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Communication, relationships and care a reader I edited by Martin Robb

Communication, relationships and care: A reader

Communication culture: Issues for health and social

Cameron, Deborah

Routledge

2004

63-73

9780415326605

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CHAPTER 7

COMMUNICATION CULTURE: ISSUES FOR HEALTH AND SOCIAL CARE

Deborah Cameron

INTRODUCTION

In 1994, applicants for a vacant position in a National Health Service hos- pital were sent a 'person specification' describing the ideal candidate as someone who could:

B demonstrate sound interpersonal relationships and an awareness of the individual client's psychological and emotional needs;

• nnderstand the need for effective verbal and nonverbal communication; and

B support clients and relatives in the care environment by demonstrating empathy and understanding.

These might seem unremarkable requirements for a caring professional- a nurse, psychologist, counsellor or social worker, but in fact, the hospital was advertising for a cleaner. Although cleaners do talk to patients and relatives, this is not usually thought of as their core function, nor is it a kind of talk that requires specialist expertise. Some commentators sug- gested that the person specification was a 'politically correct' attempt to boost cleaners' status by describing the ordinary ability to converse with other people as if it were an arcane professional skilL

But this cannot be the whole story, for similar language can be found in job and person specifications across the occupational spectrum. Institu- tions not often suspected of political correctness, from engineering firms to

64 COMMUNICATION CUlTURE

banks, all routinely inform job applicants - whether they aspire to be the receptionist or the chief executive - that they 'must have excellent commu- nication skills'. If we substituted 'customer' for 'client' and took out the reference to 'the care environment', the text quoted above would not be out of place in a specification for an estate agent, hotel manager or insur- ance broker.

Concern about communication is not confined to the sphere of employ- ment. Communication is one of the 'key skills' that are now emphasised in the national school curriculum and in higher education. Self-help books and television talk shows preach that fulfilling relationships depend on our ability to communicate with partners, family and friends. All kinds of problems, from marital breakdown to teenage suicide, are blamed on inad- equate communication. In short, we live in a 'communication culture': a culture obsessed with communication and the skills that it supposedly demands. Here I want to explore critically what lies behind that obsession. Where did ir come from and what are its effects? I will begin by examining these questions in general terms, then move on to consider the implications for the field of health and social care specifically.

WHAT IS COMMUNICATION CULTURE AN WHERE DID IT COME FROM

According to the sociologist Anthony Giddens (1991), it is characteristic modern societies that traditional ways of knowing and acting are sively displaced by 'expert systems', specialised and technical produced and regulated by professionals. The displacement of healing practices by modern medicine .is an obvious instance. recent example offered by Giddens is 'parenting'. The skills involved · child-rearing were once acquired informally, through practice, · and advice from older relatives. Today, by contrast, 'parenting' is a set skills which experts define, Parents may still take informal advice, but are also likely to turn to books, magazines and classes for more anrhortr-1 tive guidance. In Britain, parents who are judged inadequate can be pelled to receive training in parenting.

'Communication' is an analogous case. The mundane social activity talking to others has been redefined as a set of skiUs requiring effort expert guidance to master. As with parenting, the message of Pv1"1Prt•H communication is that there's a right way and a wrong way. AU '"'"'"'" sources, ranging from training courses to radio phone-ins to popular help books, explain what the 'right way' is. Many people who have sought it out voluntarily will encounter this body of expert through education or workplace training.

So, the rise of 'communication skills' is an example of a much

DEBORAH CAtv\ERON 65

general trend. Bur why has communication, specifically, become such a prominent concern in recent years? There are a number of reasons, but two are particularly important.

