Available online at www.sciencedirect.

com

ScienceDirect
Journal of Pragmatics 90 (2015) 12--25
www.elsevier.com/locate/pragma

Clients’ resistance to therapists’ proposals:

Managing epistemic and deontic status
Katie Ekberg a,*, Amanda LeCouteur b
a
School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Queensland 4072, Australia
b
School of Psychology, University of Adelaide, North Terrace Campus, Adelaide, SA 5005, Australia
Received 22 May 2015; received in revised form 2 October 2015; accepted 6 October 2015

Abstract
This paper uses conversation analysis (CA) to examine client resistance in Cognitive Behavioural Therapy (CBT) sessions for clients
with depression. Analysis focuses on clients’ responses to therapists’ proposals for behavioural change. Typically, clients displayed
active resistance to such proposals by drawing on one of three types of ‘inability to comply’ account: (1) appeals to restrictive situational
factors; (2) appeals to fixed physical states; (3) assertions of previous effort to do what the therapist was proposing. Each type of account
involved clients utilising knowledge from personal experience as their reason for resisting the proposal. In formulating their accounts,
clients’ turns were designed in ways that displayed their epistemic stance in relation to the situation under discussion. By indexing their
superior epistemic authority in the domain of their experience, clients were able to invoke their ultimate right to reject the therapist’s
proposed course of action. The implications for CBT practice are discussed.
© 2015 Elsevier B.V. All rights reserved.

Keywords: Conversation analysis; Psychotherapy; Client resistance; Epistemics; Deontics; Proposals

1. Introduction

Advice-giving has previously been identified as a potentially problematic activity in both mundane (Jefferson and Lee,
1992) and institutional interaction (Heritage and Sefi, 1992; Kinnell and Maynard, 1996; Vehviläinen, 2001; Waring, 2005,
2007). The delicate nature of advice-giving can arise from assumed or established asymmetries between the participants
in respect to a given issue or topic. The activity of advice-giving generally constitutes the advice-giver as the
knowledgeable, authoritative and competent party, and can carry the opposite assumptions of the advice-receiver
(Heritage and Sefi, 1992). For these reasons, advice or similar ‘proposals for future action’ can often lead to resistant
responses (e.g., Heritage and Sefi, 1992; Kinnell and Maynard, 1996; Waring, 2005).
A number of conversation analytic studies have examined client resistance to recommendations or advice delivered by
healthcare professionals (e.g., Heritage and Sefi, 1992; Kinnell and Maynard, 1996; Koenig, 2011; Muntigl, 2013; Silverman,
1997; Stivers, 2005b; Vehviläinen, 2008). Repeatedly, this work has identified patterns of ‘passive resistance’ that include
client actions such as withholding a response or providing a minimal acknowledgement such as ‘‘mmhm’’, ‘‘yeh’’ or ‘‘that’s
right’’ (e.g., Heritage and Sefi, 1992; Kinnell and Maynard, 1996; Koenig, 2011; Silverman, 1997; Stivers, 2005b). There has
also been some exploration of more active forms of resistance to advice/recommendations (e.g., Heritage and Sefi, 1992;

* Corresponding author at: Communication Disability Centre, School of Health and Rehabilitation Sciences, The University of Queensland,
St Lucia, Queensland 4072, Australia. Tel.: +61 07 3365 8547.
E-mail addresses: k.ekberg@uq.edu.au (K. Ekberg), amanda.lecouteur@adelaide.edu.au (A. LeCouteur).

http://dx.doi.org/10.1016/j.pragma.2015.10.004
0378-2166/© 2015 Elsevier B.V. All rights reserved.
 K. Ekberg, A. LeCouteur / Journal of Pragmatics 90 (2015) 12--25 13

Koenig, 2011; Muntigl, 2013; Stivers, 2005b). Stivers (2005b) defined active resistance within the context of primary care
interaction as any ‘‘action that questions or challenges the physician’s treatment recommendation’’ (p. 2).
Client resistance has also been explored within the environment of psychotherapy. For example, previous studies
have identified several strategies by which clients resist therapists’ problem formulations or re-formulations (e.g., Antaki
et al., 2004; Davis, 1986; Madill et al., 2001). These strategies include clients: (a) reasserting or revising their prior case;
(b) avoiding uptake of aspects of a prior turn; (c) managing and rejecting topic shifts; (d) withdrawing cooperation (Madill
et al., 2001); (e) describing instances from their life where the therapist’s formulation did not apply (Davis, 1986); (f)
withholding appreciation of the therapist’s formulation; and (g) competitively overlapping the therapist with a disafilliative
version of the current theme (Antaki et al., 2004). Clients have also been found to resist therapists’ optimistic questions
during therapy by (a) downgrading the optimism of the question, (b) providing a joking or sarcastic response, (c) shifting
the focus to more non-optimistic aspects of their life, or (d) re-assigning the optimistic aspects to other persons
(MacMartin, 2008). The ways in which therapists confront aspects of clients’ behaviour or descriptions during therapy
have also been examined (Vehviläinen, 2008; Weiste, 2015). It has been observed that these actions from therapists can
lead to defensive responses from clients resulting in an expanded argumentative sequence (Vehviläinen, 2008; Weiste,
2015). In the environment of couples counselling, Muntigl (2013) has examined a therapist’s management of prolonged
client resistance across sessions. The therapist became increasingly disaffiliative in their orientation to the client’s
resistance, facilitating an alliance between the counsellor and the partner against the client. This disaffiliation typically
occasioned further disengagement by the client and a breakdown in the progressivity of the therapeutic work.
The present paper builds on this prior CA research by examining active forms of client resistance observed within
Cognitive Behavioural Therapy sessions for depression. In particular, analysis focuses on client resistance to therapists’
proposals for behavioural change. Resistance to change on the part of the client is a major limiting factor to the success of
CBT treatment for depression (Leahy, 2001). While CBT theory outlines possible causes of client resistance, it does not
provide therapists with information concerning how clients typically display such resistance within the therapy interaction.
This study provides insight into these details; demonstrating how clients display resistance to behavioural change, in real-
time, within therapy interactions.

