Joint Decision Making in a Mental Health Rehabilitation Community : The Impact of Support Workers’ Proposal Design on Client Responsiveness

Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ccpq20 Counselling Psychology Quarterly ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ccpq20 Joint decision making in a mental health rehabilitation community: the impact of support workers’ proposal design on client responsiveness Melisa Stevanovic , Taina Valkeapää , Elina Weiste & Camilla Lindholm To cite this article: Melisa Stevanovic , Taina Valkeapää , Elina Weiste & Camilla Lindholm (2020): Joint decision making in a mental health rehabilitation community: the impact of support workers’ proposal design on client responsiveness, Counselling Psychology Quarterly, DOI: 10.1080/09515070.2020.1762166 To link to this article: https://doi.org/10.1080/09515070.2020.1762166 © 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. Published online: 07 Jun 2020. Submit your article to this journal Article views: 183 View related articles View Crossmark data ARTICLE Joint decision making in a mental health rehabilitation community: the impact of support workers’proposal design on client responsiveness Melisa Stevanovic a , Taina Valkeapää a , Elina Weiste a and Camilla Lindholm b a Faculty of Social Sciences, University of Helsinki, Helsinki, Finland; b Faculty of Communication Sciences, Tampere University, Tampere, Finland ABSTRACT Using both statistical methods and conversation analysis, we examined how support workers in a mental health rehabilitation community encourage clients to participate in joint decision-making processes. Drawing on video-recordings of 29 community meetings as data, we considered support workers’proposals (N = 449) and clients’responsiveness to them. Support workers’proposals were coded for their linguistic and other features and clients’responsiveness was assessed by three independent raters. Multiple linear regression (MLR) analysis was carried out. A significant regression equation with seven predictor variables accounted for 24% of the variance in the data. Four variables predicted a higher level of client responsiveness: the use of explicit recipient address term, “quasiopen”proposal form, support worker’s long work experience, and the average level of client participation during a session. Three variables predicted a lower level of client responsiveness: grammatical complexity of proposal form, modal declarative proposal form, and the presence of only one support worker in a session. The qualitative conversation-analytic investigation highlighted the advantages of the careful fine-tuning of openness vs. closedness of proposal form, the reflexive awareness of which, we argue, may help mental health professionals to encourage clients’responsiveness in joint decision-making processes and thereby their participation in communal life. ARTICLE HISTORY Received 1 September 2019 Accepted 6 March 2020 KEYWORDS Mental health rehabilitation; joint decision making; proposals; responsiveness; participation; conversation analysis Joint decision-making provides the basis for “procedural democracy”(Dahl, 1998) and is thus the basic locus of participation in society. At the micro-level of social interaction, the possibility to participate in joint decision-making is not only about being able to influence common matters in line with one’s personal preferences. In addition, participation in joint decision-making is of value in itself, given its implications for people’s social identities and agency. Experiences of empowerment through participation have been regarded as a central building block of a healthy sense of self, as they involve the individuals perceiving and constructing themselves as active, self-determining agents (Pulvirenti, McMillan, & Lawn, 2014). Another consequence of participation is the sense of social recognition (Honneth, 2001), given that the awareness of one’s social worth as a person who has CONTACT Melisa Stevanovic melisa.stevanovic@helsinki.fi COUNSELLING PSYCHOLOGY QUARTERLY https://doi.org/10.1080/09515070.2020.1762166 © 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http:// creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. a word to say in common matters can only be constituted intersubjectively in interactions with other people (Marková, 2003). Participation is of particular importance for individuals with mental illness. In this context, a high level of participation has been linked to improved quality of life (Sibitz et al., 2011a), stigma resistance (Sibitz, Unger, Woppmann, Zidek, & Amering, 2011b), and illness recovery (Kirby & Keon, 2006). Mental health rehabilitation has thus become increasingly concerned with the development of practices to encourage client participation (Petersen, Hounsgaard, & Nielsen, 2008). Participation is a particularly important ideal in community-based programs seeking to support individuals with mental illness to take control over their own lives (Doyle, Lanoil, & Dudek, 2013; Hänninen, 2012). In these contexts, participation is connected to responsibilities arising from one’s membership in communities (Hopper, 2007; Warner, 2009,2010). Such responsibilities draw attention to the individuals with mental illness also have something to offer and contribute to the community as a whole, instead of being focused only on their own care (Pulvirenti et al., 2014). In this paper, we use both statistical methods and conversation analysis (CA) to examine how support workers at a Finnish Clubhouse mental health rehabilitation community may encourage clients to participate in joint decision-making processes. Assuming that the primordial site of human social life where participation realizes is the face-to-face real-time interaction between individuals (Schegloff,2006), we examine the support workers’concrete