One has to do with economic change. In a 'post-industrial' age, fewer jobs are about manufacturing things, while more are about providing ser- vices to customers and clients. Whereas a traditional assembly-line worker's communication skills were of marginal relevance, service jobs inherently involve communication. There has been a growing tendency for businesses to regulate and standardise the language in which employees interact with customers, treating their speech as part of the corporate 'brand'. In addition, global competition has spurred many businesses, in both the service and manufacturing sectors, to restructure their operations and introduce new management approaches emphasising quality, flexibil- ity and teamwork. This rneans that talking, in settings like team meetings, 'quality circles' or appraisal interviews, has come to play a more significant 'behind the scenes' role at work.

The second key factor underlying the rise of communication culture has to do with shifts in the way we think about our identities and personal relationships. Giddens ( 1991) points out that modernity loosens the tradi- tional ties people have to their kinfolk and local communities. Few people now spend their whole lives in the same place, among others who have known them from birth: they are continually having to reinvent them- selves. Under these conditions, Giddens argues, 'the self becomes a reflex- ive proiect' (1991: 32) - something to be worked on, perfected. Just as dieting and exercise can reshape our physical bodies, so other technologies of self-improvement can reshape our inner selves. Working on one's 'com- munication skills' has a particular significance, because communication is seen as vital to the ability to form and maintain intimate relationships with others. In modern conditions, these relationships often do not have the external supports they would have had in traditional society (for instance, couples no longer stay together because of inviolable religious and moral codes). Maintaining intimacy depends on a continuous process of mutual self-disclosure, so that parties to a relationship remain in touch with one another's activities, feelings, needs and desires.

It might seem as if these two sets of developments are unrelated: one set affects individuals in their lives as workers and consumers, while the other affects them in their personal lives. But in fact there is a relationship. Com- munication was a central concern of what is often loosely referred to as the 'personal growth' movement of the 1960s and 1970s, when significant numbers of people turned to the ideas and techniques of psychology and therapy - to approaches such as transactional analysis (Berne 1966) and assertiveness training (Rakos 1991) - as part of a quest for personal fulfil- ment. While this began as a counter-cultural movement, with 'personal growth' being seen as a form of resistance to mainstream corporate culture, the same ideas were soon taken up by the corporate sector itself.

66 COMMUNICATION CULTURE

If training in assertiveness or transactional analysis could help people lead happier lives outside the workplace, then perhaps it could also help them to function better inside it. Organisations managed and staffed by effective communicators would be more efficient, more harmonious and ultimately more successful economically.

Because of their shared roots, communication training materials designed for professional contexts have much in common with those that focus on personal growth and relationships. In both types we find the same recommendations - for instance, speak directly using 'I' state~ ments, use open rather than dosed questions, listen without judging, use verbal acknowledgement tokens like 'yes', 'I see', don't interrupt. The expertise being drawn on, whether or not this is made explicit, is that of psychiatrists, psychologists, therapists and counsellors. Almost invari· ably, the rules and recommendations can be traced to some practice that originated in a therapeutic setting. Assertiveness training, for instance, began as a behavioural therapy for psychiatric patients who had become passive and withdrawn. Transactional analysis emerged out of the practice of group therapy. Non-judgemental listening is a central technique of counselling.

The linguist, Norman Fairclough (1992), uses the term 'technologisa-' tion of discourse' to theorise the process whereby a way of talking designed for one context gets transferred to a wide range of others, as if it were part of an ideologic<1lly neutral 'toolkit'. He regards the language of therapy as a particularly important contemporary 'discourse technology'~ and argues that there is nothing neutral about its use in non-therapeutic contexts. Consider workplace appraisal, a discourse practice which uses many of the conventions of a counselling session. The appraisee talks about her or his achievements and problems while the appraiser listens and supports. But the goals of appraisal, and the power relations that are oper~ ative in an appraisal interview, are quite different from the goals and re!a .. tionships involved in counselling. The appraiser is not there primarily to help the appraisee meet his or her own goals, but to judge how well the organisation's goals are met- a judgement that may have consequences for the appraisee's job prospects. In Fairclough's view, the 'therapeutic' frame obscures what is really going on.

