Client-centred practice: an interactional case study of dietary counselling

Abstract

It is likely that a contemporary interest in more effective medical communication saw the emergence of ‘client-centred practice’ espoused in western medicine today. As ideology, however, the notion of client-centred practice is open to critique, and indeed Armstrong (1984) argues that current practices may simply be an artefact of changes in perception. At the core of this dilemma lies the imperative nature of medical discourse in negotiating treatment plans. This paper takes a particular empirical view and examines one way in which client-centred practice may be operationalized through talk itself. In this case we examine instances of dietary counselling in the context of a teaching clinic. If client-centredness were to achieve the aims of client participation in decision-making, then agreements on dietary change would provide the evidence of how this might be so. Methods of conversation analysis were applied to extracts of interviews involving student dietitians who had been trained to work in a client-centred fashion. The perspective display series identified by Maynard (1991) in paediatric consultations provided a focal point for this analysis. Observed studentdriven interviews were of specific interest because it would be all the more difficult for clients to disagree with proposals in this context. Analytical findings displayed a preponderance of perspective invitations resulting in agreed dietary changes. This agreement was strong where there was also evidence of active client participation in the decision-making process. Deviant case analysis found that where strong agreement failed to occur, the practitioner tended to foreclose on changes without a fuller exploration of the client opinion. While this may well reflect the constraints of the teaching clinic context, it does suggest that a client-centred approach may appear to operate at a superficial level if it is not adequately followed through in subsequent turns at talk.