1.1. The interactional environment: Therapists’ proposals for behavioural change

This paper is part of a larger project which examined how the CBT task of ‘Behavioural Activation’ is accomplished
through interaction in the therapy session. Conversation analysis can be a valuable way of explicating how codified tasks
within theories of therapy are accomplished in practice (Peräkylä and Vehviläinen, 2003). According to CBT theory,
Behavioural Activation involves engaging clients in a process of change that is designed to stimulate a sense of positive
thinking and hope, or help them solve a problem (Blackburn and Davidson, 1990). A previous study identified that one
routine way in which therapists undertook this task was to propose a suggestion for future action to clients (Ekberg and
LeCouteur, 2012). The client resistance that is the focus of this paper occurred following therapists’ proposals to
implement future actions (as a step towards behavioural change). Although these proposals accomplish a similar action to
advice-giving (Butler et al., 2010; Emmison et al., 2011; Heritage and Sefi, 1992; Kinnell and Maynard, 1996; Silverman,
1997), the term ‘proposal’ that we use here highlights the status of these therapist turns as candidate suggestions. As
such, these types of turns may initiate negotiation between therapist and client regarding behavioural change. However, a
therapist proposal begins such a discussion by suggesting what the client should do, rather than by asking the client for
suggestions. In doing so, therapist proposals open up a particular next response from the client: acceptance or rejection of
the proposal/suggestion (Pilnick, 2008).
Making proposals for behavioural change may inadvertently create a dilemma for therapists. Although they carry the
authority of a professional perspective, therapists only ever have secondary access to knowledge about a client’s life and
situation, based on what the client has shared within the therapy session. Clients will always have the ultimate epistemic
access to how situations have played out in their lives, and how their behaviour may affect their situation in the future. In
making a proposal, then, therapists have to draw on assumptions about a client’s situation, as they do not have access to
all details relating to a client’s troubles. In many cases, these assumptions may be incorrect, or may not apply to a client’s
particular circumstances. The nature of this epistemic environment may cause tensions when therapists take a more
directive role in how clients might resolve their troubles. As a result, therapist proposals can create a local interactional
environment in which resistance may emerge. In the corpus under investigation here, clients were repeatedly seen to
resist such proposals. This paper is particularly concerned with examining the second part of the sequence: clients’
responses to therapists’ proposals for behavioural change (for a detailed analysis of therapists’ proposal turns, see
Ekberg and LeCouteur, 2012). Analysis of these responses will demonstrate how clients routinely accomplished several
interactional tasks within these turns, including: (1) resistance to the therapist’s proposed action through the formulation of
an ‘inability to comply’ account (Heritage, 1984); (2) index their epistemic stance in relation to the situation under
discussion; and (3) assert their deontic right to reject a proposed course of future action.
14 K. Ekberg, A. LeCouteur / Journal of Pragmatics 90 (2015) 12--25

1.2. Epistemic and deontic status in interaction

There is a growing body of research in conversation analysis (CA) that is focussed on systematically examining the
ways in which speakers orient to epistemics and deontics in conversation (for a recent special issue on this topic see
Svennevig and Stevanovic, 2015). In the area of epistemics, a number of studies have examined key ways in which
participants in interaction attend to and manage their rights and responsibilities in relation to knowledge and
information (e.g., Butler et al., 2010; Heritage, 2010, 2012; Heritage and Raymond, 2005; Land and Kitzinger, 2007;
Lerner and Kitzinger, 2007; Raymond, 2010; Raymond and Heritage, 2006; Stivers, 2005a). Participants’ comparative
access, knowledgeability, and rights relative to a domain of knowledge is referred to as their epistemic status. These
rights and responsibilities concerning what participants know, and have rights to describe, are directly implicated in
organised practices of speaking (Heritage and Raymond, 2005). The way participants express and manage their
epistemic rights through the design of their turns-at-talk is referred to as their epistemic stance (Heritage, 2012). The
majority of work on the management of epistemic status between speakers in interaction has been conducted in the
local environments of assessments (e.g., Clift, 2006; Heritage and Raymond, 2005; Lerner and Kitzinger, 2007;
Raymond and Heritage, 2006; Stivers, 2005a) and question-answer sequences (e.g., Heritage, 2010, 2012; Heritage
and Raymond, 2010; Raymond, 2010). There has also been some more recent research into epistemic stance in
medical decision-making (Landmark et al., 2015; Toerien et al., 2013). The present study develops this prior work by
examining key ways in which clients attended to their epistemic status within their resistive responses to therapists’
proposals for behavioural change.
In addition, some recent CA research has examined how participants in conversation also attend to their deontic rights
and obligations in interaction (e.g., Kent, 2012; Landmark et al., 2015; Lindström and Weatherall, 2015; Stevanovic, 2013;
Stevanovic and Peräkylä, 2012, 2014; Toerien et al., 2013; Zinken and Ogiermann, 2011). Deontic status is concerned
with participants’ rights to determine future courses of action, that is, to determine ‘how the world ought to be’ (Stevanovic
and Peräkylä, 2012). As with epistemic status, people have varying deontic rights within different contexts, and this status
may be managed by parties in particular ways. How these rights are expressed through participants’ talk denotes their
deontic stance (Heritage, 2013a). The present study builds on this prior CA work by examining how clients invoked their
deontic right to determine their future actions outside the therapy room.

2. Method

The data for this study is a corpus of 20 audio-recorded CBT sessions, involving 9 therapists (1 male and 8 female) and
19 clients (1 male and 18 female, all over 18 years old) who were being treated for depression. The recordings were
collected in a free, university-affiliated clinic in Australia specialising in CBT treatment. Sessions involved one client and
one therapist in each case. The duration of the audio recordings for individual sessions ranged from 26 min to 75 min, with
an average duration of approximately 56 min. The total time for all recorded sessions combined was 16 h, 46 min. The
study was approved by the University of Adelaide Ethics Committee.
Recordings were transcribed using the Jeffersonian transcription system (Jefferson, 2004), and analysed using
conversation analysis (CA). CA focuses on analysis of talk as a vehicle for social action, and places particular importance
on the significance of the sequentiality of interaction to participants’ understanding (Sacks et al., 1974). CA studies of
psycho-therapeutic interaction examine how therapists and clients perform sequentially organised social actions by
designing their utterances in particular ways (Peräkylä et al., 2008). More specifically, in the current study, CA allows us to
describe how therapists and clients designed their turns-at-talk within the local interactional environment of negotiating
behavioural change. For ethical reasons, video data were not collected for analysis (which can constrain the analysis of
silences in co-present interaction). However, the present corpus still enabled an analysis of the different ways in which
therapists structure the client’s involvement in the behavioural change process, interactionally, and the consequences for
the trajectory of the therapy session. Analysis of the corpus identified 34 instances where therapists made a proposal for
future behavioural change as part of the therapeutic task of Behavioural Activation. This collection included multiple
attempts to propose behaviour change in some sessions, and none in other sessions (which were instead focussed on
another key CBT activity, that of making changes to clients’ thought patterns). Therapists’ proposals led to localised,
active client resistance in each case. These resistive responses are the focus of the current paper. In each of the
fragments presented T: therapist, and C: client.

