys goals affect the communication practices that follow. Additionally, because communication is influenced by an individuals input and physical elements of the workplace, discourse communities can be seen as social entities that, while dynamic, are distinguishable by a variety of different communicative praxes. How individuals accustom themselves to these praxes is an interesting phenomenon because, according to scholars such as Elizabeth Wardle, the process tends to follow a similar pattern regardless of the discourse community. The main goal of these individuals is to gain a sense of identity within the community. Wardle suggests a model for enculturation into the community that illustrates how an individual comes to feel as though he or she belongs in a particular workplace environment. This model shows how authority, although an intangible quality granted to persons through institutions (p. 157), is nonetheless a driving factor in an individuals quest for enculturation. As the present study will show, authority is a feature that an aspiring clinical psychologist should hope to gain after proper enculturation into the community.

Rachel Shaw 2 The authority can be considered to be bestowed upon that individual after proper education and training is received, but it is also up to the individual to exert his or her own personal sense of purpose upon the community. Wardle (2004) speculates that the process of establishing an identity within a discourse community can be highly individualistic and arbitrary. Individuals must go through a series of levels in which they find modes of belonging (p. 155). This text utilizes ethnographic research to illustrate what occurs when an individual enters a discourse community without full understanding of the lexical and technical knowledge that arises in communication with others in the community. While the development of ones unique workplace identity is certainly important to consider, the field of clinical psychology has far too many ethical issues for a person to be thrown into the rhetorical situation without adequate training and supervision. There are rigid expectations that a clinical psychologist must understand while in a session with a patient. Nonetheless, this does not dismiss the importance of taking initiative (Anson & Forsberg, 1990), as clinical psychologists have to work well under pressure and come up with solutions quickly, particularly in difficult situations. Therefore, ethical considerations in clinical psychology must be grounded in the professionals identity because of how significant they are. Do professionals within psychology have an advantage compared to professionals within other discourses because of the structured set of guidelines and expectations that are presented to them? For example, the American Psychological Associations (APA) Diagnostic and Statistical Manual for Mental Disorders (DSM) provides a framework for diagnosing clients and assessing appropriate measures for intervention. Is this a tool that can be considered a fixed rulebook (Anson & Forsberg, p. 225), or is its interpretation too varied and complex to be thought this way? This question can forward the existing dialogue about discourse communities and can provide a better

Rachel Shaw 3 understanding of how clinicians, doctors, and other medical professionals can improve the quality of communication in therapeutic sessions. Thus far, the ethnographic research used to advance the discussion of discourse community influences has mainly focused its sites on business institutions and government agencies. While this is beneficial for examining how individuals transition from an academic environment to a workplace setting, it does not observe how assimilation occurs for those advancing to professional social sciences. Clinical psychology in particular has an interesting social framework because of the prevalence of oral communication between clinician and client. Can the same theories proposed by the mentioned authors be grounded as a basis for understanding discourse communities within professional psychology? If Beaufort (1999) is correct in her analysis of how influencing factors give rise to communicative activity (p. 34), then it may be beneficial for clinical psychologists to consider their patients as a separate discourse community. That is, is it useful to consider the clientele of clinical psychologists to be in a separate discourse community? Communication between clinicians and clients can be improved with a better understanding of how both parties convey information to each other in addition to interpreting the social context. In other words, discourse communities can be better understood by expanding the study to different professional locations such as clinical psychology. Site To gather a better understanding of the communicative practices that underlie the work of clinical psychologists, the present study conducted research at Hudson Health Centers Counseling and Psychological Services (CPS), located at Ohio University in Athens, Ohio. CPS is home to trainees of clinical psychology, counseling interns, and professional psychologists who have obtained their PhD or PhysD after years of intensive training. All of these individuals

Rachel Shaw 4 are involved with providing a variety of excellent services to students, faculty, and administrators on campus. Methods According to Seth Kahn (2011), Good ethnographic writing emerges from the juxtaposition of two stances: distanced and interactive (p. 176). Hence, the present study used two main sources in order to better understand the assimilation of a neophyte into the professional psychological discourse. The first is gathered from the authors personal experience collaborating in two of the clinical health psychology research laboratories at Ohio University. This interactive experience allows for comprehension of ethical considerations in the professional field as well as familiarity of communicating with laymen (i.e., research participants). The second and primary source used was conducted via telephone with Dr. Sue Fieldsi from CPS. Dr. Fields obtained her PhD in clinical counseling and is a Licensed Professional Clinical Counselor (L.P.C.C.). Her avid engagement in the clinical community and capacity of situationally rooted knowledge (Anson & Forsberg, p. 210) made her a reliable and valid source for the purposes of this study. Not only has she gained positive regard for her presentations on topics including stress management, exam panic, and substance abuse, but she is also a co-founder of S*T*A*R*S (Students Teaching About Racism in Society). Hence, by promoting her personal knowledge and beliefs about psychology after gaining proper training in the field, she is considered an expert member of the clinical psychology discourse community. As a consequence, she has full authority in all realms of the field and is able to support her beliefs because of this. Dr. Fields provided engaging information about enculturation into the