To summarise, 'communication culture' has developed along with changing economic conditions and ideas about 'personal growth' which have influenced both organisations and individu<1ls. In communication cul- tures we find the following general characteristics:

• A widely shared belief in the importance of communication and a per- ception that many problems (and their solutions) are linked to it.

• An acceptance that there is a 'right way' and a 'wrong way' to communicate, and a proliferation of expert discourse about the 'skills' required to do it right.

DEBORAH CAMERON 67

• A growth in specific trammg in communication, and an increasing desire to assess or evaluate individuals' performance as communicators.

• A tendency to regulate and standardise communication practices within particular institutions.

COMMUNICATION CUlTURE AND THE FIELD OF HEALTH AND SOCIAL CARE

Few people would dispute that in the context of health and social care, interaction between service providers and users is important. The question is not whether it deserves attention, but about the helpfulness or otherwise of the approaches characteristic of communication culture. In the remain- der of this chapter I examine some cases where versions of these approaches used in health and social care might be deemed unhelpful or problematic. These cases illustrate more general problems with the dis- course and practice of 'communication skills'.

CASE 1

Problems of knowledge: rules for 'effective communication' are typ- ically formulated without reference to what is normal sociolinguistic behaviour.

One defining feature of communication culture is its reliance on expert knowledge about the 'right way' to perform particular communicative acts. But this is a particular kind of expert knowledge, originating mainly in therapeutic fields where the prevailing approach to language-use is normative rather than descriptive. Expert recommendations on how speak- ers ought to communicate are rarely informed by any knowledge of the patterns uncovered by empirical research on naturally"occurring talk. Con- sequently the experts may end up exhorting people to behave in ways that are linguistically unnatural and socially bizarre.

Assertiveness training (AT}, for instance, is the source of many prescrip- tions about 'effective communication', but its recommendations have been criticised for their marked divergence from 'normal' practice. In everyday non-therapeutic contexts, 'assertive' strategies like making '!-statements' or repeating a point until it is acknowledged may be interpreted as rude and egocentric (Cameron 1995; Gervasio and Crawford 1989).

One piece of AT-derived advice which is common in health education and care work with young people who are thought to be at risk of sexual

68 COMMU!'~iCATlON CULTURE

exploitation and violence is encapsulated in the slogan 'just say no': in other words, be direct in refusing unwanted sexual advances. Assertiveness training teaches that everyone has the right to refuse without apologising or giving reasons; rape prevention programmes also teach that a direct 'no' is preferable to alternative strategies because it leaves no room for mis- understanding.

However, this line of argument overlooks a large body of empirical work in conversation analysis (CA), which shows that successful refusals in naturally-occurring talk are virtually never performed in such a bald, unmitigated way. Acceptance and refusal form what CA calls a 'preference system' in relation to invitations, propositions and requests: the 'preferred' move, acceptance, is simple and brief, whereas the 'dispreferred' move~ refusal, is much more elaborate. Thus if I ask, 'd'you want to meet for a drink after work?' you can accept by simply saying 'OK'. Refusals, by con- trast, are usually prefaced by a pause or hesitation marker (urn, er), often accompanied by 'well', and they include an explanation or excuse. So in the drink-invitation case, a typical refusal might go: 'er, sorry, I'd love to, but I've got to work late tonight'.

For obvious reasons, there is little natural data available specifically on sexual refusals, but the feminist researchers Celia Kitzinger and Hannah Frith (1999) conducted a study with focus groups of young heterosexual women who were asked what they said if they wished to refuse a sexual invitation. Only two out of 58 claimed to feel comfortable saying 'No'. The rest favoured the strategies described above for making dispreferred conversational moves: hesitating, giving reasons which would not offend (e.g. 'I'm really knackered'), and sometimes inserting a 'softener' like 'I'm really flattered, but ... '. They also reported that in their own experience, men correctly interpreted these strategies as refusals.