3. Results

In the corpus under examination, therapists’ proposals were typically designed in ways that shared deontic rights for
the suggestion of behavioural change. In other words, therapists’ proposals were framed in a way that showed they were
 K. Ekberg, A. LeCouteur / Journal of Pragmatics 90 (2015) 12--25 15

contingent on the client providing their approval (Curl and Drew, 2008; Stevanovic and Peräkylä, 2012). However, as
Stevanovic and Peräkylä (2012) have previously shown, second speakers may not be satisfied with deontic symmetry,
but often seek to establish a stronger deontic position within the interaction.
Clients typically responded to proposals from therapists with active resistance. This resistance was characterised by
an account as to why the proposed action could not be implemented in their lives. These accounts drew, in some way,
upon an aspect of the client’s experience (that the therapist could not know) that allowed them to assert their inability to
accept the proposal. In this way, the accounts correspond with what Heritage (1984) termed ‘inability to comply’
formulations. Clients typically drew upon one of three types of accounts to assert their inability to accept therapists’
proposals for behavioural change:

 appeals to restrictive situational factors

 appeals to a fixed physical state
 assertions of previous effort to do what the therapist was proposing

Each of these types of account involved the client drawing on knowledge from their personal experience that the
therapist did not know as their reason for resisting the proposal. In these accounts, the trouble under discussion was
framed as something that was out of the client’s control, and therefore as unsolvable by a change in their own behaviour.
In formulating these accounts, clients also designed their turns in a way that displayed their epistemic stance in relation
to the situation under discussion. Three key interactional resources were systematically used by clients to orient to their
epistemic stance within their responses to proposals: (1) modality and primary tense (He, 1993); (2) non-conforming
responses to interrogative proposals (Heritage and Raymond, 2005); and (3) direct reported speech (Clift, 2006).
Clients thus attended to their greater knowledge status in regards to their life situation both in the content, and the
design, of their responsive turns to therapists’ proposals for behavioural change. By orienting to their primary epistemic
access to their experience, clients were able to invoke their ultimate deontic right to reject the therapist’s proposed course
of action. The following sections of analysis present representative examples of each of the key types of resistive
accounts identified in the corpus, with reference to how clients also attended to their epistemic and deontic status within
the interaction.

3.1. Appeals to restrictive situational factors

In this type of account, clients appealed to a specific, restrictive contingency in their life that rendered them unable to
accept the therapist’s proposal, including factors associated with third parties. Aspects of their lives that were routinely
invoked involved things that were external to clients and, thus, out of their personal control. Fragment (1) provides an
example of this practice. Preceding this fragment, the focus of talk for most of the session had been around the problematic
behaviour of the client’s youngest daughter, Leah. The client had claimed that her daughter’s behaviour was contributing to
her own depression. The therapist had offered several proposals concerning how the client might better manage Leah’s
behaviour, which were all resisted. In the fragment below, the therapist suggests that the client have some one-on-one time
with Leah and that she should ask her partner, Pete, to keep her elder daughter, Alison, occupied so that this can happen.

(1) [CBT 001 walks 52:15]

1 T: Do you think you could talk with Pete about (0.4) the fact that

2 you are quite worried about Leah and y’think it's really

3 importan’ for her to have some one on one time with you.

4 (0.4)

5 T: and would he mind twice a week (0.6) just (0.7) you know (0.5)

6 keeping an ear out in the house.

7 (0.2)

8 C: Yep
16 K. Ekberg, A. LeCouteur / Journal of Pragmatics 90 (2015) 12--25

9 T: So that Alison is gonna be, (0.8)

10 C: Yep see if ye- m- (0.6) makes me w↑orried what am I going to say

11 to Alison.

12 (0.2)

13 C: you know cos she always feels:: (1.3) that (0.3) n- the- she's

14 always seen Leah (2.2) with the over extended (0.5) whatever’s

15 to get the attention. =[So sh]e's always gone- (1.1)

16 T: [Mmhm ]

17 T: Yep.

18 (0.3)

19 C: sa- sat back an' ya know every time I've spoken to her

20 about it y’know .hhhh (0.8) >like I've< made her aware (0.3) m

21 I can see tha’ ya sittin back becuz your sister needs a

22 little more attention [and ] stuff like that.

23 T: [Mmhm]

24 C: and that's: y’know jea:::h you know (0.5) doesn’ matta (0.2)

25 [kind of] thing.=It's okay.

26 T: [Mmhm ]

27 (.)

28 C: [I un]derstand.

29 T: [Mmhm]

30 (0.7)
31 C: So it would be nice for her tuh (1.2) I ALways seem to leave

32 her ou:t becuz: (0.2) the youngest one is: (0.4)

33 T: Okay.

34 (0.6)

35 C: Yuh know.

The therapist’s proposal (lines 1--9), framed as an interrogative, is downgraded with an epistemic marker (‘‘do you think’’), the
use of a qualifier (‘‘could’’), and downgrading devices (‘‘quite’’, ‘‘just’’). In designing the proposal this way, the therapist
highlights the contingent nature of her proposal (Curl and Drew, 2008), inviting the client to either accept or reject in response.
In making her suggestion, she thus shares the deontic right to make the decision with the client (Stevanovic and Peräkylä,
2012).
 K. Ekberg, A. LeCouteur / Journal of Pragmatics 90 (2015) 12--25 17

The client’s response (across lines 10--35) draws upon specific knowledge about her daughters to resist the
preconditions of the proposal. The client’s reason for resistance is framed as an inability to accept the proposal, based on
the way that her other daughter (Alison) would respond to being left out. The client’s resistance is thus framed as not due to
any lack of personal desire to accept the proposal, but to the behaviour of a third party.
In the design of her turns, the client also orients to her epistemic stance in relation to the matter. She does this through the
use of several high-modality adjuncts to show that her account is not based on knowledge of one particular occasion, but on
her knowledge of how things consistently are. He (1993) has observed how modality can be used in interaction to reflect a
participant’s epistemic stance in relation to the matter at hand. The use of high modal terms (e.g., will, must, should, certainly,
always) constructs the speaker as having higher status in the claim than the co-participant (He, 1993). Specifically in this
case, when describing her daughter’s feelings towards her sibling, the client uses the adjunct ‘‘always’’ several times across
lines 13--15. Then, in her expansion at line 19, the client uses the adjunct ‘‘every’’ to describe occasions when she has tried to
talk to her daughter about her younger sister. Again, at line 31, the client states that she ‘‘always’’ seems to leave her older
daughter out. In producing her account as a factual and generalised description of what happens in her household, the client
displays her direct access to knowledge of what everyday life is like in her house, and of how her daughter generally reacts to
conversations such as the one the therapist is proposing. In designing her turn in this way, the client thus asserts a greater
epistemic status in regards to her family life, relative to the therapist. By indexing her superior epistemic authority in the
domain of her experience, the client is able to invoke her deontic right to reject the therapist’s proposed course of action.
Fragment (2) provides another example. Prior to the start of the fragment, the client has provided a troubles-telling about a
performance interview at her work that has caused her to feel depressed (because she was informed that she needed to
improve her computing skills). However, her employer (a special education school) is not willing to provide her with resources
to learn better computing skills, and the client claims not to have the money to pay for such training herself. At line 1, the
therapist proposes an alternative way for the client to implement behavioural change so as to overcome these depressed
feelings.

(2) [CBT 002 computer 10:26]

1 T: Thez um (0.6) THERE ARE qu↑ite a number o::f (0.3) ahh: computer

2 literacy skills for: sort’ve (0.5) people in your age group

3 .hhhh that are run by: librees and local councils and stuff like

4 that.

5 ((21 seconds omitted))

6 T: and some libraries will run (.) you know (0.3) ↑how to use a

7 computer for the first time sessions.

8 (0.6)

9 T: where they kind of give pe[ople jus’ a basic tu- ]

10 C: [I'm sure not at] our library

11 coz I went to our library an’ .hh (0.2) they give you fifteen

12 minutes to get o:n.

13 (0.2)

14 C: It took me fifteen minutes ta work out how to turn the bloody

15 thing o::[n.