Rachel Shaw 5 community based on her own experience. Much of what she said raises some significant questions about how and why communication within the community can be improved. Results The interview with Dr. Fields began with a discussion of how one becomes acculturated in the clinical psychology community. CPS provides a rigorous training program for interning graduate students. Based on Dr. Fields explanation, this is one of the first steps in the students enculturation into the field because it is their opportunity to put what they have learned to the test. By this time, the graduate student has a well-rounded understanding of how to be a clinical psychologist and ethical concerns involved with clinical work. When asked about what ethical concerns surrounded CPS, Dr. Fields emphasized how intensively the authoritative staff works to mentor interns throughout their time there. A supervisor must obtain direct knowledge of each client supervised, Dr. Fields explained. Furthermore, any document with clinical information about a patient must be looked over and signed by the supervisor before being sent anywhere. Even simple e-mails sent to the patient regarding scheduling must be reviewed by the supervisor. Other than the graduate students dissertation paper, these documents and e-mails are a part of a small handful of writing practices the student must engage in. This is why oral communication appears to be more significant within the field of clinical psychology. It should be of no surprise that Dr. Fields gives presentations on topics such as substance abuse and exam panic due to what Beaufort (1999) refers to as the physical conditions (p. 34) of her workplace environment. We see an overwhelming consistency among student patients who seek help here, Dr. Fields said. Having spoken with these patients on a regular basis is what provokes me to speak to other psychologists about what I have learned. These presentations are important for the future of psychology because they help add to the current

Rachel Shaw 6 conversation about Dr. Fields topics of interest. Predictably, improving knowledge within the field is one of the main goals of the psychological community. The social interactions and technical capital Dr. Fields gained throughout her years of education and clinical training gives her the linguistic capital to discuss these topics with other scholars (Wardle, p. 162). However, as some of the subject matter is considered controversial, Dr. Fields said that her presentations are not always greeted with agreement from the entire audience, although it is of the present studys opinion that this does not dismiss her authority. As Dr. Fields half-joked, psychology would be very boring if we all agreed with one another! In addition to maintaining an authoritative role within the discourse of clinical psychology, it is important for the clinician to portray themselves dependably in sessions with clients. However, the lexis that exist in an academic presentation should not exist in a clinical session. I always have to assume that the client has no education in psychology, said Dr. Fields. One of the most difficult tasks [interns] run into is the ability to convey complex information to the client. This is why video recordings of each interns session are made with the clients consent. It allows the supervisor to intervene when necessary and lets the intern know what he or she is doing right and wrong. Our interns grow dramatically with experience, especially in difficult situations interventions with crises like suicide, Dr. Fields explained. This is in part due to the interns developing understanding of what to expect from our target market. Dr. Fields went on to explain how demographic, socioeconomic, and geographic characteristics tend to collide in clinical settings. It is too challenging [for a clinician] to develop a new communication strategy each time a client seeks help, Dr. Fields answered when asked about the uniqueness of each client. This is why clinicians tend to find their niche after a certain amount of time at a particular practice. Dr. Fields, for example, found her niche within the realm

Rachel Shaw 7 of counseling and chemical dependency. As a result, she mentors interns who wish to target their own career goals toward that topic. Discussion Based on the results of the present study, there appears to be evidence supporting that the patient/doctor relationship is formed based on doctors knowledge of current literature, identity of both doctor and patient, and the doctors assimilation to the norms, ethics, and conventions of the clinical psychology discourse community. While past studies on discourse communities have discussed authority within workplace settings, they have not focused on the perception of authority in clinical settings. This is highly significant in clinical settings because the patient expects the doctor to be a figure of authority since societal norms hold that doctors are experts because of the amount of education they have received. As a result of this, it is crucial for the doctor to modify their use of language in accordance to the patients background knowledge which can be ironically difficult because of the advanced knowledge of psychological and medical jargon the clinician has obtained. Thus, one of the most difficult parts of enculturation into the clinical community is the psychologists ability to quickly relate information to the patient. Future research on this topic could help expound upon this idea of the patient/doctor discourse overlap. It would be interesting to speak with a psychologist who owns his or her practice. Since the present research was conducted very locally at a university health center, it could be that clinician/patient interactions are different elsewhere. Regardless, it can be speculated that most psychologists have to adapt to modifying their use of language to patients. As Devitt (2003) explains, Part of the difficulty when specialized communities write to nonspecialist users lies in technical language (546). While the patient is technically considered a