practices at the Clubhouse. More specifically, we investigate how they initiate joint decision-making sequences, assessing the level of client participation following these initiations. In this case, we conduct such assessments on the basis of client responsiveness to support worker initiations, which we regard as a central subdomain of client participation. By identifying the most and least successful practices, we seek (1) to increase understanding of participation as an interactional phenomenon, (2) to contribute to knowledge about the particular challenges of participation for individuals with mental illness, and thereby (3) to provide guidance for professionals working with mental health clients. Joint decision-making and professional practices Joint decision-making is a thoroughly interactional phenomenon: none of the participants alone has control over the unfolding of the process, let alone over its outcome. From all of its participants, joint decision-making requires the capacity to exercise control over the agenda of interaction and to respond flexibly to others’analogous attempts, while also mastering a range of participatory practices, such as taking a turn at an apt moment in time, regulating one’s gaze behavior, and adjusting one’s body so as to maintain the interactional encounter. The complexities and paradoxes of joint decision-making have been examined in the wealth of CA studies on meetings, negotiations and multiprofessional teamwork (for overviews, see Asmuss & Svennevig, 2009; Firth, 1995; Stevanovic, 2012,2015). Joint decision-making does not always actualize. This may be due to various reasons. One participant may dominate the conversation and leave no room for others to participate. More intricately, he or she may engage in subtle interactional work to shift the matters under discussion beyond the legitimate sphere of joint decision-making 2M. STEVANOVIC ET AL. (Stevanovic, 2012). Often, however, joint decision-making is left unrealized simply because of a lack of substantial participation on the part of some participants in the encounter. In the context of counselling and mental health care, a typical threat to joint decision-making is a lack of participation by the client, which invites consideration of the role of the professional as a facilitator of participation (Wressle, 2002). There is much literature on the conversational practices by which professionals may facilitate client participation in decision-making in different contexts such as health care (e.g. Epstein et al., 2005; Heritage & Robinson, 2006; Robinson & Heritage, 2006). According to the existing counselling literature, such practices include open-ended questions, which have been suggested to facilitate client expressiveness and spontaneous discussion among group members, and personal sharing, which has been argued to encourage clients to describe their thoughts, suggestions, and perceptions (Trotzer, 2013). Such practices also include inviting the client to ask questions, active listening, and giving information about various options (Martin, DiMatteo, & Lepper, 2001). Participation in group decision-making has been seen to demand from the counsellor that he or she maps all diverging suggestions made in the group and monitors where each client stands in their perception of these suggestions (Trotzer, 2013). In addition to counselling literature, there is a rich literature on client participation in treatment decision-making during medical consultations (Angell & Bolden, 2015; Kushida & Yamakawa, 2015; McCabe, Khanom, Bailey, & Priebe, 2013). All the evidence thus far points to the ideal of “shared decision-making”(Adams & Drake, 2006) being particularly challenging to realize in the context of mental health care (Beitinger, Kissling, & Hamann, 2014; De Las Cuevas, Rivero-Santana, Perestelo-Pérez, Pérez-Ramos, & Serrano-Aguilar, 2012; Elstad & Eide, 2009; Ernst & Paulus, 2005; Hickey & Kipping, 1998; Larquet, Coricelli, Opolczynski, & Thibaut, 2010; Stovell, Morrison, Panayiotou, & Hutton, 2016). The design of “proposals”as a window to decision-making practices In this paper, we approach the question of participation-facilitating professional practices from the point of view of proposals –conversational actions by which professionals seek to launch joint decision with clients. More generally, proposals denote turns-at-talk by which a speaker names a course of action suggesting that this be realized (Meier, 1997, pp. 165–181; Houtkoop, 1987) while conveying that the action is contingent upon the recipient’s (or recipients’) acceptance. Hence, a proposal is essentially an invitation for others to become engaged in joint decision-making. However, the connection between a proposal and subsequent joint decision-making is not inevitable. Instead, the “decisionmaking relevance”of proposals is constructed through a complex interplay of various lexico-syntactic forms, bodily behaviors and the immediate turn-by-turn context of the proposing action. The “design”of proposals –what is selected as a building block of the turn to do the action of proposing, in a way that it is understood by others as doing that action (Drew, 2013, p. 132) –is thus a central locus for speakers to encourage or discourage decision-making equality between the participants. Proposals can be designed in various ways. Previous CA literature has pointed to several contextual considerations warranting a speaker’s choice of one linguistic form over another when designing a proposal. Thus, for example, the choice between positive and negative interrogatives associated with the speakers’displays of low vs. high COUNSELLING PSYCHOLOGY QUARTERLY 3 entitlement (Asmuss & Oshima, 2012). Consistent with that finding, negatively formatted proposals have been argued to push the recipient towards acceptance in the face of earlier rejection (Drew, 