16 T: [mm↑hm.

The therapist’s proposal, here (lines 1--9), is packaged as information-giving (for a detailed analysis of these types of
proposals see Ekberg and LeCouteur, 2012). The therapist frames the client’s trouble as a generalised one, and the
18 K. Ekberg, A. LeCouteur / Journal of Pragmatics 90 (2015) 12--25

proposed behavioural change involves a generalised solution that the therapist might give to anyone in that circumstance
(lines 1--4). In framing the proposal in this way, the therapist displays lower epistemic status in relation to the client’s
individual situation, and low entitlement to tell her what to do. Framing the proposal in this way provides the client with the
opportunity to hear it as optional, and as seeking her approval.
The client rejects this proposal on the basis that the information provided by the therapist does not apply to her specific
circumstances. That is, she says that there are no computing courses offered at her particular library. She thus claims a
concrete restrictive contingency within her own life that inhibits her from accepting the proposal. Again, in this fragment, the
client’s account is framed with high modality, accomplishing the additional interactional task of asserting her epistemic stance
in relation to her own situation. In launching her rejection of the proposal at line 10, the client uses the high-modality adjunct
‘‘I’m sure’’ at the beginning of the turn. By framing her turn in this way, the client displays to the therapist that she is certain of
the factuality of her ensuing account. The use of ‘‘I’m sure’’ also displays an assertion of the client’s epistemic status over the
issue: it is only the client, and not the therapist, who can claim certainty about whether her library, specifically, offers
computing skills courses. At line 11, the client moves into an evidentiary account in which she details a specific instance of
visiting her library where the computer access supplied by the library was inadequate. This account draws on a specific
circumstance from the client’s experience which allows her to display an inability to accept the therapist’s proposal. The
client’s response thus draws upon her knowledge of her own local library to invoke her right to reject the proposal. The design
of the client’s response thus orients to both a superior epistemic and deontic stance in relation to the matter.

3.2. Appeals to a fixed physical state

In appealing to some physical state as the reason for their resistance, clients typically provided descriptions of
experiences that are internal to them. However, these experiences are framed as states that are caused by external
factors and are, thus, out of the client’s control. In Fragment (3) the therapist has been discussing the client’s current
routine of returning home from work and sitting down to have a glass of wine (the client is having problems with alcohol
consumption). The therapist proposes at lines 1--9 that, instead, the client could go for a walk after work.

(3) [CBT 017 walking after work 36:09]

1 T: .hhhh um: an’ so: (0.3) the first thing (.) uh that's come up

2 (0.2) is the wa:lking?

3 (0.6)

4 T: .tch (0.3) and I don't know if this week you wanted to actually

5 .hhh have a tri:↑al a bit of an experiment (0.2) .hh and maybe

6 (0.2) jus’ do a couple of walks::?

7 (.)

8 T: after: (0.2) ya finish your day?=after you've wor:ked or (0.9)

9 before [dinna? ]

10 C: [I won’t] (.) I'm too ti::red.

11 (0.2)

12 C: Becky honestly [it's the] (0.7) ya know by the time I've worked

13 T: [Umhm ]

14 C: all da:y I'm (0.5) lit’rally ex:hausted [I feel] sick I feel so

15 T: [Umhm ]

16 C: ti::red.
 K. Ekberg, A. LeCouteur / Journal of Pragmatics 90 (2015) 12--25 19

The therapist’s proposal across lines 1--9 is delivered in a tentative way: qualified by epistemic markers (‘‘I don’t know’’), a
low-modal adjunct (‘‘maybe’’), downgraded with essentializers (‘‘just’’), and delivered with questioning intonation. Her
proposal thus, again, is designed to share deontic responsibility for deciding on the proposed course of action with the
client.
The client’s response at line 10 is delivered with primary tense: ‘‘I won’t. I’m too tired’’. Her reason for resisting is thus
presented as being due to something which is generally the case -- she won’t go for walks because she is too tired. In
producing her resistance in a declarative manner, the client projects certainty over her account and claims a greater
epistemic status in relation to her evening behaviours (He, 1993). The client’s epistemic stance is made particularly
apparent by the declarative form of her response which provides an immediate contrast to the tentative nature of the
therapist’s prior proposal turn. By orienting to her epistemic authority of experience (Heritage, 2013b) within her resistive
account, the client positions herself as having the ultimate right to reject the proposed course of action.
The therapist does not respond to the client’s resistive account at line 11, and the client takes another turn in which she
upgrades her account. In this turn the client addresses the therapist directly using her first name, and then adds the
epistemic marker ‘‘honestly’’ which prompts a receipt from the therapist. The use of ‘‘honestly’’ here does some specific
interactional work for the client. Unlike the previously discussed types of resistive accounts that all draw upon
circumstances external to the client, this account draws upon the client’s subjective state. Because of this, the client could
be held accountable for merely providing an ‘excuse’ not to take up the proposal. By using an honesty phrase, however,
the client is able to show not only that her account is a factual one, but also that her motivation in reporting it is sincere
(Edwards and Fasulo, 2006). Primary tense is again used in the client’s turns across lines 12--16 (‘‘by the time I’ve worked
all da:y I’m (0.5) lit’rally ex:hausted I feel sick I feel so ti::red’’). Again, in designing her turn in this way highlights that it is
only she who has direct experience of her physical capabilities in the evenings, thus emphasising her epistemic status
over the situation (He, 1993). With this response, the client highlights that she is the only one who knows how she feels on
returning home from work on a daily basis, and uses this knowledge to invoke her right to reject the proposed course of
action.
Fragment (4) provides another example. This fragment comes from a sequence where the client has been talking
about feeling good after talking to a friend over the phone who needed her help with something. This telling leads to a
discussion about possible behavioural change that could occur for the client to get that feeling more often. At lines 1--2, the
therapist proposes that the client take up volunteering.

(4) [CBT 017 volunteering 28:24]

1 T: .hh that's interesting as w↑ell um I don't know if you've

2 thought about volunteer wo:rk or:: (0.9) anything like that?=

3 C: =Well yes but at the moment my I- (.) physicly

4 T: Umhm

5 C: I can't do more than I'm doing as far as my wo:rk is concerned.

Following the therapist’s proposal (lines 1--2), the client provides weak agreement with the idea (‘‘well yes’’) followed by a
rejection of the proposal (lines 3 and 5), a typical structure for a dispreferred response (Pomerantz, 1984). The client’s
account is formulated around the vague assertion that she is ‘‘physically’’ unable to do any additional activities over her
work commitments. Again, the client’s account is produced with primary tense, and framed as being a general state that
would prevent her from adopting the therapist’s suggestion (‘‘I can’t do more than I’m doing’’, line 5). Her use of primary
tense projects certainty over the account, and establishes her as having a higher epistemic status in relation to her
‘physical capabilities’. It is in orienting to her epistemic status over her experience, that the client is able to produce her
‘inability to comply’ account and invoke her deontic right to reject the proposal.