Rape prevention advice to 'just say no' is flawed in two ways. First, it is based on the assumption that less direct ways of refusing carry a high risk of misinterpretation. If, as empirical research suggests, this assumption is false, then the advice is unnecessary: other strategies will work equally well (or badly). That leads on to the second point, that the recommended strat- egy of saying 'No' without elaboration is in conflict with the norms of ordinary interaction. Kitzinger and Frith's informants were familiar with advice to 'just say no', but most unequivocally rejected that advice. Initi-' atives like rape prevention (or safer sex advice or drugs education) wiU usually be less effective where they do not take account of the target group's beliefs, values, and habitual ways of behaving. The knowledge~ base for interventions in communicative practice thus needs to include a knowledge of what is 'normal' behaviour for particular groups of people communicating in particular contexts.

DEBORAH CAMEROI'-l 69

CASE 2

Problems of power: norms for communication may gloss over conflicts and asymmetrical power relations.

In communication culture it is commonly believed that many problems are most effectively addressed by adjusting the way people communicate. This belief underpins a therapy called 'Reality Orientation' (RO) which is widely used with confused elderly people in institutional care. RO's goal is ro put patients back in touch with reality, by way of 'a continual process whereby staff present current information ... in every interaction, remind- ing the patient of time, place and person, and providing a commentary on events' (Holden and Woods 1982: 51).

The sociolinguist Karen Grainger (1998) carried out ethnographic fieldwork in a number of hospitals where RO was practised. Her analysis focuses on the problems and conflicts that the prescribed ways of com- municating created for both patients and staff. In practice, she observed that staff did not observe the rules of RO consistently. Sometimes, for instance, they would enter into patients' 'confused' fantasies (e.g. that they were someone else or somewhere else) because this made it easier to secure co-operation with routines like washing or dressing. Conversely, there were occasions when patients made coherent factual statements about current events, and carers denied that these corresponded to reality. One patient who complained that the bath water was too cold was informed that it was really 'nice and warm'; another who referred to being 'alone' was reminded that she was surrounded by other patients.

Grainger relates her observations to the conflicting realities and asym- metries of power that exist in care institutions. The 'official' reality of the institution, as represented in its mission statement or the literature given to relatives, does not coincide with reality as perceived by front-line care workers, and that in turn differs from the reality experienced by elderly patients. Power differences are highly relevant in these circumstances. Though carers are not a powerful group, one power they do have is the power to present their own definition of reality as more valid than that of a confused elderly patient. They also have a motive to do this, precisely because their working conditions disempower them. Acknowledging and dealing with the reality of patients' discomfort or distress is emotionally challenging and makes it more difficult for hard-pressed carers to get through their daily routine.

Grainger also points out that the external realities emphasised in RO are unlikely to resonate with patients' perceptions, because of their remoteness from institutional life:

70 COMMUNICATIOt',) CULTURE

For many residents ... their entire world consisted of spending night- times in the dormitory . . . and day-times sitting in a chair in the dayroom. Heat was kept at a constant level, the same group of uni- formed staff came and went around them, there was rarely a chance to go outside the room, let alone outside the hospital ... It is my uiew that external reality (i.e. the date, day, time, year, address) can have had little significance for these people.

(Grainger 1998: 52)

Grainger wonders how far the confusion of elderly patients is produced by the regime of the institution itself, as opposed to by clinical conditions like dementia. Patients' 'confused' relationship to the external world is not simply a linguistic or cognitive problem, but reflects their social isolation, the monotony of their routine and their powerless position in the institu- tional hierarchy. RO does not address these problems, and may even exac- erbate them by imposing on elderly patients a definition of 'reality' that denies their lived experience.

CASE 3

Problems of 'skill': criteria for defining and assessing 'communication skills' are often vague, subjectil!e or simply vacuous, and there is little critical reflection on underlying principles.