2013). In their study on children’s play interaction, Stivers and Sidnell (2016) found the choice between “Let’sX”and “How about X”to display the child’s understanding of whether the proposed activity was connected to a prior one or not (Stivers & Sidnell, 2016). Furthermore, in their study of Japanese outpatient psychiatric consultations, Kushida and Yamakawa (2015) found that the psychiatrist’s choice between the inclusive “we”and a declarative evaluation was informed by whether the sequential environment was ready for decision-making (Kushida & Yamakawa, 2015). More indirectly, potential insights for the analysis of proposal design features can be drawn from CA literature on various bodily behaviors and lexico-syntactic formats. Gaze, for example, has been described as a generic turn-design feature by which speakers may increase the response relevance of their turns (Stivers & Rossano, 2010). The use of explicit address terms (e.g. first names) may be assumed to work in a similar way (see, e.g. Lerner, 2003). In contrast, earlier research on multi-unit turns (e.g. Linell, et al. 2003) has demonstrated that grammatically complex turns are challenging to respond to, which might have negative consequences for the degree of participation following these turns. Furthermore, previous CA research on questions and directives has shown that the amount of more or less genuine alternatives offered in the turn may have consequences for its uptake (see, e.g. Antaki & Kent, 2015). To be able to launch joint decision-making, a proposal needs to convey the speaker’s understanding that there is a true need for the participants to make a decision about a given topic in the here-and-now of the encounter, which is not the case for all utterances that carry the surface appearance of proposals (Stevanovic, 2013). In this paper, we ask how such implicit messages are conveyed by the support workers at a Finnish Clubhouse. Methods Study design A mixed-method approach (Hanson, Creswell, Plano Clark, Petska, & Creswell, 2005)was used to achieve depth in the understanding of how support workers in a mental health rehabilitation community encourage clients to participate in joint decision-making processes. This approach involved (1) case-by-case analysis of support workers’proposals, (2) design of a scheme for coding the linguistic and other features of the proposals, (3) generation of the outcome variable through independent observers rating the level of client responsiveness to each support worker proposal, (4) multiple linear regression (MLR) analysis, and (5) CA-informed illustration of the findings through data examples. The practice of combining qualitative and statistical methods has lately become increasingly popular especially in the studies of face-to-face interactioninhealthcaresettings(Robinson,2007). Setting The study is part of a larger research project on social interaction and inclusion in the case of mental illness. The participants for the project were recruited from one Finnish 4M. STEVANOVIC ET AL. Clubhouse community, which offers individuals with mental illness community-based psychosocial rehabilitation, including daily activity around work-ordered day, social and recreational programs, employment programs, and supported education. The international Clubhouse model is established in the 1940s in the United States and currently, there are about 200 Clubhouses around the world, certified by a head-organization Clubhouse International, with the most programs in the US., followed by Finland. In the Finnish health care system, Clubhouses are non-governmental membership organizations that complement governmental services. We obtained research permits for the study from the board of directors at the relevant Clubhouse. Institutional Review Board approval was obtained from the Ethics Committee of the Helsinki University Central Hospital for those parts of our project that involved the collection of diagnosis-based personal data. For the other parts of the project, including this study, our research did not meet the requirements specified by the Finnish National Board on Research Integrity (https://www.tenk.fi/en/ethical-review-in-finland) that would have made a university-based ethical review necessary. Participation in the project was voluntary. All participants gave their written consent to the study after having been informed about the aims of the study and about their rights to withdraw their consent anytime they wished. Materials The study makes use of video-recordings of 29 weekly meetings of a rehabilitation group in one Finnish Clubhouse community. The meetings were recorded during an 11-month period, from September 2016 to August 2017. The discussions during the meetings were focused on topics related to working life. The aim of the group was to allow the clients to practice and develop their work-related skills, such as the ones needed for joint decisionmaking. The meetings lasted from 30 to 60 minutes. Participants The group meetings involved 2–10 clients and 1–2 support workers at the time. The participant constellation varied, with 29 different clients and 7 support workers participating in the meetings during the recording period. As the group participation was voluntary, some clients participated more often than others. The 29 clients in our data were both male (N = 15) and female (N = 14), at the age varying from the late twenties to mid-fifties. Two of the clients were not natives of Finland. The clients were currently outside employment and education due to mental health problems. However, due to the nature of the setting, no information of their diagnoses is available. The Clubhouse communities identify themselves as “diagnosis-free zones,” where members are neither requested nor encouraged to share information about their diagnosis. Membership is open to anyone with a history