3.3. Assertions of previous effort

Clients sometimes provided an evidentiary account of a previous instance in which they had attempted to do what the
therapist was proposing, particularly when appealing to a third party to account for their resistance. In these instances, clients
responded to therapists’ proposals by making an assertion either that they had already thought of the proposed action
themselves, or that they had already attempted to do what was being proposed, thus making the proposal redundant. Again,
in making such a claim, clients drew upon knowledge of the situation that the therapist did not and could not know.
20 K. Ekberg, A. LeCouteur / Journal of Pragmatics 90 (2015) 12--25

In the next two examples, clients account for their resistance by making assertions of previous effort, describing a
specific instance in detail. Fragment (5) comes from the same session as Fragment (1). Prior to the start of Fragment (5),
the client’s trouble talk has focussed on the behaviour being displayed by her youngest daughter, Leah. The therapist has
proposed several possible solutions to the client throughout the session. So far, all of these have been resisted. The
therapist’s proposal at lines 1--8 involves the client asking her elder daughter, Alison, to help her in the cause of keeping
Leah’s behaviour under control.

(5) [CBT 001 enlist Alison 33:51]

1 T: Well it might be um (1.4) might even be worth trying to enlist

2 Alison.

3 (0.7)

4 T: into the (0.5) cause=of saying >you know< (0.3) “↑YOU (.) you

5 know what it's like when your sister goes nuts: (0.2) I know

6 that you don't like fighting with h↑er”, (0.6) you know “l↑et's

7 (0.3) let’s see if we can make (0.6) this next week (0.7) a

8 really (0.8) happy time [no:w.” ]

9 C: [See I had] them both sittin’ there and

10 I said “l↓ook” (0.5) “wha↓tta you want”.

11 (2.1)

12 C: an’ y’know “not be anno:yed an’ (1.3) play with my sista an’

13 have f↑un n’ y’know (0.2) fur her to stop annoying me”.

14 T: Mmhm.

15 C: “now whatta you want”.

16 (.)

17 C: EXactly the same thing.

18 T: Yep.

19 (0.3)

20 C: “W↑e(h)ll?”
21 (.)

22 T: Yep.

Across lines 1--8 (with no response from the client at a point of possible speaker transition at line 3) the therapist makes a
proposal in the form of a hedged recommendation. The therapist uses low-modality operators (‘‘might’’, ‘‘worth’’), essential-
izing devices (‘‘even’’) and delaying devices (intra-turn pauses, ‘‘um’’) within her proposal turn to downgrade her deontic
authority and highlight the contingency of her proposal on the client’s acceptance. The therapist also engages in the extra
effort of an insertion repair, adding the minimising term ‘‘even’’ (line 1), that further downgrades the low-modality verb ‘‘might’’
at the beginning of her proposal. The therapist has thus marked the proposal as being contigent on the client’s acceptance.
After no response from the client at line 3, the therapist builds an incremental turn and moves into hypothetical active voicing
 K. Ekberg, A. LeCouteur / Journal of Pragmatics 90 (2015) 12--25 21

(Simmons and LeCouteur, 2011) to explain the proposal further. The therapist enacts the words that she is suggesting the
client say to her daughter. However, she includes the phrase ‘‘you know’’ before doing so, which works to imply that the talk to
come is common-sensical and something that anyone, including the client, might say in this circumstance. In this way, the use
of ‘‘you know’’ allows the therapist to manage the delicate interactional task of the proposal. By using this phrase, the
subsequent hypothetical active voicing appears less like the therapist telling the client what to do, and more as if she is merely
describing some common-sensical talk that anyone, including the client, would say in the circumstance.
At line 9, the client launches straight into a resistive account of a previous instance in which she had attempted to speak
with both her daughters about their fighting. Within her account, and subsequent to the therapist’s use of hypothetical active
voicing, the client makes use of direct reported speech (Holt, 1996). Reported speech (Holt, 1996) was another key way in
which clients displayed their epistemic rights to the situation being discussed within their resistance to proposals. This
practice by clients is similar to that identified by Clift (2006) in the environment of second assessments, where reported
speech was used by speakers to display their own prior engagement with what has been raised, thus laying claim to primary
rights to do the assessing. Here, over multiple turns, she enacts a scenario for the therapist, including voicing her own speech
and that of both daughters. The client thus provides the therapist with an evidential display of having already attempted the
proposed solution. By displaying her prior attempt in this way, the client lays claim to primary knowledge of the situation with
her daughters (Clift, 2006). In doing so, she is able to invoke her deontic right to resist the therapist’s proposed course of
action. It is interesting that in responding to the therapist’s proposal -- which was framed in terms of hypothetical active voicing
-- the client herself uses reported speech to resist it. The client’s use of reported speech within the interaction highlights the
hypothetical nature of the therapist’s enacted scenario. By reporting an actual encounter with her daughters, the client is able
to show that she is the only one with direct access to the situation under discussion.
Another example will be considered below. The focus of the client’s prior troubles-telling in this instance has been on
how her mother is causing her stress by refusing a birthday gift idea of being taken out to dinner because it will be too
expensive for the family.

(6) [CBT 002 dinner 26:35]

1 T: Do you think there would be:: hhh (1.0) something that (1.0) she

2 could accept (0.2) as a as a (0.4) g↑ift

3 (0.2)

4 T: As a (0.4) thoughtful indication of your lo:ve

5 (0.9)

6 T: Um (0.7) in the world at all?

7 (0.7)

8 T: Is there anything that she could accept?

9 (.)

10 C: Absolutely not.

11 (0.8)

12 T: Mm.

13 (0.8)

14 T: Wha:t abou:::t something tha:t (0.3) >didn't cost any< money.

15 (3.3)

16 C: I do stuff for them.

17 T: Um↑hm
22 K. Ekberg, A. LeCouteur / Journal of Pragmatics 90 (2015) 12--25

The therapist offers a proposal that the client do something for her mother’s birthday that wouldn’t cost any money, instead
of taking her out to dinner. The therapist’s proposal is in the form of an interrogative with positive polarity -- designed to
prefer a ‘yes’ response and an acceptance of the proposal. The client resists the proposal with an assertion of previous
effort; she already does things for her parents on a regular basis.
In this case, the client attends to her epistemic stance through the framing of her response to the therapist’s interrgoative.
The client responds to the proposal by launching a fully sentential response (‘‘I do stuff for them’’, line 16). Her turn does not
respond to the grammatical constraint of the interrogative, but instead departs from the terms of the question (i.e., she do not
provide any sort of ‘‘no’’ response) (Heritage and Raymond, 2010). This type of response was another common way for
clients to orient to their epistemic stance in their responses. Clients resisted the restrictions of yes/no interrogatives by using
responses that delayed or left out a yes/no response (‘non-conforming responses’) and thus modified the terms of the
question (Heritage and Raymond, 2005, 2010). Such responses work to assert the respondent’s epistemic entitlement in
regard to the matter at hand. They do so by ‘confirming’ rather than ‘affirming’ the proposition raised by the questioner, thus
exerting agency over the matter. By resisting these terms, the client displays an assertion of her epistemic rights in relation to
the issue under discussion (Heritage and Raymond, 2010). And by indexing her epistemic stance over her experience, the
client is able to invoke her deontic right to reject the proposed course of action.