Rachel Shaw 8 nonspecialist, because they are so integral to the work of a clinician, patients of clinical psychologists can be considered to be an overlapping discourse community. Beaufort (1999) discusses overlapping discourse communities, but does not delve into how this relates to professions in the social sciences. In this case, the overlap lies significantly between the clinical psychologists discourse community and each client whom the psychologist interacts. Since these interactions tend to influence the mechanisms of intercommunication among the members of clinical psychology, patients can be seen as an overlapping discourse community, regardless of whether or not the patient has any knowledge of psychology. Not only do these social events help the patient improve his or her mental health, but they help the psychologist gain a better sense of authority within the community and add to the body of psychological knowledge. Since the two individuals inadvertently help one another, it appears to be of utmost importance for the neo-clinician to be able to converse with the client as effectively as possible. Any writing practices in clinical psychology tend to stem from particular instances within these conversations. As a result, enculturation into clinical psychology occurs after the mastering of identifying and understanding the target clientele.
i

Name has been changed for anonymity.

Rachel Shaw 9

References Anson, C. M., & Forsberg, L. L. (1990). Moving beyond the academic community: Transitional stages in professional writing. Written Communication, 7, 200-231. Beaufort, Anne. (1999). The institutional site of composing: Converging and overlapping discourse communities. In Writing in the real world: Making the transition from school to work (pp. 30-61). New York, NY: Teachers College Press. Kahn, Seth. (2011). Putting ethnographic writing in context. In C. Lowe & P. Zemliansky (Eds.), Writing spaces: Readings on writing (pp. 175-192). West Lafayette, Indiana: Parlor Press LCC. Wardle, Elizabeth. Identity, authority, and learning to write in new workplaces. Enculturation 5.2 (2004): http://enculturation.gmu.edu/5_2/wardle.html

Appendix The interview with Dr. Sue Fields was conducted via telephone on March 27, 2013. The interview was recorded with Dr. Fields permission. The interview was over 30 minutes and not every word was transcribed. The most important questions and answers have been included here. RS: I noticed that there are a lot of graduate students who work at CPS. What are some of the main steps in the completion of the internship program Hudson provides? SF: The guidelines are presented explicitly to these students. There are a series of steps the student must take before even stepping foot into the clinicians office. First, they are required to take a seminar which integrates shared clinical experiences with scholarly journal articles and group discussions. Our hope is that this seminar will provide the student with relevant clinical studies that will help aid them in communicating with the client. It also gives them a chance to discuss their own opinions with the other interns. Following this seminar, students are required to take a test known by the acronym of SPEAK [Speaking Proficiencies English Assessment Kit].

Rachel Shaw 10

This test is used in most medical professions where interaction with patients is required. I have to mention that due to ethical reasons of clinical work, we have a very strict program. I try to have the friendliest relationship with any intern I mentor, but it is strictly professional and I would not hesitate to remove someone from the program if need be. RS: What type of writing would you say you engage in the most at Hudson? SF: E-mails, memos, and filling out patient medical history forms is about the meat of what I have to write here. There is far more face-to-face communication being done in clinical settings. If you are interested in experimental psychology, then be prepared to write a lot. Its a bit different being a clinician. RS: What do you believe is your main role in the field of clinical psychology? SF: Helping young adults. It is so rewarding to see positive changes in clients who have difficult issues that hinder them from having a satisfying life. Everything that I speak about in my presentations have some relation to what I have learned from my clients. Having spoken with these patients on a regular basis is what provokes me to speak to other psychologists about what I have learned. RS: How do interns learn the appropriate language to use in sessions with clients? SF: I think it comes with time but we try our best at CPS to give them the tools they need to pick up on how to speak with clients. It is a matter of picking up on little things about the client that make them who they are. Personal issues affect how the client interprets information we tell them in sessions. One of the most difficult tasks they run into is the ability to convey complex information to the client. So, I always have to assume that the client has no prior education in psychology. What is interesting about targeting a client is that we see an overwhelming consistency among student patients who seek help here. Obviously, it is wrong to generalize people, but it is too challenging for us to develop a new communication strategy each time a client seeks help. Our interns grow dramatically with experience, especially in difficult situations interventions with crises like suicide. This is in part due to the interns developing understanding of what to expect from our target market. Here at CPS, we help the interns learn how to do this. It is something all clinicians across the country have to learn.