of mental illness –specific diagnosis is not required. From the seven support workers participating in the meetings, one was male and six female, at the age varying from 30 to 50. All the support workers were professionally trained in social work and they had varying degrees of work experience in the field of mental health rehabilitation. COUNSELLING PSYCHOLOGY QUARTERLY 5 Mixed-methods procedures and analysis First stage: qualitative analysis of the support workers’proposals The video-recorded group meetings were first analyzed with conversation analysis (CA). CA is a data-driven and micro-analytic method, which considers discourse as a collective production, where meaning is constructed dynamically in co-operation between conversational participants. It is essentially about analyzing the possibilities and constraints that an utterance places to the utterances to come, while each utterance gets its “meaning”in relation to the prior utterances (Schegloff,2007). Analysis is conducted on a case-by-case manner, with the analytic claims being typically developed collaboratively in the so-called “data sessions”(Stevanovic & Weiste, 2017). Given that CA researchers use video or audio recordings of naturally-occurring social interactions as their data, they have direct access to most minute details of interaction and the possibility to scrutinize the same data segments over and over again. Previous CA work on mental health has shown how different forms of psychiatric institutions and professional ideologies may be sustained and renewed in and through participants’conversational practices. These studies have provided detailed descriptions of a variety of actions that clinicians and clients engage in during the therapeutic process, such as formulating a shared understanding of the client’s talk (Antaki, 2008; Weiste & Peräkylä, 2013), affiliating with the client’s emotional stance (Hepburn & Potter, 2007; Muntigl, Knight, Watkins, Horvath, & Angus, 2013; Ruusuvuori, 2005; Voutilainen, 2010)or resisting the clinicians’interventions (MacMartin, 2008; Vehviläinen, 2008). In this study, the aim of our qualitative analysis has been to increase context-specific understanding of how the support workers’different ways of designing their proposals open or close opportunities for the clients to participate in the ongoing decision-making. In the analytic procedure, the data were transcribed according to the CA conventions (Schegloff,2007, pp. 265–269), which help the analysts identify orderly practices of interaction (Hepburn & Bolden, 2013). Besides the words said, also the prosodic features of the participants’ speech, pauses within and between utterances, as well as overlapping talk, were transcribed (see Hepburn & Bolden, 2013 and transcription symbols in Appendix 1). The transcription process also included the anonymization of names and other personal identifiers from the conversations, and this holds also for the transcripts shown in this paper. The recordings were watched several times and all sequences where support workers and clients made a decision were identified. The first author analyzed these sequences case-by-case, paying careful attention to the social functions of support workers’utterances and to the clients’ways of responding to these utterances (see Stevanovic, Valkeapää, Weiste, & Lindholm, 2018). Second stage: creating a coding scheme To expand the scope of study beyond the qualitative case-by-case analysis, all support workers’proposals (N = 449) in our data were identified and coded for their linguistic and other features. A proposal was operationalized as a complete turn at talk that presents a future action or event as contingent on the others’acceptance and introduces it to joint discussion, thus launching (or seeking to launch) joint decision-making on it. 6M. STEVANOVIC ET AL. Each proposal was coded for its linguistic form. The tentative coding scheme was informed by the basic distinctions of interrogative vs declarative utterances (i.e. questions vs statements) and open vs polar questions (i.e. Wh-questions vs Yes/No questions). The coding scheme, however, became more and more elaborated as the work progressed and the data pointed to a need for more specific categories, for example, with reference to the presence or absence of modal verbs, such as can, could, may, might, will, would, must, need or should. Thus, according to the final coding scheme, the linguistic form for each proposal was coded into one of the following eight categories: ●Open:“Wh”or “How”question (e.g. “What do you think we should do?”) ●Quasi open:“Wh”or “How”question probing the acceptance of only one option (e.g. “What if we did X?”) ●Alternative: A question suggesting a choice between two disjunctive options (e.g. “Should we do X or should be rather do Y?”) ●Modal polar question: A polar question with a modal finite verb (e.g. “Could we do X?”) ●Non-modal polar question: A polar question with a non-modal finite verb (e.g. “Does it make sense to do X?”) ●Non-modal declarative: A declarative with a non-modal finite verb (e.g. “It makes sense to do X?”) ●Modal declarative: A declarative with a modal finite verb (e.g. “We could do X”) ●Complex: Complex grammatical structure with two or more above-mentioned forms within the same turn (e.g. “Do you think it might be a good idea to do X?”) In addition to the linguistic form, we coded for two further turn-design features in the support workers’proposals: ●Gaze: Speaker gaze at the recipients (no gaze = 0, some gaze = 1, gaze throughout the proposal = 2) ●Recipient explicated: Presence of explicit recipient address term (no address term = 0, recipient explicated = 1) The reason for choosing these features for further examination is that CA literature (see, e.g. Lerner, 2003; Sacks, Schegloff,&Jefferson, 1974; Stivers & Rossano, 2010) has demonstrated how