4. Discussion

These findings extend previous CA research into how active resistance is realised in interaction. The analysis focussed
on the interactional environment of therapists’ proposals for behavioural change in CBT. These proposals can create a
dilemma for therapists in regards to who has the greater epistemic acess to the situation under discussion. Although
therapists carry the professional authority, clients have expertise in relation to their own life experiences. This distinction has
been referred to as the ‘epistemics of expertise’ in coordination with the ‘epistemics of experience’ (Heritage, 2013b;
Lindström and Weatherall, 2015). In each case in the instances under discusion here, therapists signalled that they were
sharing the deontic right to make the decision with the client. They did this through the use of low-modal terms, essentializing
devices, interrogative forms and by packaging proposals as information-giving (see Ekberg and LeCouteur, 2012). The
current analysis focussed on how clients responded to such proposals, demonstrating how resistance was typically framed
in response to therapists’ proposals for behavioural change using three key types of account:

 appeals to restrictive situational factors

 appeals to a fixed physical state
 assertions of previous effort to do what the therapist was proposing

In each of these types of account, clients utilised knowledge from previous experience, and of the current troubling
situation, to produce reasons for their resistance. In drawing upon such knowledge to frame their accounts, clients thus
displayed their primary epistemic access to the situation under discussion. In looking at the detail of the ways in which
clients designed their turns when producing resistive accounts, we also identified three key resources that were
repeatedly used to display their epistemic stance in relation to the situation. These included: (1) high modality terms and
primary tense (e.g., I’m sure, always, every) (Halliday, 1985; He, 1993); (2) non-conforming responses to interrogatives
(Heritage and Raymond, 2010); and (3) direct reported speech (Clift, 2006). In other words, while the content of clients’
accounts claimed greater epistemic status by overtly stating new knowledge that the therapists could not have known,
there were subtle aspects in the design of the clients’ turns that also indexed their epistemic stance. By orienting to their
epistemic status within their resistive turns, clients positioned themselves as having ultimate rights to resist therapists’
proposals. As Stevanovic (2012) has shown, a pre-condition to a recipient accepting a proposal for future action is that
they have epistemic access to the content of the proposal (i.e., the situation under discussion). In the cases analysed
here, the recipients in fact have superior access to the situation under discussion relative to the proposer. Our analysis
has shown that clients routinely oriented to this fact in their responses, and indexed their superior epistemic authority of
experience as a way to invoke their deontic right to reject the therapist’s proposed course of action. Within the corpus, we
observed several lengthy sequences of interaction where therapists made multiple proposals that were each resisted by
the client. This repeated resistance to various proposals provides further evidence that clients were not only concerned
with resisting the specific suggestion from the therapist, but also with asserting their deontic authority over making the
decision as to what behavioural changes they will implement in their lives.
Through examining clients’ resistance to therapists’ proposals, we can see the interplay between claims of epistemic
and deontic stance. Clients’ resistive accounts were grounded in their superior knowledge of their own experience, and
this knowledge allowed them to invoke their deontic right to reject specific future actions for them. Thus, in this
environment, clients’ epistemics of experience could trump therapists’ epistemics of expertise. These findings build on the
 K. Ekberg, A. LeCouteur / Journal of Pragmatics 90 (2015) 12--25 23

developing body of work on the interplay between deontics and epistemics in interaction (e.g., Antaki, 2012; Heritage,
2013a; Landmark et al., 2015; Lindström and Weatherall, 2015), by illustrating some ways in which epistemic and deontic
stance can be managed by parties in second-position resistance responses.

4.1. Implications for CBT practice

Demonstrated patterns in the ways clients resist therapists’ proposals for behavioural change have important
implications for CBT practice. Analysis has demonstrated that when clients resist, they are not only concerned with
rejecting the specific proposed change, but also with claiming their epistemic and deontic stance in relation to the matter.
Such resistance can obstruct the progression of therapy goals, minimise the degree of success in implementing
behavioural change, and create a poor relationship between therapist and client (Beutler et al., 2002; Muntigl, 2013;
Safran and Muran, 1996). Therapists might therefore benefit from becoming more aware of the subtle implications carried
within proposals for behavioural change, as clients appear to be sensitive to such issues in the way that they frame their
responsive turns.
Prior research has demonstrated that a more collaborative approach, via the use of open questioning techniques
(Socratic questioning, to use CBT terminology) that co-implicate clients in the decision-making process, may not lead to
such pervasive resistance (Ekberg and LeCouteur, 2014). Therapists co-implicated clients in the process of behavioural
change through the use of information-soliciting questions (via polar or Q-word questions, Stivers, 2010), and other
collaborative turn structures. These types of questions display the therapist as being in a K-epistemic position, soliciting
the client’s opinion (Heritage, 2010; Heritage and Raymond, 2010). For example, in the fragment below, the therapist asks
the client an information-soliciting question concerning what she might do to make some time for herself. In her
subsequent response, the client provides a suggestion as to what she could do:

(7) [CBT 019 beach 47:21]

1 T: Is there anything that you could do ta (0.3) h↑elp with

2 that? Do you think? Over the next couple of wee:ks?

3 (2.8)

4 C: >I dunno just< (.) maybe (0.2) wri:ting in my list a bit of

5 time out time.

6 T: ↑Okay.

Such questions from the therapist position the client as the knowledgeable party in the interaction; as the one who would
know how to change her own behaviour. This type of turn structure has important resonances with the theory underlying
CBT which is guided by a specific working alliance referred to as ‘collaborative empiricism’ (Wright et al., 2006). This
alliance describes therapists and clients working together systematically to gather data that disconfirms core depressive
beliefs or thoughts (Beck et al., 1979). In particular, CBT theory encourages therapists to engage clients through the use of
Socratic questioning (Wright et al., 2006): asking a series of inductive or open questions in a form that does not provide
answers to which the client can respond, but which requires the client’s direct input. For example, a therapist might ask:
‘‘What action could you take in the next couple of days that would begin to make a difference?’’. In this way, CBT theory
suggests inviting clients to participate actively in the institutional activity that is underway. Fragment (7) provides an
example of such questioning. Unlike these questions however, the therapists’ proposals examined in the present study
set up the next turn from the client as acceptance/rejection. Even when therapists attempted to frame their proposals in a
way that shared deontic rights, clients made it clear that they were the ones who held the ultimate right to decide what
behavioural changes they would implement in their lives.
These findings demonstrate a gap between the ‘professional stocks of interactional knowledge’ (SIKs) (Peräkylä and
Vehviläinen, 2003) in CBT and how these activities are often accomplished within practice. To foster a relationship of
‘collaborative empiricism’ when undertaking the activity of Behavioural Activation, therapists must manage the tension
between two interactional tasks: actively engaging the client; and guiding the therapy trajectory towards change. The CA
findings suggest that the interactional realisation of these tasks may be more difficult for therapists to negotiate in situ than
the theory might suggest. However, the findings also highlight that clients will orient strongly to the right to participate
actively in their own therapy, lending support to the underlying assumptions of the ‘collaborative empiricism’ SIK.
24 K. Ekberg, A. LeCouteur / Journal of Pragmatics 90 (2015) 12--25

More broadly, these findings support Pilnick’s (2008) idea that, for clients in institutional settings, deciding to agree with
a proposal for action is not recognised as the same, and not responded to in the same way, as choosing their own action.
The therapy session is a complex epistemic and deontic environment where both parties must manage their own
knowledge and rights in relation to the activities being accomplished. Because of this, the negotiation of epistemics and
deontics may unfold differently than other institutional settings like doctor-patient consultations, where patients may be
more willing to defer to a doctor’s medical authority (e.g., see Landmark et al., 2015; Toerien et al., 2013). Further,
proposals for future behavioural change may be responded to differently from recommendations for medical treatment,
particularly if they involve clients accepting some responsibility for their trouble. Although Lindström and Weatherall
(2015) have found that even in medical consultations, patients may sometimes draw upon their deontic authority to resist
treatment recommendations. Close analysis of the present corpus has shown how the different ways in which therapists
structure the client’s involvement in the behavioural change process, interactionally, can have significant consequences
for the trajectory of the therapy session.