An important characteristic of communication culture is its concern with the explicit teaching and assessment of communication skills. This the activity of 'communication' to be broken down into discrete elemc:~nt:s, which can be taught and assessed; assessment also requires that criteria devised to distinguish various levels of performance. But the highly ._,v'n")"'"' tualised nature of social interaction makes this enterprise highly pr<)D!emt" atic. To illustrate the problem, let us examine the level 2 NVQ Vocational Qualification) in Social Care, a nationally accredited course the UK designed for trainees who work, for instance, as assistants in dential care homes.

Assessment for NVQ courses is 'competence based' - assessors COJtlSilclt: portfolios of evidence compiled by the learner to show s/he bas deJrnons1:ralt¢ the particular skills and compentencies that are required for the award slhe is seeking. 'Communication' is a category for assessment in NVQ courses, though the required skills and competencies vary with the of work as well as the level of the award. Below I reproduce seven criteria which Social Care trainees' communication skills are assessed at level 2.

DEBORAH CAMERON 71

1 Effective communication is promoted in ways consistent with the worker's role.

2 Communication with an individual is consistent with her/his under- standing, preferred form of communication and manner of expression.

3 The manner, level and pace of communication is appropriate to the individual's abilities and personal beliefs and preferences.

4 Any obstacles which may make communication difficult are minimised. 5 Effective communication is encouraged by appropriate facial expres-

sion, body language, sensory contact, position and environment. 6 Where the initial form of communication is not effective, different

approaches are used or sought. 7 Information given by an individual is checked with her/him for accuracy.

(source: NVQ Assessment Specification and Record Sheet, Element O.e)

This list illustrates how difficult it is to break communication down into a set of discrete skills, and to produce meaningful criteria for assessing its quality. One noticeable feature of the list is the overlap between supposedly different criteria (what is the difference between 2. and 3., or 4. and 6.? Does L not just subsume all the others?). Another is the lack of clarity about what key terms mean. The words 'appropriate' and 'effective' appear in several criteria, begging the question of what will count as 'appropriate' or 'effective'. (If we take criterion S., for instance, what is an 'appropriate facial expression'?} 'Appropriate' and 'effective' are terms whose meanings are inherently context-dependent. But if context is all, if good communica- tion means neither more nor less than a way of interacting that is appropri- ate and effective in the context of a particular interaction, then it might be argued that general performance criteria for communication are vacuous.

In practice, assessors will fill the vacuum with their own judgements. But judging what is appropriate communication in care settings is not like judging whether, say, a trainee electrician has followed appropriate safety procedures. There is little argument about what constitutes safe practice when dealing with electricity, for this is fundamentally a technical issue. But the question of what constitutes appropriate behaviour to clients inevitably has a moral and ideological dimension. Therefore, it is important to give trainees the opportunity to discuss- and reflect critically upon- the beliefs and values that underpin judgements on communication in care settings. If these are presented as simply common sense, there is no way to resolve the problems and contradictions which may arise in real-world situations.

For example, criterion 3. in the NVQ list, which states that communica- tion in care settings should be 'appropriate to the individual [clientfs ... personal beliefs', might look like an uncontroversial statement of the obvious. But what are the implications for black or gay carers dealing with clients whose personal beliefs are racist or homophobic? Does meeting the

72 COMlv\UNlCATlON CUlTURE

NVQ standard require them to abdicate their own right to respectful treat- ment? If not, how should they deal with interactions where a client's preju- dices become overt? This is not some abstruse philosophical problem with no place in a vocational training programme, but a matter of immediate practical relevance for many care workers. But the competence-based schemes that are typical of communication training leave little space for reflection on issues of this kind. That might prompt questions about the ability of such schemes to produce 'skilled' workers; for skill is not just a matter of being able to act in certain ways, it also requires a principled understanding of why you do what you do.