the practices of directing the gaze towards the co-participant(s) or addressing them explicitly by name or other address terms (e.g. “honey”, Lerner, 2003, p. 184) have the capacity to increase recipient responsiveness. In our data, the category “recipient explicated”normally involved the proposal speaker’s use of the recipient’sfirst name (e.g. mitä sä Anna ajattelet mihin me voitas se laittaa seinällä,“what do you think, Anna, where on the wall could we put it”). Moreover, during our data investigation, we noted several other features in relation to which the proposals in our data seemed to differ and whose effects on our dependent variable we wanted to control for (see Table 1). Therefore, to isolate the effects of the linguistic design of support workers’proposals that solicit a high degree of client participation, we also noted the following features of the proposals and the sessions in which they were embedded: COUNSELLING PSYCHOLOGY QUARTERLY 7 ●Preparatory same-turn talk: Number of words in the same turn preceding the proposal ●Proposal length: Number of words in the proposal ●Number of clients: Number of clients present in the session ●Session length: Length of the session in minutes ●Number of proposals: Number of proposals in a session ●Speaker’s expert status: Experience of the proposal speaker (support worker with a yearlong Clubhouse experience = 1, temporary worker = 0) ●Support worker alone: Number of support workers present in the session (support worker alone = 1, two or more workers = 0) A total of 10% of the 449 proposals in our data –that is, 45 proposals –were randomly selected and double coded. The kappa coefficient for the agreement was calculated for Linguistic form and Gaze. This was done because the coding for these features (unlike the more straightforwardly identifiable features such as the number of clients in the encounter) involves an element of subjective interpretation, which cannot be completely avoided even when using a detailed coding scheme. The kappa coefficients were assessed according to the conventions outlined by Landis and Koch (1977), who characterize values 0–0.20 as poor agreement, 0.21–0.40 as fair agreement, 0.41–0.60 as moderate agreement, 0.61–0.80 as substantial agreement, and 0.81–1.0 as excellent agreement. For Linguistic form, the kappa was 0.80 (95% CI: 0.70–0.92), which represents substantial agreement. For Gaze, the kappa was 0.46 (95% CI: 0.20–0.72), which represents moderate agreement. We noted that the distribution of different proposal features was not independent of the sessions during which the proposals were made, χ2 (184, N = 449) = 287.31, p < 0.001. Most notably, 37% of the proposals with the form of modal polar questions were produced during only two sessions out of the 29. Furthermore, 24% of the proposals with the form of open questions were made during one session only. These observations led us to undertake specific measures to avoid bias from over-representation of particular sessions in our statistical analysis (see the section “Fourth stage: Regression analysis” below). Third stage: rating the levels of client responsiveness The outcome variable was measured and created by three independent observers rating the level of client responsiveness to each of the 449 support workers’proposals in our data. The three observers were the second, third, and fourth authors of the study, who (unlike the first author) were blind to the informal working hypotheses of the study during Table 1. The means and standard deviations for the following predictor variables: Number of clients, session length, number of proposals, preparatory sameturn talk, and proposal length. Predictor variable Mean Std. Deviation Preparatory same-turn talk (in number of words) 5.80 10.33 Proposal length (in number of words) 15.81 15.66 Number of clients 5.37 2.16 Session length (in minutes) 49.93 10.42 Number of proposals in a session 15.00 16.21 8M. STEVANOVIC ET AL. (SW2) produces several affirmative response particles (kyllä “yes,”lines 4 & 7) to express agreement with the proposal. All the clients, however, remain silent. It is only after a silence (line 8) and the support worker’s (SW1) subsequent positive evaluation of some features of the text (lines 9–10) that the situation changes: following a minimal response particle by the other support worker (line 11), a client member of the group, Leo, produces a similar particle(line 12). In addition, after the support worker’s further suggestion on what not to include in the text (line 13), Leo expresses agreement with the suggestion by twice repeating the negation word ei “no”, which was used in the support worker’s previous turn (line 14). These types of agreements, as the ones produced by Leo, constitute preferred responses to proposals and assessments (Davidson, 1984; Pomerantz, 1984). As suchthey,however,runattheriskofbeingheardas“merely responsive”(Heritage &Raymond,2005,p.31)–that is, as responses without independence of position. The lack of the element of substantial client participation in Extract 2 is reflected in the relatively low participation rating given to the segment (mean = 2.33). This pattern, which is generic to our data set, accounts for our earlier statistical results concerning the participation-decreasing effect of the modal declarative proposal form.Whilethemodaldeclarativeformmarkstheplanpro forma as contingent on recipient acceptance, the form appears to be less effective in conveying a true need for the participants to take an independent stance toward the matter at hand. Complex Previous CA research has described how complex, extended turns of talk are typically produced by speakers adding non-projected items to their utterances. We classified support worker proposals with such linguistic structure into the category “complex”An example of such proposals in provided in