References

Antaki, Charles, 2012. Affiliative and disaffiliative candidate understandings. Discourse Stud. 14 (5), 531--547.
Antaki, Charles, Barnes, Rebecca, Leudar, Ian, 2004. Trouble in agreeing on a client’s problem in a cognitive-behavioural therapy. Riv.
Psicolinguist. Appl. 4, 127--138.
Beck, Aaron T., Rush, John, Shaw, Brian, Emery, Gary, 1979. Cognitve Therapy of Depression. The Guilford Press, New York.
Beutler, Larry E., Moleiro, Carla, Talebi, Hani, 2002. Resistance in psychotherapy: what conclusions are supported by research? J. Clin. Psychol.
58 (2), 207--217.
Blackburn, Ivy-Marie, Davidson, Kate, 1990. Cognitive Therapy for Depression and Anxiety: A Practitioner’s Guide. Blackwell Scientific
Publications, Oxford.
Butler, Carly, Potter, Jonathan, Danby, Susan, Emmison, Michael, Hepburn, Alexa, 2010. Advice implicative interrogatives: Building ‘client
centred’ support in a children’s helpline. Soc. Psychol. Q. 73, 265--287.
Clift, Rebecca, 2006. Indexing stance: reported speech as an interactional evidential. J. Sociolinguist. 10 (5), 569--595.
Curl, Traci, Drew, Paul, 2008. Contingency and action: a comparison of two forms of requesting. Res. Lang. Soc. Interact. 41 (2), 129--153.
Davis, Kathy, 1986. The process of problem (re)formulation in psychotherapy. Sociol. Health Illn. 8 (1), 44--74.
Edwards, Derek, Fasulo, Alessandra, 2006. ‘‘To be honest’’: sequential uses of honesty phrases in talk-in-interaction. Res. Lang. Soc. Interact. 39
(4), 343--376.
Ekberg, Katie, LeCouteur, Amanda, 2012. Negotiating behavioural change: therapists’ proposal turns in Cognitive Behavioural Therapy.
Commun. Med. 9 (3), 229--239.
Ekberg, Katie, LeCouteur, Amanda, 2014. Co-implicating and re-shaping clients’ suggestions for behavioural change in Cognitive Behavioural
Therapy practice. Qual. Res. Psychol. 11 (1), 60--77.
Emmison, Michael, Butler, Carly, Danby, Susan, 2011. Script proposals: a device for empowering clients in counselling. Discourse Stud. 13 (1), 3--
26.
Halliday, Michael A.K., 1985. An Introduction to Functional Grammar. Edward Arnold, London.
He, Agnes, 1993. Exploring modality in institutional interactions: cases from academic counselling encounters. Text 13 (2), 503--528.
Heritage, John, 1984. Garfinkel and Ethnomethodology. Polity Press, Cambridge.
Heritage, John, 2010. Questioning in medicine. In: Freed, A.F., Ehrlich, S. (Eds.), ‘‘Why Do You Ask?’’: The Function of Questions in Institutional
Discourse. Oxford University Press, New York, pp. 42--68.
Heritage, John, 2012. The epistemic engine: sequence organization and territories of knowledge. Res. Lang. Soc. Interact. 45 (1), 30--52.
Heritage, John, 2013a. Action formation and its epistemic (and other) backgrounds. Discourse Stud. 15 (5), 551--578. http://dx.doi.org/10.1177/
1461445613501449
Heritage, John, 2013b. Epistemics in conversation. In: Sidnell, J., Stivers, T. (Eds.), The Handbook of Conversation Analysis. Wiley-Blackwell,
Sussex, UK, pp. 370--394.
Heritage, John, Raymond, Geoffrey, 2005. The terms of agreement: indexing epistemic authority and subordination in talk-in-interaction. Soc.
Psychol. Q. 68 (1), 15--38.
Heritage, John, Raymond, Geoffrey, 2010. Navigating epistemic landscapes: acquiescence, agency and resistance in responses to polar
questions. In: deRuiter, J.-P. (Ed.), Questions. Cambridge University Press, Cambridge.
Heritage, John, Sefi, Sue, 1992. Dilemmas of advice: aspects of the delivery and reception of advice in interactions between health visitors and
first time mothers. In: Drew, P., Heritage, J. (Eds.), Talk at Work: Interaction in Institutional Settings. Cambridge University Press, Cambridge,
pp. 359--419.
Holt, Elizabeth, 1996. Reporting on talk: the use of direct reported speech in conversation. Res. Lang. Soc. Interact. 29 (3), 219--245.
Jefferson, Gail, 2004. Glossary of transcript symbols with an introduction. In: Lerner, G. (Ed.), Conversation Analysis: Studies from the First
Generation. John Benjamins, Philadelphia, pp. 13--23.
Jefferson, Gail, Lee, J.R.E., 1992. The rejection of advice: managing the problematic convergence of a ‘‘troubles-telling’’ and a ‘‘service encounter’’.
In: Drew, P., Heritage, J. (Eds.), Talk at Work: Interaction in Institutional Settings. Cambridge University Press, Cambridge, pp. 521--551.
Kent, Alexandra, 2012. Compliance, resistance and incipient compliance when responding to directives. Discourse Stud. 14 (6), 711--730. http://
dx.doi.org/10.1177/1461445612457485
Kinnell, Anne-Marie, Maynard, Douglas.W., 1996. The delivery and receipt of safer sex advice in pretest counselling sessions for HIV and AIDS. J.
Contemp. Ethnogr. 24, 405--437.
Koenig, Christopher J., 2011. Patient resistance as agency in treatment decisions. Soc. Sci. Med. 72, 1105--1114.
 K. Ekberg, A. LeCouteur / Journal of Pragmatics 90 (2015) 12--25 25