CONCLUSION

I have suggested that there are problems with the application of currently favoured approaches to communication in the field of health and social care. Am I saying then that communication skills training is useless? Not entirely: the mere fact of drawing attention to questions of communication may have a useful awareness-raising function. Some genres of care-talk (such as counselling and medical history taking) are founded on principles that do require explicit teaching; many benefit from practice in 'safe' situ- ations where poor performance will not do serious harm.

Yet a lot of what goes on under the heading of communication skills training is of unproven value. In research carried out in commercial service organisations (Cameron 2000), I asked managers whether training had any measurable impact on recipients' subsequent performance. Though they aU had an opinion, not one was able to produce any non-anecdotal evidence to support it: they did not carry out systematic evaluations. Responses to my follow-up question - a diplomatically-worded version of 'why do you spend money on training when you don't know if it works?'- were ger1er•· ally along the lines of 'our competitors do it'. I detected, however, other factors at work.

One was the need managers felt to regulate the behaviour of ind· employees, subordinating their individual styles to a corporate style or brand. They cared less whether training 'skilled' communicators than whether it produced 'standard' '-"''uu•u•u .... , tors who all followed the same rules. The second factor was a belief in almost magical power of messages to determine the behaviour of the ret:m·, ient. Words, phrases or gestures, used in just the right way, were "'""'"'"'"'"v' by many of my informants with the ability to clinch the sale, defuse argument, win the customer's lifelong loyalty. This magical thinking overt in magazine articles and adverts for 'inspirational' business sernmtar:\if which are full of the 'seven secrets of X' and the 'ten top tips about Y'. miracle solutions rarely hold up when put to the test in a real-life

DEBORAH CAMERON 73

I once chaired a panel interviewing candidates for an administrative position in my University department. The last candidate, when asked 'do you have any questions for us?', replied: 'where is your organisation going and where does it want to be in five years' time?' Afterwards, a panellist remarked that this candidate must have been on a course where the ques- tion was presented as an example of effective interview technique. But we all agreed that in this case it had not been effective at all. For one thing it came across as glib and formulaic. For another, it assumed an attitude to change and a collective commitment to corporate objectives at odds with academic culture. The candidate's 'magic words' did not fit the context, and their effect on us was negative.

Attempts to promote 'better communication' will not succeed unless they are based on an understanding that all human communication is necessarily embedded in social contexts and relationships. Since these are complex and variable, there is no single 'right way' to communicate, no universally applicable 'magic words', and no quick fix for every problem. 'Skilled' communicators are those with the resources (linguistic, intellec- tual and experiential) to reflect on the context and the relationships involved in a particular communicative event, and in the light of that reflection, gauge the effects of different ways of interacting. Without this deeper dimension, communication skills training becomes a superficial exercise, of little benefit either to trainees themselves or to the recipients of their professional attentions.

REFERENCES

Berne, E. (1966) The Games People Play, New York: Grove Books. Cameron, D. (1995) Verbal Hygiene, London: Routledge. Cameron, D. (2000) Good To Talk? Living and Working in a Communication

Culture, London: Sage Publications Fairclough, N. (1992) Discourse and Social Change, Cambridge: Polity Press. Gervasio, A. and Crawford, M. (1989) 'Evaluations of assertiveness: a critique and

speech act reformulation', Psychology of Women Quarterly 13: 1-25. Giddens, A. (1991) Modernity and Self-Identity: Self and Society in the Late

Modern Age, Cambridge: Polity Press. Grainger, K. (1998) 'Reality Orientation in institutions for the elderly: the view

from interactional sociolinguistics',]ourna/ of Aging Studies 12 (1): 39-56. Holden U.P. and Woods, R.T. (1982) Reality Orientation: Psychological

Approaches to the 'Confused' Elderly, Edinburgh: Churchill Livingston. Kirzinger, C. and Frith, H. (1999) 'Just say no? The use of conversation analysis in

developing a feminist perspective on sexual refusal', Discourse and Society 10: 293-316.

Rakos, R. {1991) Assertiveness Training: Theory, Training and Research, London: Routledge.