Extract 3, where the participants are discussing the matter when, where, and by whom the ultimate decisions about who gets to enter the transitional work program are made. As has been discussed in prior Clubhouse literature (e.g. Valkeapää, Lindholm, Tanaka, Weiste, & Stevanovic, 2019), the possibility to enter the program is the utmost importance to many clients at the Clubhouse and the decisions related to the running of the program can therefore often be emotionally loaded. Extract 3 is produced as a reaction to one of the clients having just previously asked about the maker of the employment decisions. At the beginning of the extract, the support worker (SW1) states that this “meta-decision”about the decision-making procedure has not yet been “hammered through”(lines 1–2). Immediately thereafter she suggests that the participants in the current meeting would make that decision now (lines 3–5). In essence, according to the support worker’s proposal, they would need to make the decision on whether the employment decisions, which will become critical some time in the future, would be made by this particular group or by some other group that also gathers at the same Clubhouse community. COUNSELLING PSYCHOLOGY QUARTERLY 15 Extract 3 (SW1/SW2=support workers, Jan=client) 01 SW1: This has not been 02 hammered through in any clubhouse meeting so 03 maybe we should ((decide it)) now. 04 I would think that 05 we could decide now which of the two groups ((is selected)). 06 It probably does not matter much so that at least for us 07 SW2: Mmm. 08 SW1: as staffeither one is fine. So what do you think? 09 (.) 10 SW1: And then we take this proposition 11 to the Clubhouse meeting and hammer it through there. 12 Jan: Are there now any jobs existing? 13 (.) 14 SW1: No not yet. There are negotiations going on. 15 Jan: Okey. ((starts to talk about his own employment problems)) The support worker’s proposal starts with a pivotal construction (“now we maybe should now,”line 3) –a linguistic resource that allows the speaker to modify the projected trajectory of his or her utterance on the flow (Lindström, 2013; Norén & Linell, 2013). Then, the support worker produces a series of self-repairs (“I quesestimatlike think that,” line 4). Thereafter, she produces the “core”of her proposal: making a choice between “the two groups”(line 5). The sentence is, however, aborted before completion, so that it is left inexplicit what exactly the selected group should do. Instead, the support worker rushes to downgrade the importance of the content of the decision (lines 6–7). Thereafter, by asking “so what do you think”(line 7), she makes it clear that the decision is nonetheless for the group members to make. Given the lack of recipient uptake in line 9, the support worker goes on to add details about the further unfolding of the decision-making process (lines 10–11). Even if the mentioning of the Clubhouse meeting highlights the significance of the decision in the official life of the Clubhouse community, the use of the verb nuijitaan “hammer through”nonetheless suggests that the decision will most likely raise no opposition. As the analysis above shows, the grammatical structure of the support worker’s proposal turn is complex, consisting of several component constructions, many of which work to decrease the high stakes that the participants might have in the decision to be made. This interactional work, however, has the consequence of obscuring the proposal: what the support worker’s proposal is precisely about is something that the recipients must infer from the context of interaction. It is therefore of no surprise that the proposal does not get any direct response. Instead, one of the clients, Jan, asks about the existence of jobs in the transitional employment program (line 12), which leads to the interaction moving far away from the concrete dealing with support worker’sproposal. The matter that the support worker’s proposal did not manage to encourage substantial participation in the content of the proposal is reflected in the low participation rating given to the segment (mean = 1.67). This segment thus exemplifies the participation-decreasing pattern associated with the category “complex,”which our statistical analysis pointed to. 16 M. STEVANOVIC ET AL. Discussion In this paper, we have investigated how the support workers’design of proposals influences the sharedness of decisions in the context of mental health rehabilitation. Our findings may be elucidated with reference to the CA notion of sequence organization and the associated idea that different proposal forms place different constraints on the responsive actions to be produced by the recipients (Schegloff,1968; Stivers & Hayashi, 2010). As for the matter of participation per se, such constraints are most distinctive in the support workers’use of explicit address terms to select the client who should provide a response to his or her proposal (Lerner, 2003; Sacks et al., 1974)–a practice that, unsurprisingly, predicted a higher level of client responsiveness than those support worker proposals that were targeted generally to all. When we, however, consider the content of interactional contributions, the linkage between constraints and participation becomes more complex. As has been pointed out above, “Wh”and “How”questions have been generally considered to give the recipients a relatively great degree of freedom to design their responses, which has been assumed to encourage responsiveness and participation precisely by virtue of the lack of constraints associated with open question forms. Thus, also counselling literature has encouraged professionals to use these types of open-ended questions to facilitate the group discussion (Trotzer, 2013). While such open proposal forms may thus come across as an optimal way to allow the clients to take control over