Land, Victoria, Kitzinger, Celia, 2007. Some uses of third-person reference forms in speaker self-reference. Discourse Stud. 9 (4), 493--525.
Landmark, Anne Marie Dalby, Gulbrandsen, Pål, Svennevig, Jan, 2015. Whose decision? Negotiating epistemic and deontic rights in medical
treatment decisions. J. Pragmat. 78, 54--69. http://dx.doi.org/10.1016/j.pragma.2014.11.007
Leahy, Robert, 2001. Overcoming Resistance in Cognitive Therapy. The Guilford Press, New York.
Lerner, Gene, Kitzinger, Celia, 2007. Extraction and aggregation in the repair of individual and collective self-reference. Discourse Stud. 9, 526--557.
Lindström, Anna, Weatherall, Ann, 2015. Orientations to epistemics and deontics in treatment discussions. J. Pragmat. 78, 39--53.
MacMartin, Clare, 2008. Resisting optimistic questions in narrative and solution-focused therapies. In: Peräkylä, A., Antaki, C., Vehviläinen, S.,
Leudar, I. (Eds.), Conversation Analysis and Psychotherapy. Cambridge University Press, Cambridge, pp. 80--99.
Madill, Anna, Widdicombe, Sue, Barkham, Michael, 2001. The potential of conversation analysis for psychotherapy research. Couns. Psychol. 29,
413--434.
Muntigl, Peter, 2013. Resistance in couples counselling: sequences of talk that disrupt progressivity and promote disaffiliation. J. Pragmat. 49, 18--
37. http://dx.doi.org/10.1016/j.pragma.2013.01.003
Peräkylä, A., Vehviläinen, S., 2003. Conversation analysis and the professional stocks of interactional knowledge. Discourse Soc. 14, 727--750.
Peräkylä, A., Antaki, C., Vehviläinen, S., Leudar, I., 2008. Conversation Analysis and Psychotherapy. Cambridge University Press, Cambridge.
Pilnick, Alison, 2008. ‘It’s something for you both to think about’: choice and decision making in nuchal translucency screening for Down’s
syndrome. Sociol. Health Illn. 30 (4), 511--530.
Pomerantz, Anita, 1984. Agreeing and disagreeing with assessments: some features of preferred/dispreferred turn shapes. In: Atkinson, J.M.,
Heritage, J. (Eds.), Structures of Social Action: Studies in Conversation Analysis. Cambridge University Press, Cambridge, pp. 57--101.
Raymond, Geoffrey, 2010. Grammar and social relations: alternative forms of yes/no-type initiating actions in health visitor interactions. In: Freed,
A., Ehrlich, S. (Eds.), ‘‘Why Do You Ask’’: The Function of Questions in Institutional Discourse. Oxford University Press, New York, pp. 87--107.
Raymond, Geoffrey, Heritage, John, 2006. The epistemics of social relations: owning grandchildren. Lang. Soc. 35, 677--705.
Sacks, Harvey, Schegloff, Emanuel, Jefferson, Gail, 1974. A simplest systematics for the organization of turn-taking for conversation. Language
50 (4), 696--735.
Safran, Jeremy D., Muran, J. Christopher, 1996. The resolution of ruptures in the therapeutic alliance. J. Consult. Clin. Psychol. 64, 447--458.
Silverman, David, 1997. Disourses of Counselling: HIV Counselling as Social Interaction. Sage, London.
Simmons, Katie, LeCouteur, Amanda, 2011. ‘Hypothetical active-voicing’: therapists ‘modelling’ of clients’ future conversations in CBT
interactions. J. Pragmat. 43 (13), 3177--3192.
Stevanovic, Melisa, 2012. Establishing joint decisions in a dyad. Discourse Stud. 14 (6), 779--803.
Stevanovic, Melisa, 2013. Constructing a proposal as a thought: a way to manage problems in the initiation of joint decision-making in Finnish
workplace interaction. J. Pragmat. 23 (3), 519--544.
Stevanovic, Melisa, Peräkylä, Anssi, 2012. Deontic authority in interaction: the right to announce, propose, and decide. Res. Lang. Soc. Interact.
45 (3), 297--321. http://dx.doi.org/10.1080/08351813.2012.699260
Stevanovic, Melisa, Peräkylä, Anssi, 2014. Three orders in the organization of human action: on the interface between knowledge, power, and
emotion in interaction and social relations. Lang. Soc. 43 (2), 185--207. http://dx.doi.org/10.1017/S0047404514000037
Stivers, Tanya, 2005a. Modified repeats: one method for asserting primary rights from second position. Res. Lang. Social Interact. 38 (2), 131--158.
Stivers, Tanya, 2005b. Parent resistance to physicians’ treatment recommendations: one resource for initiating a negotiation of the treatment
decision. Health Commun. 18 (1), 41--74. http://dx.doi.org/10.1207/s15327027hc1801_3
Stivers, Tanya, 2010. An overview of the question--response system in American English conversation. J. Pragmat. 42, 2772--2781.
Svennevig, Jan, Stevanovic, Melisa, 2015. Special issue: epistemics and deontics in conversational directives. J. Pragmat. 78, 1--112.
Toerien, Merran, Shaw, Rebecca, Reuber, Markus, 2013. Initiating decision-making in neurology consultations: ‘recommending’ versus ‘option-
listing’ and the implications for medical authority. Sociol. Health Illn. 35 (6), 873--890.
Vehviläinen, Sanna, 2001. Evaluative advice in educational counselling: the use of disagreement in the ‘‘stepwise entry’’ to advice. Res. Lang.
Soc. Interact. 34 (3), 371--398.
Vehviläinen, Sanna, 2008. Identifying and managing resistance in psychoanalytic interaction. In: Peräkylä, A., Antaki, C., Vehviläinen, S., Leudar,
I. (Eds.), Conversation Analysis and Psychotherapy. Cambridge University Press, Cambridge, pp. 120--138.
Waring, Hansun Zhang, 2005. Peer tutoring in a graduate writing centre: indentity, expertise, and advice resisting. Appl. Linguist. 26 (2), 141--168.
Waring, Hansun Zhang, 2007. Complex advice acceptance as a resource for managing asymmetries. Text Talk 27 (1), 107--137.
Weiste, Elina, 2015. Describing therapeutic projects across sequences: balancing between supportive and disagreeing interventions. J. Pragmat.
80, 22--43.
Wright, Jesse, Basco, Monica, Thase, Michael, 2006. Learning Cognitive-Behavioural Therapy. American Psychiatric Publishing Inc., Washington.
Zinken, Jörg, Ogiermann, Eva, 2011. How to propose an action as objectively necessary: the case of polish trzeba x (‘‘one needs to x’’). Res. Lang.
Soc. Interact. 44 (3), 263--287. http://dx.doi.org/10.1080/08351813.2011.591900

Katie Ekberg is a Postdoctoral Research Fellow in the School of Health and Rehabilitation Sciences at The University of Queensland, Australia.
Her interests involve conversation analysis, healthcare interactions, and psychotherapy interactions. Her previous research has involved
examining client-practitioner communication in Cognitive Behavioural Therapy sessions for clients diagnosed with depression, calls with
specialist nurses on a major UK cancer helpline, consultations with neurologists and patients suffering from seizure disorders (including
epilepsy), and most recently audiology consultations with hearing-impaired patients.

Amanda LeCouteur is Associate Professor in Psychology at the University of Adelaide, Australia, where she is Co-Director of the Discourse and
Social Psychology Unit and teaches in the fields of social psychology and gender. She has published in the areas of racism, education, and health.
She also has a long-standing interest in the field of elite achievement, and acts as a recruiting and development consultant in the Australian
Football League. Her current research involves analysis of real-life interaction in contexts such as help-line, medical and counselling interactions.