the conversational agenda (see, e.g. Wang, 2006), our data suggest otherwise. What seemed best encourage client responsiveness were those proposals that shared some surface-level features of open proposals, while yet constraining the recipients’response options to be either in favor or against one already set-out action plan. In the context of mental health rehabilitation, the great freedom of responding associated with “genuinely”open proposals might make the production of a substantial participatory contribution too big a responsibility for the clients to cope with. In contrast, the proposals in the “quasi-open”form reduce this challenge, while still leaving the clients enough space to construct their responses in substantial ways. At the other extreme, our data pointed to the disadvantages in using modal declarative proposals as attempts to initiate joint decision-making, since they invite only minimal confirmation from the recipients as a response (Stevanovic, 2013). Our findings also highlight the importance of clarity in the support workers’expressions. Similar to previous CA research on the use of complex, extended turns of talk in the context of delicate topics (e.g. Betz, 2008; Silverman & Peräkylä, 1990; Weijts, Houtkoop, & Mullen, 1993), the support workers in our data often used complex proposal forms when discussing decisions with a relatively delicate content. These “complex”proposal forms were seldom met with substantial forms of client participation. Instead, these proposals were met with open class repair initiators (e.g. “what”or “huh”), silence, and/or turns with content tangential to the proposal, as we could see happening in Extract 3. Our findings suggest that the fine-grained interactional work that people accomplish by circling around problematic issues in hope that the recipients would still contribute to the discussion in expected ways seems not to work in encounters with mental health clients. Inasmuch as the level of client participation needs to be increased, more straightforward proposal forms would need to be produced. COUNSELLING PSYCHOLOGY QUARTERLY 17 In addition, our results emphasize the importance of support workers’expertise in working with mental health clients. In psychotherapy research, several studies and metaanalyses have concluded that therapist’s expertise is modestly linked with better client outcomes and lower rates of therapy dropouts (e.g. Goldberg et al., 2016; Stein & Lambert, 1995; Tracey, Wampold, Lichtenberg, & Goodyear, 2014). In our data, the level of client participation was much more substantial if the proposal was made by either one of the two support workers who had several years of experience on working in Clubhouse communities. This might be due to the fact that during their long experience of working in Clubhouse communities, they had learned what sort of issues are worth taking into the joint decision-making processes and what is more efficient to decide alone. It is also possible that years of experience reflect a stronger commitment to the Clubhouse model and empathy toward individuals with severe and persistent mental illness, which might have given them the ability to build a better alliance with clients (see Horvath, 2001). The study has several limitations. First, our data are drawn from only one Finnish Clubhouse, with a set of support workers and clients that happened to participate in the recorded meetings during the period of data collection, which needs to be taken into account when considering the applicability of the findings in other contexts. Second, we may not be sure about whether and how video recording influenced the conduct of the participants in our data. However, a body of research in visual sociology and CA (see, e.g. Lomax & Casey, 1998; Pringle & Stewart-Evans, 1990; Tuncer, 2016) suggests that the contingencies of the moment-by-moment unfolding of interaction take a precedence in the participants’conduct –even if the very beginning of an interactional encounter often involves the participants establishing a shared perception of the recording situation. This is also the impression that we got from our data. Third, the ratings of responsiveness were based on the raters listening to the context prior to the proposal. Even if we had important methodological reasons to do so (see the section “Methods”), this might also have constituted an uncontrollable source of bias for the ratings. Finally, our coding scheme was not sensitive to the content of the participants’conversations. Even if this is a standard take in CA-informed quantitative research designs (see, Stivers, 2015), in considering the degree of participation in response to various proposals from, the question of what the proposal in each case is about may have influenced the level of motivation for certain clients to respond to it. Even if the support workers’proposal were basically about the activities of the group as part of the everyday activities at the Clubhouse, it is possible that the success of Clubhouse experts in encouraging client participation may be partly attributed to their skill to predict the motivation of the specific clients present in the meeting to get involved in specific issues. Future research should target the question about the ways in which linguistic form and other proposal features discussed in this study serve to encourage mental health clients to participate specifically in those decisions that are subjectively most meaningful to them. Conclusions Client participation in decision-making is important in all types of mental health care and counselling (e.g. Position statement, 2009). In this paper, we have studied a specific type of group counselling in the context of communal mental health rehabilitation. In this context, as in many counselling settings in which clients have severe mental health 18 M. STEVANOVIC ET AL. problems, the main challenge to joint decision-making is a lack of participation by the client (see Wressle, 2002). Our contribution has therefore been to increase understanding about which practices the counsellor may use to facilitate client participation. In light of our results, the presence of explicit recipient address terms and the use of what we refer to as the “quasi-open”proposal forms may be promoted as ways to increase client responsiveness. Both of these turn-design features make it clear to the clients that the professional is expecting a response from them. Then again, our findings suggest that proposals in the form of the modal declarations should be used scarcely –only to announce those action plans that the clients may be assumed to be willing to accept anyway. In sum, the support workers must balance between providing the clients genuine possibilities to contribute to the emerging decisions, while making the participation easy enough for them. As pointed out at the beginning of this paper, there are strong rehabilitation-ideological grounds for the Clubhouse support workers to hearten the clients to take on responsibilities arising from their membership in the community. This kind of community-centered rehabilitation ideology can, however, constitute a tension with those rehabilitation ideologies that focus on the need of clients to take control over their lives. This is because it seems that, as one aspect of self-determination, the clients should also have the right to refrain from joint decision-making if they want to (see Elstad & Eide, 2009). In the face of these two partly contradictory ideologies, the support workers’tasks are particularly demanding. Besides regulating the optimal level of response pressure to encourage client participation, the support workers must also balance between the clients’freedom not to participate and encouraging them nevertheless to do so. In making a proposal, a speaker always exerts some pressure on the recipient to get involved in decision-making about a particular item. In mental health rehabilitation, such pressure serves as a central instrument for the professionals to accomplish their work tasks when interacting with their clients. Inasmuch as the facilitation of client participation is the professionals’primary goal, response pressure –just like any other instrument for that matter –may be used in more or less effective ways. While previous literature has discussed the possible challenges in this regard as difficulties of individual decisionmaking capacities (see, e.g. Beitinger et al., 2014; Stovell et al., 2016), in considering how the support workers’design of proposals influences the clients’responsiveness to them, and thereby the degree of sharedness of the decisions about to be made, this paper has increased understanding of the interactional underpinnings of these challenges. Participation in interaction is always a joint accomplishment. In terms of practice, our findings indicate that even the smallest linguistic and grammatical choices matter in clinical communication, making a difference to the expected degree of client participation. Joint decision-making can be a particularly complex interactional task for counsellors, especially in a group setting, where they face the dilemma of needing actively to guide the group interaction, while also offering the clients the opportunity to be genuinely involved in decision-making. A detailed description of counsellors’interactional practices enables counsellors to become reflexively aware of the practices that they use, and it also allows the development of training procedures targeting those specific interactional patterns that should be present in good quality counselling interaction. COUNSELLING PSYCHOLOGY QUARTERLY 19 Disclosure statement The authors are not aware of any current or potential personal benefit to publication or conflict of interest, financial or otherwise. Funding Research for this study was supported by the Academy of Finland [grant no. 307630] and the University of Helsinki. Notes on contributors Melisa Stevanovic is a university lecturer in sociology at the University of Helsinki. She has investigated collaborative decision making in both naturally occurring interaction at the workplace and in experimental settings. She has also published on the topic of interactional deficits and experiences of interaction. Taina Valkeapää has MA in sociology. She has background in social counselling, and as a trained sociologist she uses conversation analysis she has conducted research on interactions involving individuals with intellectual disabilities and mental health problems. Elina Weiste is a post-doctoral researcher in sociology. She earned her PhD on therapeutic interaction at the University of Helsinki and has a long experience in training clinical professionals. Weiste holds a researcher position at the Finnish Institute of Occupational Health. Camilla Lindholm is a professor of Scandinavian languages at the University of Tampere. 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A pause of less than 0.2 seconds (0.0) Pause: silence measured in seconds and tenths of a second °word ° Talk lower volume than the surrounding talk WORD Talk louder volume than the surrounding talk.hhAn in breath hh An out breath mt, krhm vocal noises £word£ Spoken in a smiley voice @word@ Spoken in an animated voice #word# Spoken in a creaky voice wo(h)rd Laugh particle inserted within a word ((word)) Transcriber’s comments () Transcriber could not hear what was said word Accented sound or syllable - Abrupt cut-offof preceding sound : Lengthening of a sound >word< Talk faster than the surrounding talk <word> Talk slower than the surrounding talk ↑↓ Rise or fall in pitch ? Final rise intonation, Final level intonation. Final falling intonation 24 M. STEVANOVIC ET AL.